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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 19 of 19. This is the beginning of the thread.
Posted by ChicagoKat on October 1, 2012, at 10:04:51
Hi Jono, I hope you are feeling better.
You gave me a recommendation for a starting dose of Nortryp. and how slowly to go up on it and like a dolt I forgot to write it down and I can't find the post.
I wonder if you could give me the info again. Just to remind you, I will be starting Nardil, and titrating it to a dose of 45mg/day, and I want to add Notryp. to it per you and Scottt's advice. And my pdoc's blessing. But like I said, he's never done such a thing before, though he does know it is done, and wants info on how to go about it. He trusts my judgement in thinkingg you guys reallly know what you are talking about so will go with your recommendation.
I am seeing him tomorrow ( my med wash is almost over, yay!), so I will need the info by tomorrow afternoon if you are able.
Thanks so much, and again, I'm sorry to bother you with this.
Kat
ps if you could also tell me the final dosage you think I should be on that would be great. keep in mind, i'm pretty sensitive to meds, so a lower dose would prob be better. thanks again, and if there is ever anything i can do for you, don't hesitate to ask.
Posted by ChicagoKat on October 1, 2012, at 11:53:04
In reply to Jono, sorry to bother you, but need rpt info, posted by ChicagoKat on October 1, 2012, at 10:04:51
No worries, Jono! I found the relevant posts and now have the info safely stored in my poor defective brain. One of the posts, regarding starting dose and titration rate had actually been Scott's, so I hope that clears up any confusion if you had any. And thanks Scott!
Thanks again Jono!!!!!!!!!!! You're the best :)
Posted by SLS on October 1, 2012, at 15:33:17
In reply to Jono, sorry to bother you, but need rpt info, posted by ChicagoKat on October 1, 2012, at 10:04:51
> if you could also tell me the final dosage you think I should be on that would be great.
I am missing something. Why are you limiting yourself to 45 mg/day Nardil? Was ataxia a problem?
I still like the idea of your starting nortriptyline at 10 mg/day taken at night. You might wish to stay at that dosage for 5 - 7 days. You could then increase to 25 mg/day taken at night. You can either wait there for 2 - 3 weeks or proceed to 50 mg/day after 1 week. You are going to need to use your judgment based upon how you feel and how well you are tolerating side effects. People who are slow metabolizers usually settle on a dosage of 50 - 75 mg/day. Rapid metabolizers often need 150 mg/day. It is almost as if there were no middle ground. Fortunately, you can take blood tests to help guide you on nortriptyline dosage. I like to split my dose to three times a day. You can just as easily continue to take 75 mg at night. If you need to go higher, I would split it.
I would think about starting Nardil at 7.5 mg/day and move up to 15 mg/day after 5 - 7 days. I would go from 15 mg/day to 30 mg/day after 1 week. Thereafter, you can go up by 15 mg every 2 - 3 weeks. This is a rather gradual titration schedule.
These are only guidelines that seem appropriate based upon my experience with these two drugs. Increasing the dosage of either drug too quickly might lead to intolerable hypotension, urinary retention, and other autonomic side effects. With time, things like dry mouth, constipation, sweating, and blurred vision should dissipate if they do occur. They may not.
For me, I need full therapeutic dosages of both the MAOI and the TCA in order for the combination to be effective. Just because the two drugs are being administered together doesn't mean that you can use lower dosages of each. I hope you don't suffer too much while you are going through the dosage discovery process.
I kind of like the idea of your going to Nardil 45 mg/day and nortriptyline 50 mg/day as your initial target dosages. It might take 3 weeks to respond to this. If you don't respond, I would then move the nortriptyline to 75 mg/day if you are tolerating the drug. After two weeks at this dosage, you could then get a blood test. If you are in the therapeutic range, you could then continue for another 1 - 2 weeks. If you are below the therapeutic range and you are tolerating it, you will need to consider increasing the nortriptyline by 25 mg every 2 weeks and get blood levels. If there is no response to a therapeutic dosage of nortriptyline as per blood tests, it would make sense to increase the Nardil to 60 mg/day if you can tolerate it. Again, I remember someone having an ataxia problem with higher dosages of Nardil. I thought it was you, but it is likely that my memory fails me.
I would be curious to see what you and your doctor come up with.
Good luck.
