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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 67. This is the beginning of the thread.
Posted by Brainbeard on October 2, 2010, at 13:06:13
Looking back, I wonder how I got here, but I did: I've arrived at a staggering 187.5-225mg of clomipramine (brand Anafranil actually, for those who care) combined with 50mg fLUVOXamine. It's like climbing a mountain, and it's getting harder to breathe. I experienced some depersonalization that was probably due to (ab)using marijuana - it's a pity that our national pride has become so insanely strong, containing way too much tetrahydracannabinol and way too little cannabidiol - but that's a different thread altogether.
While on a holiday on one of the Dutch wadden-islands, I got back my blood levels after persistent telephonic inquiries: 267 / 184 microgram (?) per milliliter for clomipramine and desmethylclomipramine, respectively. Desmethylcl. is the noradrenergic metabolite. These blood values are theoretically near-perfect: if you look here: http://www.medscape.com/druginfo/monograph?cid=med&drugid=1305&drugname=Clomipramine+Oral&monotype=monograph&secid=9 (second search result, at least at the date of starting this thread), you can see that 'optimal therapeutic response may be obtained in' folks 'with plasma clomipramine concentrations ranging from 100250 ng/mL and plasma desmethylclomipramine concentrations ranging from 230550 ng/mL'.
I had backed down from 225 to 187.5mg because of the depersonalization, but with these near-perfect blood levels I quickly went back to 225mg.
Now I've become ill with the flu, and I'm suffering from pretty bad anxiety. This may be due to having used and discontinued Concerta (methylphenidate) recently. Anxiety hits me hard at work - I work as a call center agent for the Dutch tax telephone. But it also creeps on me as a dread for having to writhe myself through the small and endless tunnels of time.
And then there's the tremor. Shaking hands, shaking legs.. What body part do I have that is not trembling? I feel insecure when walking steps.
And... The weird, raving dreams at night.. I feel exhausted when waking up. I wake up early, and fight to get some extra sleep.. Like back in the days with Paxil..
Because of the flu and the anxiety I have cut back to 187.5mg. I wonder if it is necessary at all to go as high as 225mg, as per my psychiatrist wishes. Or is start-up anxiety a token of approaching relief, as is often the case with the SSRI's?
I do know that if I take Concerta and Ritalin, I leave anxiety far behind. But I also experience hypomanic impulsiveness, egoism and banality.
Would adding Abilify (aripiprazole) be an idea? Plus mirtazapine (Remeron) for better sleep and perhaps less anorgasmia? I so hope that Abilify could turn me into a mean chore-busting machine.
I'm not quite there yet, folks. I had hoped for quicker and dramatic results with clomipramine, but alas.. Maybe someday. Hope I don't die before that day.
And really, I KNOW that Christ Jesus is the ultimate medicine (for those who wondered).
Posted by Phillipa on October 2, 2010, at 13:51:00
In reply to Clomipramine's Tail Is Smashing My Little Future, posted by Brainbeard on October 2, 2010, at 13:06:13
Brainbeard I noticed you are also taking luvox? Low dose. What do you feel you should do? Would a call back to the doc help? Phillipa ps so sorry you have the flu or is it withdrawal from going down on the clormipramine?
Posted by Roslynn on October 2, 2010, at 15:37:18
In reply to Clomipramine's Tail Is Smashing My Little Future, posted by Brainbeard on October 2, 2010, at 13:06:13
Hi Brainbeard,
I'm sorry, I don't have any answers, but I am also on clomipramine--although can't get above 50 mg. It seems to be a strong med! I can relate to you about the shaking...my legs shake and my handwriting is just atrocious now.
Posted by europerep on October 2, 2010, at 15:37:29
In reply to Re: Clomipramine's Tail Is Smashing My Little Future » Brainbeard, posted by Phillipa on October 2, 2010, at 13:51:00
maybe bupropion (wellbutrin) could help, since it is dopaminergic too, but less so than methylphenidate.. and sometimes it relieves sexual side effects too?
as for your national pride :)
you could grow your own, no? or you might do some strain searching, I am sure there are decent, less heavy ones out there.. although, from what I've gathered, sativas aren't good for anxiety..
