![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 14 of 14. This is the beginning of the thread.
Posted by tom2228 on June 21, 2010, at 19:46:31
Anyone on or been on Trileptal with any MAOI? Or even carbamazepine (tegretol), please respond!
So here's the story, I've got ADHD, social anxiety, and some sort of bipolar, I suspect cyclothymia. I started cycling some time in childhood but I can't pinpoint when.. I'm 18 now and the cycling has gotten more and more rapid .. from months to weeks and days at one point. Heavy weed smoking and all the antidepressants and stimulants (I've been on 18 meds and many more combos) have probably contributed to this, though it could be the natural progression of the disorder too.
Anyway daily and weekly mood swinginess has greatly leveled out since starting trileptal in March.. things have slowed down a lot. Long story short, I'm pretty sensitive to meds so I was taking the oxcarbaz 4x/day to minimize SEs. OXC has a short half-life and "wears off" within a couple hours, the active metabolite is what allows for the usual twice-daily dosing. OXC itself is active and releases serotonin and dopamine in the in the limbic system.. another reason I kept on the QID schedule, it just felt nice, lol. But it left me with an antidepressant effect as the receptors eventually downregulated (I've been on plenty of serotonin meds, trust me I know the feeling).. I started to get all serotonin'd out (all flat and "mushy brain" feeling). Spacing the doses out a little more, and eventually switching to 3x a day, dealt with this nicely and I felt pretty good. SSRIs have sucked *ss for me but serotonin action JUST in the limbic system (none in the pre-frontal cortex, which throws my judgement way off, makes me impulsive, moody and I usually wind up in a mixed state) was nice!
Definitely not depressed, sorta happy really, but my drive (sexually and motivationally) and pleasure were lacking. Content, stable mood but "Where's the spark?" -- you guys know how it is. So we went down to the standard BID dosing and the pseudo-SSRI effect disappeared. Major depression set in but now that the d/c syndrome is done now I'm left with the chronic atypical dysthymia that I've had all my life. Plus the social anxiety. Oh and my stimulant won't work anymore as a result -- I can still focus OK but now the Vyvanse just makes me really anxious and I have no motivation to attend to anything important.
There's not much left to try. My Life As A Medicated Motion Picture, screenplay written by 3 docs and starring: Lexapro, Wellbutrin, Abilify, Risperdal, Lamictal, Prozac, Adderall, Focalin, Dexedrine, Zoloft, Remeron, Neurontin, Geodon, Buspar, Daytrana, Trileptal, Vyvanse... I'm starting at Boston University in a lil over 2 months so I don't have any more time to waste on the med-go-round. I want something to WORK.. I've read a lot of posts on here of treatment-resistant ppl who felt that they had basically wasted their lives suffering, and others who said they wished they had tried an MAOI 20, 30 years ago.. NO WAY is that happenin' to me, I'm gonna LIVE my life whether it means I'll never eat Annie's aged cheddar creamy mac n cheese again!!!
So when I on the phone with my doc the other day and said I didn't wanna try a tricyclic, I was THRILLED when he brought up MAOIs as what's left (I was hesitant to bring them up myself)-- I've only seen this guy 3 times, he's awesome!! Thing is I'll be doing a pre-med track w/ major in neurosci so I told him I was real worried about my ADHD and having to go off stims. And he goes "well, in low doses the combo is pretty OK" -- SERIOUSLY, this guy is awesome! But I'm really sensitive as it is -- anything over 20mg Vyvanse is too much for me -- that's the lowest dose so I don't think I could take a stim with an MAOI. Who knows though, when I wasn't depressed I tolerated the Vyvanse muchh better. But given that it's not even working because of the depression.. no point in holding onto it.