- Scott
Posted by ChicagoKat on October 1, 2012, at 16:55:05
In reply to Re: Jono, sorry to bother you, but need rpt info » ChicagoKat, posted by SLS on October 1, 2012, at 15:33:17
> > if you could also tell me the final dosage you think I should be on that would be great.
>
> I am missing something. Why are you limiting yourself to 45 mg/day Nardil? Was ataxia a problem?
>
> I still like the idea of your starting nortriptyline at 10 mg/day taken at night. You might wish to stay at that dosage for 5 - 7 days. You could then increase to 25 mg/day taken at night. You can either wait there for 2 - 3 weeks or proceed to 50 mg/day after 1 week. You are going to need to use your judgment based upon how you feel and how well you are tolerating side effects. People who are slow metabolizers usually settle on a dosage of 50 - 75 mg/day. Rapid metabolizers often need 150 mg/day. It is almost as if there were no middle ground. Fortunately, you can take blood tests to help guide you on nortriptyline dosage. I like to split my dose to three times a day. You can just as easily continue to take 75 mg at night. If you need to go higher, I would split it.
>
> I would think about starting Nardil at 7.5 mg/day and move up to 15 mg/day after 5 - 7 days. I would go from 15 mg/day to 30 mg/day after 1 week. Thereafter, you can go up by 15 mg every 2 - 3 weeks. This is a rather gradual titration schedule.
>
> These are only guidelines that seem appropriate based upon my experience with these two drugs. Increasing the dosage of either drug too quickly might lead to intolerable hypotension, urinary retention, and other autonomic side effects. With time, things like dry mouth, constipation, sweating, and blurred vision should dissipate if they do occur. They may not.
>
> For me, I need full therapeutic dosages of both the MAOI and the TCA in order for the combination to be effective. Just because the two drugs are being administered together doesn't mean that you can use lower dosages of each. I hope you don't suffer too much while you are going through the dosage discovery process.
>
> I kind of like the idea of your going to Nardil 45 mg/day and nortriptyline 50 mg/day as your initial target dosages. It might take 3 weeks to respond to this. If you don't respond, I would then move the nortriptyline to 75 mg/day if you are tolerating the drug. After two weeks at this dosage, you could then get a blood test. If you are in the therapeutic range, you could then continue for another 1 - 2 weeks. If you are below the therapeutic range and you are tolerating it, you will need to consider increasing the nortriptyline by 25 mg every 2 weeks and get blood levels. If there is no response to a therapeutic dosage of nortriptyline as per blood tests, it would make sense to increase the Nardil to 60 mg/day if you can tolerate it. Again, I remember someone having an ataxia problem with higher dosages of Nardil. I thought it was you, but it is likely that my memory fails me.
>
> I would be curious to see what you and your doctor come up with.
>
> Good luck.
>
>
> - Scott
>Yes Scott, it was me who had the ataxia problem. Thanks for your dosage recommendations. But I think I will go up faster on the Nardil (only) b/c I was titrated to 60mg/day within a week the first time I took it and had no problem, except the eventual ataxia...but I had the very good side effect from the rapid titration of my anxiety disappearing almost overnight. Thanks again.
Kat
Posted by jono_in_adelaide on October 1, 2012, at 17:52:29
In reply to Re: Jono, sorry to bother you, but need rpt info » SLS, posted by ChicagoKat on October 1, 2012, at 16:55:05
I'm a bit more agressive than Scott - I'd start on nardil 15mg/day and nortriptyline 25mg at bedtime, and increase slowly to 45mg of nardil a day (if thats your limit) and 75mg of nortriptyline at bedtime.
How quickly you increase needs to be guided by what happens, but I'd think between 1 and 2 weeks would be an adequate time frame for most people...... having said that, scotts approach would definatly lead to less side effects
Some people find nortriptyline quite sedating, other hardly at all, I guess which group you fall into will guide you on this.
Posted by jono_in_adelaide on October 1, 2012, at 18:18:44
In reply to Re: Jono, sorry to bother you, but need rpt info, posted by jono_in_adelaide on October 1, 2012, at 17:52:29
Sorry, that should read "I'd start on 15mg of nardil and 25mg of nortriptyline"
I'd then aim to be at your full dose (nardil 45mg and nortriptyline 75mg) after 1-2 weeks, depending on side effects
Some people find nortriptyline very sedating, others hardly at all - let how you're feeling be your guide to the dose increases.