Posted by Brot on October 3, 2010, at 7:53:43
In reply to Re: Clomipramine's Tail Is Smashing My Little Future, posted by europerep on October 2, 2010, at 15:37:29
Fluvoxamine is a strong enzyme inhibitor (CYP1A2). you shouldnt take it with clomipramine.... if I recall correctly.
Posted by Brainbeard on October 3, 2010, at 8:19:23
In reply to Re: Clomipramine's Tail Is Smashing My Little Future » Brainbeard, posted by Phillipa on October 2, 2010, at 13:51:00
> Brainbeard I noticed you are also taking luvox? Low dose. What do you feel you should do? Would a call back to the doc help? Phillipa ps so sorry you have the flu or is it withdrawal from going down on the clormipramine?
No, there would rather be updrawal than withdrawal at this point.. Doc has already said I'd bite the bullet. Am inclined to make my own decisions. Going up and down only 37.5mg probably won't be anything dramatic for old p-doc. (He's not old, though.)
Posted by Brainbeard on October 3, 2010, at 8:21:29
In reply to Re: Clomipramine's Tail Is Smashing My Little Future, posted by Roslynn on October 2, 2010, at 15:37:18
> Hi Brainbeard,
>
> I'm sorry, I don't have any answers, but I am also on clomipramine--although can't get above 50 mg. It seems to be a strong med! I can relate to you about the shaking...my legs shake and my handwriting is just atrocious now.Ah, a fellow clomipramine popper! It's good to hear I'm not the only one trembling without awe.
It is a strong med indeed. What happens when you go over 50mg?
Posted by Brainbeard on October 3, 2010, at 8:23:55
In reply to Re: Clomipramine's Tail Is Smashing My Little Future, posted by europerep on October 2, 2010, at 15:37:29
> maybe bupropion (wellbutrin) could help, since it is dopaminergic too, but less so than methylphenidate.. and sometimes it relieves sexual side effects too?
>
> as for your national pride :)
> you could grow your own, no? or you might do some strain searching, I am sure there are decent, less heavy ones out there.. although, from what I've gathered, sativas aren't good for anxiety..When the season's right, there will be some outdoor weed available. Growing my own.. Not sure what my wife would think of it. And a lot of work too, I'm afraid. Couple of houses further a neighbour grows hemp just for fun, and the plants (2) smell terrific (lovely).
Bupropion is out of the question for me, since it lowers the seizure threshold and clomipramine carries a risk of seizures in itself.
Posted by Brainbeard on October 3, 2010, at 8:27:53
In reply to Re: Clomipramine's Tail Is Smashing My Little Future, posted by Brot on October 3, 2010, at 7:53:43
> Fluvoxamine is a strong enzyme inhibitor (CYP1A2). you shouldnt take it with clomipramine.... if I recall correctly.
Brot, you're my man. You're absolutely right.
But this is precisely why my p-doc put me on this combination. fLUVOXamine, by strongly inhibiting 1A2, inhibits clomipramine's metabolism, which results in lower levels of the noradrenergic metabolite and higher levels of clomipramine itself (the mother drug), clomipramine being a potent SRI and therefore probably most important for treating OCD. So it's a matter of tweaking, really.
The fact that this p-doc knew all about this favourable interaction made me know for sure he was the right doc for the job.
Posted by Roslynn on October 3, 2010, at 16:26:42
In reply to Re: Clomipramine's Tail Is Smashing My Little Future, posted by Brainbeard on October 3, 2010, at 8:21:29
Hi Brainbeard,
Over 50mg, I get terrible insomnia..
>
> Ah, a fellow clomipramine popper! It's good to hear I'm not the only one trembling without awe.
>
> It is a strong med indeed. What happens when you go over 50mg?
Posted by Brainbeard on October 4, 2010, at 2:17:28
In reply to Re: Clomipramine's Tail Is Smashing My Little Future » Brainbeard, posted by Roslynn on October 3, 2010, at 16:26:42
> Hi Brainbeard,
>
> Over 50mg, I get terrible insomnia..
> >That could be countered, possibly, by adding 25-50mg of nortriptyline, or 10-50mg of amitriptyline. Nortrip would be the safest option. Alternatively, you could add a sleep-promoting antipsychotic like Risperdal.
