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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 18 of 18. This is the beginning of the thread.
Posted by Conundrum on July 15, 2010, at 23:21:24
I have been taking Mirtazapine since June 25. On June 29th I added prozac. On July 4 I noticed a big increase in my desire to play music. A few days later this went away. I know that feeling wasn't from prozac, since it doesn't work that soon or that well. Mirtazapine directly blocks some serotonergic receptors. Prozac indirectly activates those same receptors. Could it be that the opposing actions is what made the motivation from mirtazapine go away? Or is it that quick mirtazapine poop out? I have heard that it poops out fast like in a month or something. My pdoc said thats a good sign that it will work better later on at a higher dose. When the receptors down regulate from prozac will the drugs work better?
I'm wondering if I should have restarted prozac while starting mirtazapine. Maybe I should stop taking prozac and just stay at 30 mgs mirtazapine for awhile. Anyone have any ideas or experience with adding an SSRI to mirtazapine in that order?
I'm not sure if I should stay on the prozac and increase the mirtazapine later, or just let the prozac leave my system and then increase the mirtazapine, so I know what is doing what.
Posted by Phillipa on July 16, 2010, at 0:08:13
In reply to Need some advise, posted by Conundrum on July 15, 2010, at 23:21:24
Five weeks dont they say for prozac to leave your system? Prozac was extremly activating for me. Couldn't tolerate it. I'd think that would be uplifting? Phillipa
Posted by Hombre on July 16, 2010, at 1:17:21
In reply to Need some advise, posted by Conundrum on July 15, 2010, at 23:21:24
Hi Conundrum,
I started 15mg mirtazapine after 2 weeks of prozac. Granted, there were about 3-4 days between ending prozac (couldn't tolerate it) and starting mirtazapine. After the initial knockout, I felt better than I'd felt in a long time, each day getting better than the rest. After 10 days, however, it started to fade fast. I think this had a lot to do with smoking at the time, which increases one of the cytochrome enzymes that metabolizes mirtazapine.
I upped the mirtazapine to 30 then 45mg, but never got the feeling back. I even tried adding 10mg prozac a day, but that still felt crappy.
Adding 75mg venlafaxine really got things going. I had a strong if not somewhat rocky response to venlafaxine previously. We brought mirtazapine back down to 30mg, but it felt weird trying to bring it down any lower than that. Insomnia, some anxiety, and lack of focus were still a problem with this combo, but the depression was gone.
Every dose increase of mirtazapine resulted in a few days of higher energy, some anxiety/butterflies, and constipation. To me that suggests some NE-type action, but I'd get used to it in a few days. I finally stabilized at 30mg mirtazapine/150mg venlafaxine. A mild form of California Rocket Fuel. I started taking herbs for the side effects and got some nice effects in terms of metabolism and drive.
I suppose you could consider adding an SNRI or even buproprion, but as you know it's a game of roulette. Keep spinning that wheel, though.
Good luck,
Hombre
Posted by g_g_g_unit on July 16, 2010, at 2:51:40
In reply to Need some advise, posted by Conundrum on July 15, 2010, at 23:21:24
these days, i'm more of a fan of a one-thing-at-a-time approach. i know the desire to get a response, coupled with uncertainty about the future, can generate undue haste in making decisions, so it might be better if you just deal with the mirtazapine for now. do you think your doc would be willing to prescribe an NRI like desipramine to augment the mirtazapine? i saw you recommend the combo to another poster and it sounded like a potentially good idea?
Posted by linkadge on July 16, 2010, at 6:27:00
In reply to Need some advise, posted by Conundrum on July 15, 2010, at 23:21:24
Usually I get the desire to play piano when initiating SSRI's. The effect never much lasts.