He suggested Emsam and I agreed, as it would probably be the best MAOI to handle ADHD symptoms as well. If unsuccessful he agreed to try Parnate next. So today is day 2 on the patch.. so far it's nice, stimulating and calming. I'm going to wind up on the 9mg/24hr or 12mg; I'm not being overambitious/ pessimistic or anything, I just know that I need some serotonin to feel content and "happy" .. and to balance the dopamine, and for the ADHD -- I have a lot of trouble switching tasks on stims alone.
------------------------------------------------------------------
If you're still with me at this point here's where the real concern is. So trileptal (and tegretol) are contraindicated with MAOIs for some reason.. possibly because of structural similarities to tricyclics it could cause serotonin syndrome. But clinically who knows.. except you guys maybe? (I'm hoping)My doc understands that trileptal is working well and that I'm actually tolerating it, so he said the benefits outweigh the risk so we're sticking with it -- and lowered the dose from 300-375 to 150mg (75mg BID). Which is pretty damn low -- trileptal usually STARTS at 600!
I have also read that carbamazepine can increase the plasma levels of MAOIs twofold.. oxcarbaz doesn't have the same enzymatic pharmacokinetics as CBZ but who knows, and I'm worried because if it DOES, then I'm getting more than the 6mg/24hrs, and the MAO-A action could start up.
In which case the tyramine IS an issue then... so should I do the diet just to make sure?!
The diet is manageable though... the REAL concern is that if the selegiline loses its MAO-B selectivity, then the possible serotonin syndrome could be very problematic. I know trileptal dose have some serotonin releasing properties, which i CAN feel, but again, I'm on a very small dose.. but still this is my life we're talkin about.
Sooo is anyone on trileptal/tegretol + MAOI?!? If so, what is your doc's take on the contraindication/ interaction?
Thanks for reading all of this!!
Posted by tom2228 on June 23, 2010, at 14:05:17
In reply to Oxcarbazepine (Trileptal) + MAOIs (sort of urgent), posted by tom2228 on June 21, 2010, at 19:46:31
Anybody??
Not diggin' the emsam... gonna ask my doc about moving on to Parnate when he calls me back.
Parnate having the MAO-A inhibition would be more of an issue with the trileptal (possible serotonin issues?)...
I will follow my doc's suggestion, which I'm guessing would be to stay on the low dose of 150mg trileptal... but it would sure ease my worries if someone had any input/experiences with trileptal , even tegretol, with MAOIs!!
Tom
Posted by Rockin Robyn on June 25, 2010, at 20:21:44
In reply to MAOI + trileptal/ tegretol -- anybody?!, posted by tom2228 on June 23, 2010, at 14:05:17
So tom, you seem like you have been sealing with this for a few years or so now. I have some questions for you if you dont mind. My son is 9, he is also going on the medication roller coaster. He has been on all sorts of medication for his ADHD and his conduct disorder. I am worried about him. We have an appointment tuesday to see a new doctor. He he been on almost all the medication you are talking about. The stimulants seem to work "OK", but the stimulants cause his to loss weight rapidly. I finally after 6 years, he is over 70 lbs. The doctor had him on a few other but nothing seemed to work. What is your suggestion since it seems you have been dealing with allot of this for some time now?
Posted by Ron Hill on July 3, 2010, at 3:23:27
In reply to MAOI + trileptal/ tegretol -- anybody?!, posted by tom2228 on June 23, 2010, at 14:05:17
> Anybody??
>
> Not diggin' the emsam... gonna ask my doc about moving on to Parnate when he calls me back.
>
> Parnate having the MAO-A inhibition would be more of an issue with the trileptal (possible serotonin issues?)...
>
> I will follow my doc's suggestion, which I'm guessing would be to stay on the low dose of 150mg trileptal... but it would sure ease my worries if someone had any input/experiences with trileptal , even tegretol, with MAOIs!!
>
>
> Tom--------------------------
Tom,
I usually take 600 mg/day of Trileptal (oxcarbazapine) with 90 mg/day of Nardil and my other meds; see my complete combo list at the end of this post.
I have no problems at all combining Trileptal and Nardil. Trileptal is my anti-hypomanic medication.