Posted by g_g_g_unit on October 4, 2010, at 2:57:26
In reply to Re: Clomipramine's Tail Is Smashing My Little Future » Roslynn, posted by Brainbeard on October 4, 2010, at 2:17:28
Hey Brainbeard,
I'm trying to be patient with this med, but likewise am not having the best experience. On 100mg, I experienced insatiable muscle twitching, speech-slurring, sedation and mental confusion.
I've dropped back down to 75mg. The twitching has eased off, thank God, and I can piece together a coherent sentence now, but I'm still having difficulty trying to pin down a suitable dosing time. If I take the drug at night, I experience insomnia and difficulty falling asleep, whereas if I take it in the morning, I'm paradoxically sleepy all day.
No concrete OCD benefits as of yet either.
Posted by Brainbeard on October 4, 2010, at 13:58:36
In reply to Re: Clomipramine's Tail Is Smashing My Little Future » Brainbeard, posted by g_g_g_unit on October 4, 2010, at 2:57:26
G_g_g my comrade, don't give up yet! I'm biting my way through 225 freakin' milligrams of clomipramine and believe me, it's not a day at the beach. Don't see much therapeutic benefit either. But since I got here, I think I must endure for at least six more weeks and see wether clomipramine is the golden drug I have made it out to be. Actually, I'm not experiencing much brain fog anymore, and even the dry mouth seems to have gotten better. Remember, SRI's often need six weeks or more to become effective against OCD.
Posted by Roslynn on October 4, 2010, at 15:30:49
In reply to Re: Clomipramine's Tail Is Smashing My Little Future » Brainbeard, posted by g_g_g_unit on October 4, 2010, at 2:57:26
I'm experiencing the slurred speech as well, with some stuttering. It must be due to my entire med cocktail since I am only on 50mg clomipramine.
Posted by Roslynn on October 4, 2010, at 15:48:43
In reply to Re: Clomipramine's Tail Is Smashing My Little Future » Roslynn, posted by Brainbeard on October 4, 2010, at 2:17:28
Hi Brainbeard,
Thank you for your message. I fear adding nortrip would increase my already terrible dry mouth. (I've taken it before.)
Just for some background, my med combo is Clomipramine 50mg, Prozac 60mg, Seroquel 100mg, lithium 300mg and ativan 2-4 mg as needed. I am desperately trying to get off the seroquel as it causes me a lot of mental confusion.
> That could be countered, possibly, by adding 25-50mg of nortriptyline, or 10-50mg of amitriptyline. Nortrip would be the safest option. Alternatively, you could add a sleep-promoting antipsychotic like Risperdal.
Posted by g_g_g_unit on October 5, 2010, at 0:11:16
In reply to Re: Clomipramine's Tail Is Smashing My Little Future » g_g_g_unit, posted by Brainbeard on October 4, 2010, at 13:58:36
Thanks for the encouragement, Mr Brainbeard! You truly are a pioneer, and I am honored to be trailing in your steps.
One question: I was thinking of asking my GP for a bethanechol script tomorrow, so I can obtain it online. How effective and broad-acting is it in relieving your anticholinergic side-effects? Forgive the revelation, but I suffer from a sensitive stomach as it is, and the constipation caused by the clomipramine is making it difficult to breathe clearly at times. I'm also experiencing chest pains.
It's strange that we are both experiencing sleep disturbances on the drug. One of my prime motivations in trying it was because of its reputed effectiveness against insomnia.
> G_g_g my comrade, don't give up yet! I'm biting my way through 225 freakin' milligrams of clomipramine and believe me, it's not a day at the beach. Don't see much therapeutic benefit either. But since I got here, I think I must endure for at least six more weeks and see wether clomipramine is the golden drug I have made it out to be. Actually, I'm not experiencing much brain fog anymore, and even the dry mouth seems to have gotten better. Remember, SRI's often need six weeks or more to become effective against OCD.
>
>
>
Posted by Roslynn on October 5, 2010, at 10:35:45
In reply to Re: Clomipramine's Tail Is Smashing My Little Future » Brainbeard, posted by g_g_g_unit on October 5, 2010, at 0:11:16
Hi guys,
I just wanted to add that clomipramine has been a stimulating drug for me as well, and it's causing some insomnia. My pdoc was expecting it to be sedating and was very surprised at my reaction to it.