I never seem to be able to recreate the first few days on an SSRI.Linkadge
Posted by Conundrum on July 16, 2010, at 8:53:11
In reply to Need some advise, posted by Conundrum on July 15, 2010, at 23:21:24
@ G-unit: perhaps you are right, since like phillipa said it takes a long time to get prozac out of your system, and lets suppose that combo didn't work and I wanted to find out if mirtazapine alone would work. I would have to weight 5 weeks and my Pdoc would probably be impatient as well. I'm sure she wouldn't say it would take that long, but I can feel it based on some, well how shall i say it... factors! Also, one could argue the drugs have opposing actions.
@Hombre: You know I took desvenlafaxine and had an initial good response, but then it went away and felt more like an SSRI. Perhaps adding that to remeron would help since Remeron only really increases norepinephrine and dopamine. Venlafaxine would keep those transmitters around and stop any negative side effects from serotonin.
@ GGG-unit: you know that is a good idea, but my pdoc doesn't seem too crazy about TCAs. She told me desipramine could make me constipated, well maybe I should tell her I generally have kinda the opposite problem, and emphasize the joint pain, which TCAs help with. Also adding it to remeron might have me respond to a lower dose of desipramine.
Hmm still haven't made my freakin mind up. lol
Posted by Conundrum on July 16, 2010, at 18:57:27
In reply to Re: Need some advise, posted by Hombre on July 16, 2010, at 1:17:21
I'm guessing you are not on that combo now? Did the trouble focusing ever get better on that combo? Did you already have trouble focusing before starting the combo?
Posted by Hombre on July 20, 2010, at 16:29:18
In reply to Re: Need some advise » Hombre, posted by Conundrum on July 16, 2010, at 18:57:27
Oh hey, haven't been checking the meds board lately.
I'm still taking venlafaxine and mirtazapine. My living situation is such that it's been like I've been living out of a hotel room for almost a year, so trouble focusing may have more to do with the fact that I'm either cooped up or sort of wandering around outside trying not to spend money on $5 coffees and whatnot.
But for the past 2+ months I've been taking some Chinese herbs to help with energy and lack of drive, and I feel like they've added a lot of calm energy to the mix. Basically they help with the side effects of the venlafaxine, since mirtazapine doesn't really cause side effects for me anymore. I can focus really well for long periods of time and my physical energy is growing along with lots of varied exercise. The exercise is a major catalyst for generating energy, a lack of which can also encourage lack of focus.
I hope that helps.
Posted by jade k on July 20, 2010, at 19:33:37
In reply to Re: Need some advise )) all posters, posted by Conundrum on July 16, 2010, at 8:53:11
Hey Conundrum,
You know I'd be posting if I could help you. I just have no real experience with those meds.
Good Luck!~Jade
Posted by Conundrum on July 21, 2010, at 23:30:16
In reply to Re: Need some advise » Conundrum, posted by Hombre on July 20, 2010, at 16:29:18
I'm glad to hear that the combo is helping along with the herbs and exercises, it sounds like it helps with some of the mental dulling form the drugs.
I'm considering adding an SSRI to mirtazapine if I don't get more benefit at a higher dose. I wonder if it can be combined with parnate?
Posted by Conundrum on July 21, 2010, at 23:30:45
In reply to Re: Need some advise )) all posters » Conundrum, posted by jade k on July 20, 2010, at 19:33:37
No problem. Thanks for the thought though!
Posted by Hombre on July 22, 2010, at 3:18:27
In reply to Re: Need some advise » Hombre, posted by Conundrum on July 21, 2010, at 23:30:16
I wouldn't know about Parnate...do you not tolerate SNRI's well?
Posted by Conundrum on July 22, 2010, at 8:21:58
In reply to Re: Need some advise, posted by Hombre on July 22, 2010, at 3:18:27
I had a lot of joint pain with pristiq, but it did seem to help in the beginning and then stop working as well and felt more like an SSRI. Perhaps cymbalta would be betteer?
Posted by jade k on July 22, 2010, at 8:47:02
In reply to Re: Need some advise » Hombre, posted by Conundrum on July 21, 2010, at 23:30:16
> I'm glad to hear that the combo is helping along with the herbs and exercises, it sounds like it helps with some of the mental dulling form the drugs.