If I become hypomanic due to sleep deprivation, I increase my Trileptal dosage to 900, or 1200, or 1800 mg/day, depending on the severity of my hypomania. Usually 900 or 1200 is sufficent. Rarely, do I need 1800 mg/day to reel in my hypomania. I take these higher dosages of Trileptal with my med combo, which includes 90 mg/day of Nardil.
I've taken 2400 mg/day of Trileptal with the rest of my combo, including Nardil, but I could not walk; I could only march. Strange feeling.
Tom, I have been questioned by my pharmacy about taking Trileptal with Nardil because they said that it is contraindicted. But, when they read the fine print, it is actually only Tegretol which is contraindicated.
I know nothing about Tegretol combined with an MAOI. I know that it is contraindicated, but someone else will have to give you input about combining Tegretol and an MAOI.
But, why in the world would anyone use Tegretol instead of Trileptal? Trileptal is a MUCH cleaner medication.
-- Ron
P.S. My computer is having problems. I will follow-up in my next post with my med combo. I've never seen my computer do this before. Ummm!
Please forgive my misspelling. My computer is locked on this PB post page and, therefore, I cannot get to a comprehensive spell checker.
Posted by Ron Hill on July 3, 2010, at 3:50:21
In reply to MAOI + trileptal/ tegretol -- anybody?!, posted by tom2228 on June 23, 2010, at 14:05:17
Tom,
Here is my dx and med combo:
dx: Bipolar II with ultra rapid cycling, and mild OCPD
600 mg/day Trileptal
200 mg/day Lamictal
500 mg/day Keppra
90 mg/day Nardil3.75 mg/day Deplin (taken with 2500 mcg/day of sublingual methyl B-12, and 12.5mg/day of sublingual P-5-P)
35 ml of Calsons Bottled Fish Oil
100 mg/day phosphatidylserene
Centrum Chewable Multi-vitamins; Only 100% of all the usual vitamins
2000 IU Vitamin E
850 mg/day of Mg 212% of RDA (as 5 grams of MgMalate).
Dark therapy via LowBlueLight glasses (When I remember)
Whats next to add:25 mg/day agomelatine (if my p-doc wakes up and smells the roses due to my submitted research) {Valdoxan}
300 mg/day of lithum carbonate
CoQ10
NAC, + 8 to 10 glasses of water, + Acetyl-L-Carnitine, + Alpha-Lipoic Acid, + Vitamin C
GTF Chromium
Cromium Picolinate
Cinnamon
Posted by Ron Hill on July 3, 2010, at 5:21:39
In reply to Oxcarbazepine (Trileptal) + MAOIs (sort of urgent), posted by tom2228 on June 21, 2010, at 19:46:31
> So here's the story, I've got ADHD, social anxiety, and some sort of bipolar, I suspect cyclothymia. I started cycling some time in childhood but I can't pinpoint when.. I'm 18 now and the cycling has gotten more and more rapid .. from months to weeks and days at one point. Heavy weed smoking and all the antidepressants and stimulants (I've been on 18 meds and many more combos) have probably contributed to this, though it could be the natural progression of the disorder too.
-------------------Tom, I do not know you, so I run the risk of coming off as a know-it-all jacka*s. It is currently in the middle of the night, so forgive me for being blunt.
You are Bipolar II. And, your p-docs have induced your rapid cycling by giving you antidepressants and pstims without a full complement of moodstablizers fully ramped up first.
The same thing happened to me, 14 years ago. I was misdiagnosed as ADHD and given Ritalin and SSRI's. The two worst things that can be done to a Bipolar patient is to give the patient a pstim and/or an SSRI without moodstabilizers on board FIRST.
As a result, I go through one complete cycle every 15 days consisting of six days of debilitating depression, and nine days of normal mood. My 15-day ultra rapid cycle repeats over, and over, and over, without end. My depressive episodes used to be a lot worse in severity and duration. The treatment of bipolar ultra rapid cycling is VERY difficult.