Roslynn
>
> It's strange that we are both experiencing sleep disturbances on the drug. One of my prime motivations in trying it was because of its reputed effectiveness against insomnia.
>
> > G_g_g my comrade, don't give up yet! I'm biting my way through 225 freakin' milligrams of clomipramine and believe me, it's not a day at the beach. Don't see much therapeutic benefit either. But since I got here, I think I must endure for at least six more weeks and see wether clomipramine is the golden drug I have made it out to be. Actually, I'm not experiencing much brain fog anymore, and even the dry mouth seems to have gotten better. Remember, SRI's often need six weeks or more to become effective against OCD.
> >
> >
> >
>
>
Posted by Brainbeard on October 5, 2010, at 10:38:29
In reply to Re: Clomipramine's Tail Is Smashing My Little Future » Brainbeard, posted by Roslynn on October 4, 2010, at 15:48:43
> Hi Brainbeard,
>
> Thank you for your message. I fear adding nortrip would increase my already terrible dry mouth. (I've taken it before.)
>
> Just for some background, my med combo is Clomipramine 50mg, Prozac 60mg, Seroquel 100mg, lithium 300mg and ativan 2-4 mg as needed. I am desperately trying to get off the seroquel as it causes me a lot of mental confusion.
>
>
>Dudette, if you're on 60mg of Prozac, your clomipramine is boosted like a rocket. Your blood levels of desmethylclomipramine, the metabolite working on noradrenaline and mostly responsible for dry mouth and cognitive blurring, are bound to be very high. Desmethylclomipramine gets eliminated through 2D6 enzymes, and Prozac is a major 2D6 inhibitor. So your dose of clomipramine is in fact a very high one. Did you have your blood levels checked? Your doc oughta check on them with this combo.
With 60mg of Prozac, 5-10mg instead of 25-50 of nortriptyline may already be enough for better sleep, since nortriptyline is also metabolized through 2D6.
Posted by Brainbeard on October 5, 2010, at 10:45:39
In reply to Re: Clomipramine's Tail Is Smashing My Little Future » Brainbeard, posted by g_g_g_unit on October 5, 2010, at 0:11:16
Me, a pioneer?! I'm taking a fifty year old drug!! ;)
Yeah, bethanechol, and you may be pleased to hear it, actually works far better for me against constipation than it does for dry mouth. It's superb for constipation. I just wish it would also make me drool, but the effects on dry mouth are subtle rather than dramatic.
Sleep disturbances... Yes, clomipramine inhibits 1A2, the enzyme group that breaks down melatonin, and thereby it could promote sleep. But its SRI can counter deep sleep. Clomipramine is probably too weak a 5HT2A-inhibitor to help out with that. I'm thinking of asking my p-doc to add mirtazapine (Remeron) for better sleep.
Hang in there, brother. This drug is/may be/oughta be/ worth its weight in gold.
Posted by Roslynn on October 5, 2010, at 11:52:38
In reply to 50mg clomipramine is a HIGH dose with 60mg Prozac » Roslynn, posted by Brainbeard on October 5, 2010, at 10:38:29
Brainbeard,
Thank you so much, I didn't realize this. No, my pdoc has not requested blood levels.
The combo was not intentional. My doc put me on clomipramine to try to bridge me over while I stopped Prozac in order to start an MAOI.
The thing is, I felt much better when the clomipramine was added to my cocktail, and I wasn't able to stop the Prozac anyway. So now I am on both those meds and I don't think my doc is thrilled with me. He thinks I'm bipolar and should take less antidepressant meds, not more. Complicated, huh?
Thank you so much for your info. I may ask my doc for 5mg of nortrip, maybe it will help me sleep.
Roslynn
>
> Dudette, if you're on 60mg of Prozac, your clomipramine is boosted like a rocket. Your blood levels of desmethylclomipramine, the metabolite working on noradrenaline and mostly responsible for dry mouth and cognitive blurring, are bound to be very high. Desmethylclomipramine gets eliminated through 2D6 enzymes, and Prozac is a major 2D6 inhibitor. So your dose of clomipramine is in fact a very high one. Did you have your blood levels checked? Your doc oughta check on them with this combo.
