![[dr. bob]](/dr-bob-sm.gif)
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 Erewhonian on December 26, 2011, at 13:39:35
tl;dr Emsam worked (really worked not hypomania) for a period of two weeks, then stopped working. Suspect cause of poop out was insufficient sleep over the two months I was on emsam before it stopped working. I'm sleeping now, thanks to pharmacological help, but despite adequate sleep full effect has not returned over the last 5 months. Been on emsam for a total of 7 months. Will another maoi work?
(Hello. New user. First time, long time.)
The long version:
I've been suffering from atypical depression for (literally) half my life (now aged 28). Also have some (generalized-ish) anxiety and general social anxiety (no panic attacks or acute symptoms), now mostly under control with propranolol and klonopin (both prn, I'm taking as little of the klonopin as possible to avoid cross tolerance with my sleep meds I'm totaling about 1.5mg per week now).
I've previously been on a good number of antidepressants, all at high doses and for at least a couple of months, but I never had one work.
That changed with Emsam. Started with the 6mg patch in the middle of May, going up to 9mg after two weeks. After being on the 9mg for four weeks (so total time on Emsam, regardless of dose, was six weeks at this point) one morning I just realized things were different: no physical fatigue, had motivation, and my default mood was slightly positive.
This glorious victory lasted for two weeks.
Soon after starting the Emsam, the insomnia had kicked in. I was only able to sleep 3 hours at a stretch, then woke up energized without feeling tired again for sometime. I'd nap again in the afternoon for another 2-3 hours. But after more than two months of sleeping 5 or (at most) 6 hours a day it seems the sleep debt demon decided to take away almost all the benefit I was getting from the Emsam (I still have some partial response, limited mostly to helping with the leaden paralysis).
About a month after the antidepressant effect faded my pdoc bumped the emsam up to the 12mg patch and added seroquel to help with sleep. The seroquel helped great with sleep initially, but I adapted quickly to its antihistamine effects and had to keep bumping the dosage.
The pdoc that first prescribed the emsam was overly wary about drug interactions and really didn't feel comfortable prescribing much alongside it, so I changed psychiatrists. The new pdoc changed the seroquel out for ambien cr and ativan.
So, I've been able to sleep now for over 4 months but the emsam isn't giving me anywhere near the effect it had between weeks 6 and 8. I've been on the emsam for more than 7 months total.
Now I want to switch to another maoi, like nardil, but my current pdoc thinks changing between MAOIs won't give me any additional benefit.
So, a couple of questions that I haven't been able to find answers to (maybe my google-fu is weak, but I can't find these asked or answered anywhere else):
1. Does the idea of the insomnia causing the emsam to (mostly) stop working make sense? Has anyone else had something similar happen to them?
2. Is this enough time for longer term brain adjustments to the emsam to have taken effect? Basically, have I given this enough time?
3. Is my current pdoc correct in believing that a different maoi won't be any more effective? I've read some things in medical books and journals that suggest one maoi trial just isn't enough, yet the experiences of his past patients suggest otherwise to him (for whatever it's worth, he is an academic pdoc, and supposedly a skilled psychopharmacologist, though I suspect he's strongly motivated to tell me this because of his fear of oral MAOIs).
Posted by SLS on December 26, 2011, at 14:26:20
In reply to Emsam poop out, a new maoi?, posted by Erewhonian on December 26, 2011, at 13:39:35
> 1. Does the idea of the insomnia causing the emsam to (mostly) stop working make sense?
It is hard to know for certain. It is true that some systemic stressors can cause medication breakthrough. In my own experience, sleep deprivation has not been one of them. It seems likely to me that the Emsam would have pooped-out on you with or without optimal sleep hygeine.
> 2. Is this enough time for longer term brain adjustments to the emsam to have taken effect? Basically, have I given this enough time?
After 4 months, I think you have given Emsam 12mg/24hr enough time so as to evaluate its usefullness as monotherapy.
> 3. Is my current pdoc correct in believing that a different maoi won't be any more effective?
Your pdoc is not correct - but you knew that already.
When treating depression, Emsam will get fewer people well than either Nardil or Parnate. I would not hesitate to try another MAOI, especially if you have already tried multiple reuptake inhibitors.
- Scott
Posted by Erewhonian on December 26, 2011, at 15:06:31
In reply to Re: Emsam poop out, a new maoi? » Erewhonian, posted by SLS on December 26, 2011, at 14:26:20
> > 3. Is my current pdoc correct in believing that a different maoi won't be any more effective?
>
> Your pdoc is not correct - but you knew that already.Yeah, I did know that already. Truthfully, question #1 is the only one I'm really uncertain of.