Scotts approach has a lot of merit - you've been ill for years, and extra week for dode titalation isnt going to make much difference in the big picture
Best of luck
J
Posted by phillipa on October 1, 2012, at 18:42:08
In reply to Re: Jono, sorry to bother you, but need rpt info » SLS, posted by ChicagoKat on October 1, 2012, at 16:55:05
Kat if my memory isn't failing didn't you once write that you are a tiny female barely l00lbs. If not you apologies. Phillipa
Posted by ChicagoKat on October 1, 2012, at 19:32:08
In reply to Re: Jono, sorry to bother you, but need rpt info, posted by jono_in_adelaide on October 1, 2012, at 18:18:44
> Sorry, that should read "I'd start on 15mg of nardil and 25mg of nortriptyline"
>
> I'd then aim to be at your full dose (nardil 45mg and nortriptyline 75mg) after 1-2 weeks, depending on side effects
>
> Some people find nortriptyline very sedating, others hardly at all - let how you're feeling be your guide to the dose increases.
>
> Scotts approach has a lot of merit - you've been ill for years, and extra week for dode titalation isnt going to make much difference in the big picture
>
> Best of luck
>
> JThanks Jono...I tend to agree with you, I'd like a faster approach and I'm sure I can tolerate it..I tend to adjust to meds pretty quickly (sorry Scott!) Plus, opposite to what you've said, I've been suffering for such a long time, I want the suffering to end sooner rather than later! I'll let you know how it goes. Thanks again.
Kat
Posted by ChicagoKat on October 1, 2012, at 19:33:31
In reply to Re: Jono, sorry to bother you, but need rpt info » ChicagoKat, posted by phillipa on October 1, 2012, at 18:42:08
> Kat if my memory isn't failing didn't you once write that you are a tiny female barely l00lbs. If not you apologies. Phillipa
Oh, how I wish Phillipa! You made me smile :)
Posted by phillipa on October 1, 2012, at 21:51:05
In reply to Re: Jono, sorry to bother you, but need rpt info » phillipa, posted by ChicagoKat on October 1, 2012, at 19:33:31
Got that one wrong. Only reason had asked was afraid for a tiny person too high too fast could be bad. Glad I made you smile!!!! Phillipa
Posted by SLS on October 1, 2012, at 22:08:45
In reply to Re: Jono, sorry to bother you, but need rpt info » jono_in_adelaide, posted by ChicagoKat on October 1, 2012, at 19:32:08
> > Sorry, that should read "I'd start on 15mg of nardil and 25mg of nortriptyline"
> >
> > I'd then aim to be at your full dose (nardil 45mg and nortriptyline 75mg) after 1-2 weeks, depending on side effects
> >
> > Some people find nortriptyline very sedating, others hardly at all - let how you're feeling be your guide to the dose increases.
> >
> > Scotts approach has a lot of merit - you've been ill for years, and extra week for dode titalation isnt going to make much difference in the big picture
> >
> > Best of luck
> >
> > J
>
> Thanks Jono...I tend to agree with you, I'd like a faster approach and I'm sure I can tolerate it..I tend to adjust to meds pretty quickly (sorry Scott!)Don't worry about it. From what you wrote earlier in this thread, I was just under the impression that you were extremely med-sensitive. If you can tolerate a more rapid titration, I see no reason why you should not be able to arrive at your target dosages sooner than what I suggested. Just be aware that you will not get the full effects of Nardil right away. Don't be lulled into a false sense of security. It might take a full week for a peak accumulation of monoamine neurotransmitters to occur after a dosage increase. This can produce a delay in the emergence of side effects. I am still concerned about a synergism in the production of hypotension and urinary retention. Otherwise Jono's suggestion is reasonable. Good luck.
- Scott
Posted by ChicagoKat on October 2, 2012, at 8:54:02
In reply to Re: Jono, sorry to bother you, but need rpt info » ChicagoKat, posted by phillipa on October 1, 2012, at 21:51:05
> Got that one wrong. Only reason had asked was afraid for a tiny person too high too fast could be bad. Glad I made you smile!!!! Phillipa
:D
Posted by ChicagoKat on October 2, 2012, at 9:02:33
In reply to Re: Jono, sorry to bother you, but need rpt info » ChicagoKat, posted by SLS on October 1, 2012, at 22:08:45
> > > Sorry, that should read "I'd start on 15mg of nardil and 25mg of nortriptyline"
> > >
> > > I'd then aim to be at your full dose (nardil 45mg and nortriptyline 75mg) after 1-2 weeks, depending on side effects
> > >
> > > Some people find nortriptyline very sedating, others hardly at all - let how you're feeling be your guide to the dose increases.