Even with moodstabilizers, a bipolar patient should not be given an SSRI, and maybe not a pstim. Over time, the pstim will more than likely destabilize the Bipolar II patient's mood. In the end, the pstim often causes irritability.
Tom, if it is okay with you, I want to follow up and give you some free screening tests tomorrow or in the next few days. Also, I will try with all my heart to convince you to pay about $80 to take a very in depth test.
> OXC has a short half-life and "wears off" within a couple hours, the active metabolite is what allows for the usual twice-daily dosing.
Not true, Tom. The half life of the parent is 2 hours, but the half life of the pharmacologically active 10-monohydroxy metabolite is nine hours. See the Pharmacokinetics section on page 2.
http://www.pharma.us.novartis.com/product/pi/pdf/trileptal.pdf
-- Ron
dx: Bipolar II with ultra rapid cycling, and mild OCPD
600 mg/day Trileptal
200 mg/day Lamictal
500 mg/day Keppra
90 mg/day Nardil3.75 mg/day Deplin (taken with 2500 mcg/day of sublingual methyl B-12, and 12.5mg/day of sublingual P-5-P)
35 ml of Calsons Bottled Fish Oil
100 mg/day phosphatidylserene
Centrum Chewable Multi-vitamins; Only 100% of all the usual vitamins
2000 IU Vitamin E
850 mg/day of Mg 212% of RDA (as 5 grams of Mg Malate).
Dark therapy via LowBlueLight glasses (When I remember)
Whats next to add:25 mg/day agomelatine (if my p-doc wakes up and smells the roses due to my submitted research) {Valdoxan}
300 mg/day of lithum carbonate
CoQ10
NAC, + 8 to 10 glasses of water, + Acetyl-L-Carnitine, + Alpha-Lipoic Acid, + Vitamin C
GTF Chromium
Cromium Picolinate
Cinnamon
Posted by SLS on July 3, 2010, at 6:08:15
In reply to Re: MAOI + trileptal/ tegretol -- anybody?! » tom2228, posted by Ron Hill on July 3, 2010, at 3:23:27
I believe the contraindication involving Tegretol rests upon the nature of its molecular structure. It is tricyclic. It has nothing to do with its pharmacology.
- Scott
---------------------------------
J Clin Psychiatry. 1995 Oct;56(10):471-5.
Addition of monoamine oxidase inhibitors to carbamazepine: preliminary evidence of safety and antidepressant efficacy in treatment-resistant depression.Ketter TA, Post RM, Parekh PI, Worthington K.
Biological Psychiatry Branch, National Institute of Mental Health, Bethesda, Md. 20892, USA.
AbstractBACKGROUND: Depression is often resistant to treatment with mood stabilizers. The antidepressant effects of carbamazepine can be potentiated by lithium supplementation, but some patients fail to respond to the combination. Although monoamine oxidase inhibitors (MAOIs) appear useful in atypical and bipolar depressions, concerns have been raised regarding safety and pharmacokinetic interactions when they are combined with carbamazepine. METHOD: Ten inpatients (7 bipolar, 3 unipolar) with refractory DSM-III-R major depression, also resistant to double-blind treatment with carbamazepine, plus lithium augmentation in 8, received double-blind MAOI augmentation (phenelzine in 4, tranylcypromine in 6). RESULTS: All 10 patients tolerated the addition of an MAOI well, and mean self-rated side effect scores did not change significantly. Four of 10 patients improved substantially and became euthymic, allowing discharge from hospital on the carbamazepine +/- lithium plus MAOI combination. These 4 patients improved in spite of prior inadequate responses to the same MAOI without carbamazepine and carbamazepine without an MAOI. CONCLUSION: This preliminary evidence suggests that the addition of MAOIs to carbamazepine +/- lithium may be well tolerated, may not affect carbamazepine and lithium pharmacokinetics, and may provide relief of refractory depressive symptoms in some patients. Further studies are needed to establish the safety and efficacy of combining carbamazepine with MAOIs.