Question #2 was brought about by something a different pdoc at the same school said. I'm aware that antidepressants can have improved response over the longer term, but I told him I thought I was likely beyond the point of getting any additional improvement. He wasn't sanguine about the possibility, but he held onto it as a chance.
And #3, well, I'm just disappointed, is all. Ok, more than that: after I had a chance to sleep on it, I was pissed at him. A lot of work to find another pdoc willing to prescribe an oral maoi. I'd hoped that an academic pdoc would be different, but turns out they're just as human as every other pdoc.
At least I'm motivated to keep trying. Before the emsam worked, I'd almost given up hope of something working to lift the depression. Now I'm sure SOMETHING will work, eventually.
Posted by Phillipa on December 26, 2011, at 15:26:16
In reply to Re: Emsam poop out, a new maoi? » SLS, posted by Erewhonian on December 26, 2011, at 15:06:31
Sorry about the Emsam but personally I feel that insomnia can lead to depression. Another poster is doing quite well when didn't think it worked with the addition of some other meds. Phillipa
Posted by SLS on December 26, 2011, at 16:47:52
In reply to Re: Emsam poop out, a new maoi? » SLS, posted by Erewhonian on December 26, 2011, at 15:06:31
> At least I'm motivated to keep trying. Before the emsam worked, I'd almost given up hope of something working to lift the depression. Now I'm sure SOMETHING will work, eventually.
Yes.
- Scott
Posted by Christ_empowered on December 26, 2011, at 18:49:17
In reply to Re: Emsam poop out, a new maoi? » Erewhonian, posted by Phillipa on December 26, 2011, at 15:26:16
I dunno man. Parnate?
Posted by williamockham on January 2, 2012, at 11:07:12
In reply to Emsam poop out, a new maoi?, posted by Erewhonian on December 26, 2011, at 13:39:35
I started keeping the patches on a few days...up to 3 at a time (the 9mg has 30mg in the patch, so if absorption is linear, basically 3 9mg patches gives 9 + 6 + 4 = 19mg/day.) Definitely felt a difference vs 9 or 12, although still not nearly as much as Nardil.
No one (AFAIK) has done tyramine pressor tests on higher Emsam doses, so it might make the diet mandatory...maybe to a lesser extent since transdermal leaves gut MAO-A pretty much intact (tested in rats up to absurd doses). If you gotta really watch the diet, and deal with multiple patches in various states of falling off, kinda defeats the benefits of Emsam vs Parnate/Marplan.
Best of luck convincing the pdoc. I've certainly had my share of shy ones with MAOIs..
Posted by Erewhonian on January 2, 2012, at 16:08:28
In reply to Re: Emsam poop out, a new maoi?, posted by williamockham on January 2, 2012, at 11:07:12
> so if absorption is linear
Which it probably isn't. It hasn't been studied, to the best of my knowledge, but the drug manufacturer is always careful to say that it doesn't guarantee a release rate. The things I've read about emsam around the web suggest that most of what is going to be absorbed is absorbed in the first 12 hours.
> No one (AFAIK) has done tyramine pressor tests on higher Emsam doses, so it might make the diet mandatory...maybe to a lesser extent since transdermal leaves gut MAO-A pretty much intact (tested in rats up to absurd doses). If you gotta really watch the diet, and deal with multiple patches in various states of falling off, kinda defeats the benefits of Emsam vs Parnate/Marplan.
Yeah, as far as I know these http://www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4186b2_01_01_somerset-emsam.pdf are THE tyramine pressor studies. The 6mg/24hr and 9mg/24hr were basically non-interfering (seems the advice to adhere to the diet starting at 9mg is CYA). With the 12mg patch it seems a small percentage of people might have slight problems. (The number of people in the study is kinda small). Basically, it's going to vary from individual to individual. But I love one mental image that document paints for me, that of a bunch of scientists trying to force subjects to eat 2lbs of cheddar cheese in 30 minutes.
> Best of luck convincing the pdoc. I've certainly had my share of shy ones with MAOIs..
Thanks. I'm going to start making calls tomorrow. Hopefully I can find a pdoc.