> > >
> > > Scotts approach has a lot of merit - you've been ill for years, and extra week for dode titalation isnt going to make much difference in the big picture
> > >
> > > Best of luck
> > >
> > > J
> >
> > Thanks Jono...I tend to agree with you, I'd like a faster approach and I'm sure I can tolerate it..I tend to adjust to meds pretty quickly (sorry Scott!)
>
> Don't worry about it. From what you wrote earlier in this thread, I was just under the impression that you were extremely med-sensitive. If you can tolerate a more rapid titration, I see no reason why you should not be able to arrive at your target dosages sooner than what I suggested. Just be aware that you will not get the full effects of Nardil right away. Don't be lulled into a false sense of security. It might take a full week for a peak accumulation of monoamine neurotransmitters to occur after a dosage increase. This can produce a delay in the emergence of side effects. I am still concerned about a synergism in the production of hypotension and urinary retention. Otherwise Jono's suggestion is reasonable. Good luck.
>
>
> - ScottHi Scott, hope you are well.
I do have to tell you that I experienced a complete disappearance of my anxiety within a week of starting Nardil ( and remember, like I told you, it had been ramped up veery fast). I am aware it takes longer, weeks even for the anti-depresant effects to kick in, and at my relatively low dose it may take much longer if ever.
I really appreciate your concern over the autonomic SEs with the combo. With the hypotension especially. I have a BP monitor, and I will use it multiple times through the day. I will also pass on your concern to my pdoc today.
Also, I will smoke LOL..yes, sadly I'm a smoker, but I onlly smoke 2 or 3 a day. It's played hell with my BP up to this point, but with the Nardil and Nortryp., it may be a good thing...a good quick rescue if my BP goes way too low.
But I've been meaning to ask you, to ask you all, actually...do you know of any interactions between smoking and Nardil or Nortryp? I mean like kinetic and metabolic interactions that could lower blood concentrations, that sort of things. I've checked my references and they've mentioned nothing, but I thought I'd pass it by you too.
Thanks!
Kat
Posted by SLS on October 2, 2012, at 13:25:54
In reply to Re: Jono, sorry to bother you, but need rpt info » SLS, posted by ChicagoKat on October 2, 2012, at 9:02:33
> But I've been meaning to ask you, to ask you all, actually...do you know of any interactions between smoking and Nardil or Nortryp? I mean like kinetic and metabolic interactions that could lower blood concentrations, that sort of things. I've checked my references and they've mentioned nothing, but I thought I'd pass it by you too.
There should be no pharmacokinetic interaction between Nardil and nortriptyline.
I reviewed the metabolism of Nardil recently, and I could find no data indicating that cytochrome enzymes are involved. Nor does it seem that Nardil inhibits any. Tricyclics are metabolized by cytochrome enzymes. The main metabolic pathway for Nardil metabolism is actually oxidation via MAO. Nardil inhibits its own metabolism. Nardil is also metabolized via acetylation, albeit to a lesser extent.
- Scott
Posted by jono_in_adelaide on October 2, 2012, at 18:19:16
In reply to Re: Jono, sorry to bother you, but need rpt info » ChicagoKat, posted by SLS on October 2, 2012, at 13:25:54
Scott and I should set up in competition the the Meninger clinic! We coud be rich!
Posted by ChicagoKat on October 2, 2012, at 18:23:40
In reply to Re: Jono, sorry to bother you, but need rpt info » ChicagoKat, posted by SLS on October 2, 2012, at 13:25:54
> > But I've been meaning to ask you, to ask you all, actually...do you know of any interactions between smoking and Nardil or Nortryp? I mean like kinetic and metabolic interactions that could lower blood concentrations, that sort of things. I've checked my references and they've mentioned nothing, but I thought I'd pass it by you too.
>
> There should be no pharmacokinetic interaction between Nardil and nortriptyline.