Posted by ed_uk2010 on July 3, 2010, at 7:59:14
In reply to Re: MAOI + trileptal/ tegretol -- anybody?!, posted by SLS on July 3, 2010, at 6:08:15
>I believe the contraindication involving Tegretol rests upon the nature of its molecular structure. It is tricyclic. It has nothing to do with its pharmacology.
Yep, it's not a 'real' contraindication.
Posted by tom2228 on July 3, 2010, at 12:16:08
In reply to Re: MAOI + trileptal/ tegretol -- anybody?!, posted by ed_uk2010 on July 3, 2010, at 7:59:14
Thanks SLS, I saw that abstract before and referred my doc to it when we were discussing the safety of the combo.. Ya I originally thought the whole "structurally related to tricyclics" thing was a BS contraindication. But I did further research to be sure, and it turns out the risk of serotonin syndrome is not completely unfounded ... oxcarbazepine IS serotonergic (along with carbamazepine, you can find that on pub med also). Releasing agent to be specific, and I can definitely "feel" the serotonin -- I've been on 19 meds, I'm pretty sure I know what 5-HT feels like!
----------------------------------------------
http://www.ncbi.nlm.nih.gov/pubmed/16139430
Hippocampal dopamine and serotonin elevations as pharmacodynamic markers for the anticonvulsant efficacy of oxcarbazepine and 10,11-dihydro-10-hydroxycarbamazepine.
Abstract
We recently showed that dopamine (DA) and serotonin (5-HT) exert anticonvulsant effects against limbic seizures in rats mediated by hippocampal D(2) and 5-HT(1A) receptor stimulation. For exogenously administered monoamines, anticonvulsant activity was only observed following 70--400% and 80--350% increases in baseline levels for dopamine and serotonin, respectively. The aim of the present microdialysis study was to investigate whether oxcarbazepine and its active metabolite, 10,11-dihydro-10-hydroxycarbamazepine (MHD) promote the release of hippocampal monoamines. Initially, concentration-response experiments were performed. Different concentrations of both compounds were perfused into the hippocampus via the microdialysis probe and tested for their effects on extracellular monoamine levels and anticonvulsant properties against pilocarpine-evoked seizures in rats. Anticonvulsant activity was always accompanied by significant increases in dopamine and serotonin levels. The anticonvulsant threshold concentrations for oxcarbazepine (100 microM) and 10,11-dihydro-10-hydroxycarbamazepine (250 microM) were associated with, respectively, 140 and 205% increases in hippocampal dopamine and 288 and 176% increases in serotonin concentrations. Co-perfusion of these anticonvulsant threshold concentrations for both compounds either with a selective D(2) or 5-HT(1A) antagonist abolished all anticonvulsant effects. This study shows that oxcarbazepine and 10,11-dihydro-10-hydroxycarbamazepine exert important monoamine promoting effects that, at least partly, contribute to the anticonvulsant mechanism of action of these compounds. The effects on dopamine and serotonin levels are therefore proposed as pharmacodynamic markers for the anticonvulsant activity of these compounds. These pharmacodynamic markers are here shown to be useful for the selection of anticonvulsant threshold concentrations of oxcarbazepine and 10,11-dihydro-10-hydroxycarbamazepine.
Posted by tom2228 on July 3, 2010, at 12:55:38
In reply to Re: Oxcarbazepine (Trileptal) + MAOIs (sort of urgent) » tom2228, posted by Ron Hill on July 3, 2010, at 5:21:39
> > So here's the story, I've got ADHD, social anxiety, and some sort of bipolar, I suspect cyclothymia. I started cycling some time in childhood but I can't pinpoint when.. I'm 18 now and the cycling has gotten more and more rapid .. from months to weeks and days at one point. Heavy weed smoking and all the antidepressants and stimulants (I've been on 18 meds and many more combos) have probably contributed to this, though it could be the natural progression of the disorder too.