What you said about multiple patches though, it makes me think again about something other than the insomnia that might have caused the poop out. It was an awfully hot summer here (often got 110+ Fahrenheit), which caused me to sweat off some patches. I sometimes also felt sick when I could feel the patch dumping WAY too much selegiline into me because of the heat. Maybe replacing a patch (or on at least one day I can remember, two) plus all that heat was dumping a lot more of the drug into my system. Maybe enough that I became resistant to normal dosing?I dunno. Just wondering. I started discontinuing the emsam about a week ago. I'm expecting any pdoc I can find to give me an oral maoi would want a two-week washout anyway. Plus I'm hoping a clean slate might help the new drug (hell, I've even read that it might restore the effectiveness of the emsam, but I'm not willing to potentially waste the time testing that out)
Posted by williamockham on January 3, 2012, at 13:53:11
In reply to Re: Emsam poop out, a new maoi? » williamockham, posted by Erewhonian on January 2, 2012, at 16:08:28
> > so if absorption is linear
>
> Which it probably isn't. It hasn't been studied, to the best of my knowledge, but the drug manufacturer is always careful to say that it doesn't guarantee a release rate. The things I've read about emsam around the web suggest that most of what is going to be absorbed is absorbed in the first 12 hours.Fig 3 in the Emsam PI seems to indicate it's pretty linear, but maybe I'm reading this wrong.
> But I love one mental image that document paints for me, that of a bunch of scientists trying to force subjects to eat 2lbs of cheddar cheese in 30 minutes.
>Hahaha. Oh you don't want any more cheddar? Have some chicken liver that's been lying around a week...
> What you said about multiple patches though, it makes me think again about something other than the insomnia that might have caused the poop out. It was an awfully hot summer here (often got 110+ Fahrenheit), which caused me to sweat off some patches. I sometimes also felt sick when I could feel the patch dumping WAY too much selegiline into me because of the heat. Maybe replacing a patch (or on at least one day I can remember, two) plus all that heat was dumping a lot more of the drug into my system. Maybe enough that I became resistant to normal dosing?
Huh. You know, every time I went up in dose, I'd get insomnia/physical anxiety for a few days. And every so often I'd get it without any dose increase, for a day or two--might be this same phenomena, as it was also during an occasionally scorching summer.>
> I dunno. Just wondering. I started discontinuing the emsam about a week ago. I'm expecting any pdoc I can find to give me an oral maoi would want a two-week washout anyway. Plus I'm hoping a clean slate might help the new drug (hell, I've even read that it might restore the effectiveness of the emsam, but I'm not willing to potentially waste the time testing that out)
>I waited four days after stopping Emsam; pdoc thought that sufficient to get rid of the selegiline and amphetamine metabolites. "No point in waiting for MAO to regenerate if you're just going to wipe it out again."
Posted by Erewhonian on January 3, 2012, at 17:16:37
In reply to Re: Emsam poop out, a new maoi?, posted by williamockham on January 3, 2012, at 13:53:11
> Fig 3 in the Emsam PI seems to indicate it's pretty linear, but maybe I'm reading this wrong.
Citing actual facts and figures instead of relying on vaguely remembered things you've read on the internet seems like cheating. But yeah, that looks like a nice line from 12 to 24 hours. Since only ~25%-30% is absorbed in 24hrs, there's a decent amount of selegiline left on the patch. But if there's a peak around 4hrs, I'd expect there'd be a valley at some point in the future, right? (Such biopharmaceutics/pharmacokinetics is beyond my knowledge, just horse sense here) Not that it would make a difference to your steady-state plasma levels if you've got a newer patch or two on.
> Huh. You know, every time I went up in dose, I'd get insomnia/physical anxiety for a few days. And every so often I'd get it without any dose increase, for a day or two--might be this same phenomena, as it was also during an occasionally scorching summer.
I wish the effects of heat on the patch were made plainer. I read the PI and Medication Guide before I started EMSAM, but this section somehow escaped my memory:
External Heat: The effect of direct heat applied to the EMSAM patch on the bioavailability of selegiline has not been studied. However, in theory, heat may result in an increase in the amount of selegiline absorbed from the EMSAM patch and produce elevated serum levels of selegiline. Patients should be advised to avoid exposing the EMSAM application site to external sources of direct heat, such as heating pads or electric blankets, heat lamps, saunas, hot tubs, heated water beds, and prolonged direct sunlight.
They should have BOLDED that section. Effect is not merely theoretical. Wish my doctor had been informed enough to mention this.
> I waited four days after stopping Emsam; pdoc thought that sufficient to get rid of the selegiline and amphetamine metabolites. "No point in waiting for MAO to regenerate if you're just going to wipe it out again."
Sounds like a knowledgeable pdoc. I wouldn't place too high a bet on me finding one that won't blindly follow the 14 day washout rule of thumb though.