>
> I reviewed the metabolism of Nardil recently, and I could find no data indicating that cytochrome enzymes are involved. Nor does it seem that Nardil inhibits any. Tricyclics are metabolized by cytochrome enzymes. The main metabolic pathway for Nardil metabolism is actually oxidation via MAO. Nardil inhibits its own metabolism. Nardil is also metabolized via acetylation, albeit to a lesser extent.
>
>
> - ScottMaybe I misunderstood, or maybe you did Scott, but I was asking about interactions between SMOKING and nardil and/or Nortryp.
Kat
Posted by ChicagoKat on October 2, 2012, at 19:10:17
In reply to Re: Jono, sorry to bother you, - SLS, posted by jono_in_adelaide on October 2, 2012, at 18:19:16
> Scott and I should set up in competition the the Meninger clinic! We coud be rich!
LOL you crack me up!
Posted by SLS on October 2, 2012, at 22:42:43
In reply to Re: Jono, sorry to bother you, but need rpt info » SLS, posted by ChicagoKat on October 2, 2012, at 18:23:40
> > > But I've been meaning to ask you, to ask you all, actually...do you know of any interactions between smoking and Nardil or Nortryp? I mean like kinetic and metabolic interactions that could lower blood concentrations, that sort of things. I've checked my references and they've mentioned nothing, but I thought I'd pass it by you too.
> >
> > There should be no pharmacokinetic interaction between Nardil and nortriptyline.
> >
> > I reviewed the metabolism of Nardil recently, and I could find no data indicating that cytochrome enzymes are involved. Nor does it seem that Nardil inhibits any. Tricyclics are metabolized by cytochrome enzymes. The main metabolic pathway for Nardil metabolism is actually oxidation via MAO. Nardil inhibits its own metabolism. Nardil is also metabolized via acetylation, albeit to a lesser extent.
> >
> >
> > - Scott
>
> Maybe I misunderstood, or maybe you did Scott, but I was asking about interactions between SMOKING and nardil and/or Nortryp.
> Kat
Oh. Sorry...I have never encountered any research nor has any doctor ever mentioned to me any kind of interactions between smoking and these two drugs. I think you would be in a better position than me to research it. I am not familiar with how smoking affects the levels of different drugs. If smoking is an inhibitor or inducer of CYP2D6, nortriptyline levels would be affected. CYP1A2 is only a minor metabolic pathway.
- Scott
Posted by ChicagoKat on October 3, 2012, at 9:31:00
In reply to Re: Jono, sorry to bother you, but need rpt info » ChicagoKat, posted by SLS on October 2, 2012, at 22:42:43
> > > > But I've been meaning to ask you, to ask you all, actually...do you know of any interactions between smoking and Nardil or Nortryp? I mean like kinetic and metabolic interactions that could lower blood concentrations, that sort of things. I've checked my references and they've mentioned nothing, but I thought I'd pass it by you too.
> > >
> > > There should be no pharmacokinetic interaction between Nardil and nortriptyline.
> > >
> > > I reviewed the metabolism of Nardil recently, and I could find no data indicating that cytochrome enzymes are involved. Nor does it seem that Nardil inhibits any. Tricyclics are metabolized by cytochrome enzymes. The main metabolic pathway for Nardil metabolism is actually oxidation via MAO. Nardil inhibits its own metabolism. Nardil is also metabolized via acetylation, albeit to a lesser extent.
> > >
> > >
> > > - Scott
> >
> > Maybe I misunderstood, or maybe you did Scott, but I was asking about interactions between SMOKING and nardil and/or Nortryp.
> > Kat
>
>
> Oh. Sorry...
>
> I have never encountered any research nor has any doctor ever mentioned to me any kind of interactions between smoking and these two drugs. I think you would be in a better position than me to research it. I am not familiar with how smoking affects the levels of different drugs. If smoking is an inhibitor or inducer of CYP2D6, nortriptyline levels would be affected. CYP1A2 is only a minor metabolic pathway.
>
>
> - Scott
>
>I think they are OK, based on the info you gave me. But did you know smoking decreases blood levels of Xanax by 50% in smokers? I think I'm gonna make a general announcement b/c research has shown that 43% of depressed people are smokers, and of them I'm sure a fair number take Xanax.
Thanks for all the info Scott, you're so darn intelligent!
Kat
This is the end of the thread.
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