> -------------------
>
> Tom, I do not know you, so I run the risk of coming off as a know-it-all jacka*s. It is currently in the middle of the night, so forgive me for being blunt.
>
> You are Bipolar II. And, your p-docs have induced your rapid cycling by giving you antidepressants and pstims without a full complement of moodstablizers fully ramped up first.
>
> The same thing happened to me, 14 years ago. I was misdiagnosed as ADHD and given Ritalin and SSRI's. The two worst things that can be done to a Bipolar patient is to give the patient a pstim and/or an SSRI without moodstabilizers on board FIRST.
>
> As a result, I go through one complete cycle every 15 days consisting of six days of debilitating depression, and nine days of normal mood. My 15-day ultra rapid cycle repeats over, and over, and over, without end. My depressive episodes used to be a lot worse in severity and duration. The treatment of bipolar ultra rapid cycling is VERY difficult.
>
> Even with moodstabilizers, a bipolar patient should not be given an SSRI, and maybe not a pstim. Over time, the pstim will more than likely destabilize the Bipolar II patient's mood. In the end, the pstim often causes irritability.
>
> Tom, if it is okay with you, I want to follow up and give you some free screening tests tomorrow or in the next few days. Also, I will try with all my heart to convince you to pay about $80 to take a very in depth test.
>
> > OXC has a short half-life and "wears off" within a couple hours, the active metabolite is what allows for the usual twice-daily dosing.
>
> Not true, Tom. The half life of the parent is 2 hours, but the half life of the pharmacologically active 10-monohydroxy metabolite is nine hours. See the Pharmacokinetics section on page 2.
>
> http://www.pharma.us.novartis.com/product/pi/pdf/trileptal.pdf
>
> -- Ron
>
> dx: Bipolar II with ultra rapid cycling, and mild OCPD
>
> 600 mg/day Trileptal
> 200 mg/day Lamictal
> 500 mg/day Keppra
> 90 mg/day Nardil
>
> 3.75 mg/day Deplin (taken with 2500 mcg/day of sublingual methyl B-12, and 12.5mg/day of sublingual P-5-P)
> 35 ml of Calsons Bottled Fish Oil
> 100 mg/day phosphatidylserene
> Centrum Chewable Multi-vitamins; Only 100% of all the usual vitamins
> 2000 IU Vitamin E
> 850 mg/day of Mg 212% of RDA (as 5 grams of Mg Malate).
> Dark therapy via LowBlueLight glasses (When I remember)
>
>
> Whats next to add:
>
> 25 mg/day agomelatine (if my p-doc wakes up and smells the roses due to my submitted research) {Valdoxan}
> 300 mg/day of lithum carbonate
> CoQ10
> NAC, + 8 to 10 glasses of water, + Acetyl-L-Carnitine, + Alpha-Lipoic Acid, + Vitamin C
> GTF Chromium
> Cromium Picolinate
> Cinnamon
>
>
>
>
>First of all thanks Ron, it's good to know you've combined that much Nardil with trileptal w/ no problems... Glad that it works for you! I'm only on 20mg Parnate (today is day 10), so I don't think it should be much of an issue. And the trileptal is very low, too low I think, probably adding another 75mg in for a total of 225.. but can't decide whether to do 150 + 75 or 75 TID.
So I'm not really worried anymore, just worried about getting the doses right.. It's tricky when you're using low doses (trileptal) because it doesn't last long enough for BID, but TID is annoying with the ups and downs. Which is related to the parent drug/ metabolite thing happening.
What was not true about what I said? When I said OXC I was referring to the parent compound itself having the short half life, not the whole med metabolites included. OXC itself as the parent has a different feel (feels stronger on the serotonin and dopamine) and "wears off" after a couple hours, and the 10-MHD is what allows Trileptal to be BID.