Yeah, inhibited MAO is inhibited MAO, I would think (at least if it's the same MAO subtype). Most of the difference in the various MAOIs should be due to metabolites (like amphetamines with selegiline and whatever it is that causes the GABA activity of nardil). But I'm trying to play it safe (as far as I can tell from what I read) and maybe restore the response to MAO inhibition if that's what I've developed resistance to. I don't know how likely that is, it seems like doctors usually go from one MAOI trial to another without concern for that. It might be for nothing, or maybe even for ill, I don't know for sure, and I get the sense that no one else really does either. But that's the adventure of psychiatric meds!
Posted by still_looking on January 11, 2012, at 14:45:28
In reply to Re: Emsam poop out, a new maoi? » williamockham, posted by Erewhonian on January 3, 2012, at 17:16:37
I took Emsam for approximately 2.5 years. It's the best antidepressant I have ever taken. I quit though because I too had insomnia (avg. sleep 5.5 - 6 hours vs. 8 without Emsam). I felt that the insomnia was wearing me down. While I was on Emsam I drank large amounts of coffee and ate huge amounts of chocolate. The substances would fairly reliably make me feel good, but I wonder if they eventually contributed to my insomnia and eventual negative returns from the antidepressant.
I have been off Emsam for a year now. It's been sheer hell. I have tried Serzone, Viibryd, Wellbutrin, Celexa and Cymbalta. Between side effects and lukewarm responses, I have found nothing that really works. Before Emsam, the only meds that I had descent responses to were Anafranil (but brutal side effects), Serzone (pooped out after a year), Adderall (worked great for ADHD and depression but eventually couldn't handle the daily ups and downs (felt like a drug addict)). Anyway, not trying to sound too depressing, but I am considering going back to Emsam, insomnia and all.
Not to complicate this, but one final thing. I have been trying to get off Klonopin (1mg for ~7 years). I have been taking it very slowly (months), but it might be interfering with my AD response.
Posted by former poster on January 12, 2012, at 12:00:47
In reply to Re: Emsam poop out, a new maoi?, posted by still_looking on January 11, 2012, at 14:45:28
>Not to complicate this, but one final thing. I have been trying to get off Klonopin (1mg for ~7 years). I have been taking it very slowly (months), but it might be interfering with my AD response.<
I was on Clonazepam 4mg. a day for 15 years and was able to stop. I believe psychological addiction, not physical addiction was the most difficult part of quitting. The most important thing for me was to get out of the anxiety causing situation/s.. I was fortunate because most people are not free to simply quit their job, end a marriage, or cure themselves of a terminal illness.
Posted by still_looking on January 12, 2012, at 17:59:57
In reply to Re: Emsam poop out, a new maoi? » still_looking, posted by former poster on January 12, 2012, at 12:00:47
Thanks "former poster" for your encouraging story. Yes, getting rid of the stressor is best, but not always possible. For me, that means my job, but at 53, with my depressed and anxiety ridden mind, that's not really an option. I am hoping to get back into meditation - it has helped in the past.
Posted by gigantor on October 18, 2012, at 11:06:19
In reply to Emsam poop out, a new maoi?, posted by Erewhonian on December 26, 2011, at 13:39:35
I started Emsam 6mg in July 2012 and felt better literally overnight. Within about ten days, I noticed that in addition to mood improvement (reduced anxiety and depression), all my fibromyalgia symptoms were also DRAMATICALLY reduced. Those include impenetrable fatigue, paraesthesia, brain fog, vision problems, myaglia, joint pain, and tender points. Although I dealt with middle insomnia, I really didn't care because I was up early in the morning and more motivated and productive than I've been since developing fibro. Early on, I had the impression that the dose was too high so I went down to 4.5mg (split a 9mg patch in half). It wasn't as effective so I dealt with feeling a little "buzzy".
But I was laughing again, my libido improved, I was losing weight, and feeling like I had my life AND my body back. I felt like my nightmare was over.
Then out of nowhere, about two weeks ago, I woke up late, and with my old typical morning fibro symptoms. I haven't been able to get myself back to the Emsam benefit since. All my fibro symptoms are coming back. The telltale sign is the vision issue. It's the one thing that can't be attributed to hormones, weather, mood, diet, stress, etc. I'm depressed, anxious, irritable, unmotivated, exhausted, asexual, in pain, and feeling really lousy.
I'm on the 6mg patch and do not want to go up to a higher dose. It seems that going down to 4.5 for awhile (cutting a 9mg patch in half) makes more sense. Then going back up to 6mg which had been an effective dose.
Since I feel the benefit I received is based on the dopaminergic qualities of the drug, is it possible I simply built up a tolerance? This has happened to me with Xanax and I just take a break from it and then my old, tiny dose is effective again. I figure this is the case and reducing for awhile could regenerate some receptors and then I can go back to 6mg. Otherwise I'll just keep increasing until any amount is useless.