>
> With 60mg of Prozac, 5-10mg instead of 25-50 of nortriptyline may already be enough for better sleep, since nortriptyline is also metabolized through 2D6.
>
>
Posted by Brainbeard on October 5, 2010, at 14:30:14
In reply to Re: 50mg clomipramine is a HIGH dose with 60mg Prozac » Brainbeard, posted by Roslynn on October 5, 2010, at 11:52:38
Roslynn, more than welcome, and thank you for clearing that up.
Hm, Prozac is a med known to compromise sleep, so it's the first suspect for your sleep problem.
Couldn't you at least lower your Prozac dose?
You could also move over to a sleep-friendly SSRI like Luvox (fluvoxamine), although then you REALLY would have to have blood levels checked - or tread carefully - since Luvox boosts clomipramine exactly the other way around as does Prozac: it boosts the mother drug, i.e. clomipramine itself, while suppressing the noradrenergic metabolite. Sorry for all this metabolism talk, I'm in this dung too deep. (Sorry for saying 'dung', it's because 'sh*t' is censored.)
Remeron (mirtazapine) could help a lot too, especially if you also fancy becoming fat as an elephant. ;)
Posted by Roslynn on October 5, 2010, at 15:26:17
In reply to Re: 50mg clomipramine is a HIGH dose with 60mg Prozac, posted by Brainbeard on October 5, 2010, at 14:30:14
Hi Brainbeard,
Unfortunately I cannot lower the Prozac dose; I've tried several times and it brings back the depression very quickly.
I really want to get off Seroquel (which I use for sleep) and I'm hoping that my doc will write a script for the 5mg Nortrip. That should help. Weight gain has also been an issue for me with Seroquel.
Thank you for all the info you've given me!
Roslynn
>
> Couldn't you at least lower your Prozac dose?
>
> You could also move over to a sleep-friendly SSRI like Luvox (fluvoxamine), although then you REALLY would have to have blood levels checked - or tread carefully - since Luvox boosts clomipramine exactly the other way around as does Prozac: it boosts the mother drug, i.e. clomipramine itself, while suppressing the noradrenergic metabolite. Sorry for all this metabolism talk, I'm in this dung too deep. (Sorry for saying 'dung', it's because 'sh*t' is censored.)
>
> Remeron (mirtazapine) could help a lot too, especially if you also fancy becoming fat as an elephant. ;)
Posted by Brainbeard on October 5, 2010, at 15:42:26
In reply to Re: 50mg clomipramine is a HIGH dose with 60mg Prozac » Brainbeard, posted by Roslynn on October 5, 2010, at 15:26:17
Roslynn, if I gave a dollar to every person appreciating my comments, I would still be a rich man.
Problem getting a script for 5mg nortriptyline is that most doctors will think you're nuts and such a dose can only be placebo. A friend of mine started taking 25mg of nortriptyline for sleep at my advise and eventually, he got a script, but his doctor's convinced that the effect is totally in his head.
These people can only think in big numbers. My p-doc is the same, he's brilliant enough, but the same all the same. (Now that's a lot of same and I know it.) So that creates the situation that he's prescribing me low doses of meds at my request thinking that it won't hurt when it won't help. Who's fooling who, huh?
In my uneducated and totally biased and unfounded opinion, Seroquel is an inferior piece of marketed thin air.
Sleep tight.
Posted by SLS on October 5, 2010, at 16:12:24
In reply to Bethanechol for dry mouth and constipation, posted by Brainbeard on October 5, 2010, at 10:45:39
> Me, a pioneer?! I'm taking a fifty year old drug!! ;)
>
> Yeah, bethanechol, and you may be pleased to hear it, actually works far better for me against constipation than it does for dry mouth. It's superb for constipation. I just wish it would also make me drool, but the effects on dry mouth are subtle rather than dramatic.Bethanechol can also help with urinary retention resulting from the anticholinergic effects of certain antidepressants. It can prevent a trip to the hospital for a catheterization. Ouch.
- Scott
Posted by linkadge on October 6, 2010, at 20:50:05
In reply to Re: Bethanechol for dry mouth and constipation, posted by SLS on October 5, 2010, at 16:12:24
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