>
> I'm considering adding an SSRI to mirtazapine if I don't get more benefit at a higher dose. I wonder if it can be combined with parnate?Hi Conundrum,
I don't know anything about mirtazapine, but I'm pretty sure you can't add an SSRI to Parnate. SSRI syndrome I believe is the reason. I would check with your pdoc about what can safely be used with Parnate.
~Jade
>
>
Posted by Conundrum on July 22, 2010, at 19:03:48
In reply to Re: Need some advise » Conundrum, posted by jade k on July 22, 2010, at 8:47:02
mirtazapine isn't an SSRI though, it doesn't increase serotonin, but i'll have to ask if there are other interactions.
Posted by inanimate peanut on July 22, 2010, at 20:40:50
In reply to Re: Need some advise » jade k, posted by Conundrum on July 22, 2010, at 19:03:48
I've been told there are no interactions between Remeron and Parnate. There's been no documented cases of reactions with the two used together. There also isn't research that I can find with the 2 used together. So, it depends on how risky your doc likes to be.
Posted by jade k on July 22, 2010, at 20:49:03
In reply to Need some advise, posted by Conundrum on July 15, 2010, at 23:21:24
Parnate and Remeron Drug Interactions - Drugs.com
A Major Drug Interaction exists between Parnate and Remeron. View detailed information regarding this drug interaction.
www.drugs.com/.../parnate-with-remeron-2225-2342-1640-1015.html - CachedI googled the two, Remeron and Parnate
~Jade
Posted by inanimate peanut on July 22, 2010, at 22:33:07
In reply to Re: Need some advise » Conundrum, posted by jade k on July 22, 2010, at 20:49:03
Yeah, that's the natural warning thrown up with MAIOs/ TCAs, too, which are safe if combined correctly. Actually, just going to wikipedia gets us a debate "Mirtazapine and MAOIs are said to be contraindicated by some sources; however, there is no true indication that this is actually the case, and there is no proper literature on the subject warning against the combination whatsoever. Only a single study has mentioned anything significantly important regarding the combination, and they reported that it does not result in any incidence of serotonin-related toxicity.[119] "
Here's the study saying that Remeron and MAOIs together do not lead to serotonin syndrome:
Biological Psychiatry Volume 59, Issue 11, Pages 1046-1051 (1 June 2006)
14 of 21
A Review of Serotonin Toxicity Data: Implications for the Mechanisms of Antidepressant Drug ActionP. Ken Gillman
Received 22 June 2005; received in revised form 9 November 2005; accepted 10 November 2005. published online 06 February 2006.Data now exist from which an accurate definition for serotonin toxicity (ST), or serotonin syndrome, has been developed; this has also lead to precise, validated decision rules for diagnosis. The spectrum concept formulates ST as a continuum of serotonergic effects, mediated by the degree of elevation of intrasynaptic serotonin. This progresses from side effects through to toxicity; the concept emphasizes that it is a form of poisoning, not an idiosyncratic reaction. Observations of the degree of ST precipitated by overdoses of different classes of drugs can elucidate mechanisms and potency of drug actions. There is now sufficient pharmacological data on some drugs to enable a prediction of which ones will be at risk of precipitating ST, either by themselves or in combinations with other drugs. This indicates that some antidepressant drugs, presently thought to have serotonergic effects in animals, do not exhibit such effects in humans. Mirtazapine is unable to precipitate serotonin toxicity in overdose or to cause serotonin toxicity when mixed with monoamine oxidase inhibitors, and moclobemide is unable to precipitate serotonin toxicity in overdose. Tricyclic antidepressants (other than clomipramine and imipramine) do not precipitate serotonin toxicity and might not elevate serotonin or have a dual action, as has been assumed.
Thanks to Jade for encouraging me to research to find the article I need to show to my doc when I ask to try Remeron-- I hadn't fuly looked into the issue yet :-). I'll also have to post this for Willful who was specifically concerned for the recent US articles on the safety on MAOI/TCA combos.
This is the end of the thread.
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