I'm now pretty much intolerant of other antidepressants which happens to many people with fibro. (Before fibro, I could tolerate any I tried and they were effective. Now, it's side-effect city with no emotional relief. The same for mood stabilizers and TCAs.)
Posted by Erewhonian on October 21, 2012, at 0:26:20
In reply to Re: Emsam poop out, a new maoi?, posted by gigantor on October 18, 2012, at 11:06:19
Xanax is different. As far as I'm aware, the MAOIs and their effect on dopamine isn't supposed to build up a tolerance. Still, if you feel able and willing to experiment with that, you could try.
Emsam partly metabolizes into amphetamine and methamphetamine, and that might be some of what you've built up a resistance to. It's been too long for me to remember all the details I used to know about Emsam, like the metabolism at different dosages, and at what point it loses selectivity for MAO-B.
Why are you hesitant to increase to 9mg? Are your side-effects at 6mg just barely tolerable?
You might get results from switching to another MAOI, like Nardil or Parnate. Nardil worked for me, and that's why I haven't posted here again until now. Sorry, but guess that's pretty much how these things work once you start to feel better, you don't want to go back and obsess over all this stuff again.
But let me fill you and the rest of the forum in on what's happened since I started this thread ten months ago. Since we had a somewhat similar experience with Emsam this might be relevant for you, though I had atypical depression and no fibro. The literature says good things about MAOIs for treatment resistant atypicals, and I'm another one of those successes.
I tapered off the Emsam and received a referral to a pdoc that wasn't afraid to prescribe Nardil. I quickly titrated up to 60mg (over a week, if I recall correctly) and then, a few days later, it worked. It really, really worked to the extent that I was hypomanic for a couple of days. It's been nine months now, and the depression is still gone. (The effect on the anxiety is a little more uneven, but not the fault of the drug I feel legitimately stressed sometimes as I have to work myself out of the hole this long depression put me in.)
I decreased to 45mg after a couple of months to reduce the side-effects. The low blood pressure and insomnia I was experiencing both improved at this lower dose, without any reduction in anti-depressant effectiveness.
I've found the warnings about the interactions with food to be vastly overstated, but I still remain a little cautious about eating things containing tyramine I'm not accustomed to. Everyone is different, and YMMV on the food issues.
Good luck, keep trying. Seems you're getting close to some lasting success.
Posted by Gigantor on October 21, 2012, at 4:06:54
In reply to Don't know, but Nardil worked for me. » gigantor, posted by Erewhonian on October 21, 2012, at 0:26:20
Thanks for great info! I'm hesitant to increase to 9mg on Emsam mostly because of the dietary restrictions that don't matter so much on 6mg. That and I've already got 3 mo worth of 6mg patches from my mail order pharmacy.
When I started on Emsam, my skin broke out horribly and I "coincidentally" developed extremely low iron anemia and my hair fell out noticeably. Since I've taken iron supplements it's improved and over time so has the acne but I equate these with Emsam and am a little selfish/vain about it, I admit.
Since I last posted, I paid more attention as to where I had been applying my patch. Trying to move it around, I had sometimes put it on the inside/underside of my bicep or on the side of my torso on my bra line. Now that the weather is cooler and I'm more covered, I applied it above my breast on my pec (like the man in the patient insert illustration), and basically back to the obvious locations as shown. I've noticed some mood improvement. It might be too soon to really know but maybe I wasn't absorbing the med when it was in more "creative" places.
Posted by fox87stars on October 27, 2012, at 14:53:43
In reply to Re: Emsam poop out, a new maoi?, posted by gigantor on October 18, 2012, at 11:06:19
I'm sorry to hear about your bad experience. It's general consensus that Emsam is an MAOI "Junior"...maybe it's time for something stronger? I have been on Parnate since 2008 and I can't imagine life without it. I've been on at least 8 antidepressants. When I was put on Parnate it was like fresh air after years in gloom. It's difficult getting accustomed to all the food you cant eat, etc...but if you are depressed enough it's probably worth it. Anyways, I hope you find something that works. Again, Parnate changed my life. Maybe a stronger MAOI will help you too.
Posted by gigantor on October 27, 2012, at 20:04:43
In reply to Re: Emsam poop out, a new maoi?, posted by fox87stars on October 27, 2012, at 14:53:43
Since my last post I've consistently applied the patch in only the locations shown on the patient insert. Mainly, the upper-outer bicep and the pectoral muscle. It seems to have made all the difference! I'll keep it up and see if I maintain the benefit. Thanks for sharing your parnate experience with me. I will certainly keep it in mind.
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.