I've been experimenting seeing whether it's better to stagger the trileptal and parnate , taken together all that serotonin at once makes me sluggish.. What's your take on this Ron?
What makes you think BP II and not cyclothymia? And does mixed episodes on antidepressants (I'm not really sure if I've had them unmedicated) make me BP I then?
I have always cycled rapidly even before meds.. hypomanias (a lot less frequent) never lasted longer than a few weeks. I would cycle between relative normality and depression a couple times a season.. but there's always been some chronic mild depression even in times of stability.. had a messed up childhood. I definitely have had major depressive episodes, but they are rare these days. When I cycle down it is usually to a dysthymic state. Haven't seen much of the hypomania for a while now, that's probably the trileptal doing its job. But I do get in these agitated states where which seem to be related to my cycle -- would you call that hypomania, or mixed, or something else?
But yes since meds things have sped up a lot, and was the worst while being a heavy weed smoker + stimulants.. cycles just like you describe but WEEKLY, that was pure hell. The depression is no longer severe or long-standing, and the environmental component which was a BIG contribution as a kid (bad childhood) seems to have gone. It simply comes out of nowhere OR at the slightest irrational trigger.. the psychomotor retardation that defines it makes it near impossible to realize what's going on, to cope, or understand that it is a cycle and will get better. I am just goneBut I am truly ADHD. I've been off my Vyvanse for 2 weeks and I am hurtin' big time.. I really do need a stimulant. The lack of functioning makes my depression and anxiety worse. Add to it that I'm physically restless to the point that it's downright uncomfortable. Ive been using caffeine to deal but it has so many more side-effects than dextroamphetamine, which just works so much better.
Doc appt on Tues I'm gonna talk about adding the Vyvanse back in lower doses.
Other things I've been thinking about is switching to depakote (gaba transaminase inhibitor) or adding some klonopin. Any time i have something GABAergic I feel brought back down to a level of peace that seems to have gone away over the years. I've heard the klonopin + parnate combo is awesome for social anxiety , which I have. Was on vacation this week and with some smirnoff on top of my meds I felt really great.. heh.
sorry this is lengthy again! can't seem to summarize off stims...
Posted by SLS on July 3, 2010, at 13:27:47
In reply to Eh, contraindication not totally structure-related, posted by tom2228 on July 3, 2010, at 12:16:08
Without more information, it is difficult to judge risk. What is the mechanism by which these changes in neurotransmitter concentrations occur? Is there an increase in neuronal receptor or transporter tone, or is there an increase in afferent input from other structures?
There is that one report from 1993. What will you be basing your decision on?
- Scott
Posted by ed_uk2010 on July 3, 2010, at 14:17:21
In reply to Re: Eh, contraindication not totally structure-related » tom2228, posted by SLS on July 3, 2010, at 13:27:47
> Without more information, it is difficult to judge risk.
I agree. There are a small number of reports of safe concomitant use of carbamazepine with phenelzine, tranylcypromine and moclobemide in the medical literature. As far as I can see, there are no reports of serious interactions such as serotonin syndrome.
My overall impression is that it's vital to be cautious when adding most other psych meds to MAOIs. Provided that there is a clear clinical justification for prescribing it, I don't think there is any reason to believe that carbamazepine should be contraindicated . Initial doses should obviously be low and careful monitoring should take place. The main problem with the carbamazepine + MAOI combination is probably medico-legal, due to the warning on the package insert. In my opinion, an initial test dose of 50mg carbamazepine would be prudent.
Ed
Posted by tom2228 on July 5, 2010, at 23:23:18
In reply to Re: Eh, contraindication not totally structure-related » tom2228, posted by SLS on July 3, 2010, at 13:27:47
> Without more information, it is difficult to judge risk. What is the mechanism by which these changes in neurotransmitter concentrations occur? Is there an increase in neuronal receptor or transporter tone, or is there an increase in afferent input from other structures?
>
> There is that one report from 1993. What will you be basing your decision on?
>
>
> - Scott
> > Without more information, it is difficult to judge risk.
>
> I agree. There are a small number of reports of safe concomitant use of carbamazepine with phenelzine, tranylcypromine and moclobemide in the medical literature. As far as I can see, there are no reports of serious interactions such as serotonin syndrome.
>
> My overall impression is that it's vital to be cautious when adding most other psych meds to MAOIs. Provided that there is a clear clinical justification for prescribing it, I don't think there is any reason to believe that carbamazepine should be contraindicated . Initial doses should obviously be low and careful monitoring should take place. The main problem with the carbamazepine + MAOI combination is probably medico-legal, due to the warning on the package insert. In my opinion, an initial test dose of 50mg carbamazepine would be prudent.
>
> EdScott and Ed, I agree with both of you. I tried my best to search for more information and at least there seems to be no liver enzyme issues between the two.. so nothing pharmacological to worry about. Any pharmacodynamic problems I'd be able to tell (like SS or something).
All I know is that OXC and the active metabolite are serotonin (and DA) releasing agents.. but not sure if that SRA properly involves blocking the 5-HT transporter like MDMA.. which would not be too good. Also I believe the SRA properties are exclusive to the reward center but not sure. Is is possible to get SS from too much 5-HT action in the reward center or does SS result from other brain structures?
A big part of my decision is my doc's confidence. He knows I know a lot about this stuff so he said it's fine as long as I monitor myself, how I'm feeling ya know. His tone and everything gave me the impression that there's nothing to worry about. Also knowing that others have been on the combo with no issues, and that my doses are relatively low.
That's all on paper, ok now to my experience. I haven't noticed anything remotely dangerous. But today I felt the dopamine effect from the 2nd dose of OXC was too strong.. felt like Ritalin which I don't like.
My appointment is actually later today (tuesday) and I'm going to be begging my doc to get back on Vyvanse. Thats if I need to beg lol, I really doubt it, we already touched on it briefly and I really am buggin' out. The stimulating nature of parnate is definitely is not cuttin' it for my ADHD. But the issue is vyvanse also hits the dopamine so I'm afraid that with the trileptal it'll just be too much. And I REALLY need to get back on a stimulant for my sanity so I'm thinking maybe the trileptal just isn't the best idea..
Thinking about depakote or possibly using klonopin as a mood stabilizer, I heard somewhere that it can be. Question about depakote. Being a gaba transaminase inhibitor, is it calming? How does it feel compared to alcohol or benzos? What about cognition, does it f that up?
And what's your take on the klonopin for mood stabilization? It's not so much episode prevention that I need a stabilizer for, it's mostly that naturally my mood through the day is shaky and it feels like something is "not okay" .. mood stabilizers level that out where I'm not thinking about my mood and can simply function. Also stimulants and antidepressants make this unstable mood issue worse// I get overstimulated on stimulants. So I need a stabilizer to benefit from both of those. So might klonopin help?
Thanks for the help guys I could really use it. Finally nearing the end of my meds journey. At this point I understand that I need Vyvanse (my fave stim), a mood stabilizer, and an AD. Just a matter of doses and narrowing down the choices. Maybe a benzo too but too early to tell. But at least I know what's wrong and what needs fixin now!
Posted by Ron Hill on August 15, 2010, at 0:22:05
In reply to Re: Oxcarbazepine (Trileptal) + MAOIs (sort of urgent) » Ron Hill, posted by tom2228 on July 3, 2010, at 12:55:38
> What was not true about what I said? When I said OXC I was referring to the parent compound itself having the short half life, not the whole med metabolites included. OXC itself as the parent has a different feel (feels stronger on the serotonin and dopamine) and "wears off" after a couple hours, and the 10-MHD is what allows Trileptal to be BID.
--------------------------------------What you said is true. Sorry for the confusion. And sorry for the delay in my response.
-- Ron
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