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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 17 of 17. This is the beginning of the thread.
Posted by ChicagoKat on October 4, 2012, at 20:38:32
Hey guys,
As you know I'm on Nardil plus Nortryptiline, thanks in large part to your help. But I have a dilemma. I suffer from severe insomnia. Gabapentin was helping for a while until about yesterday when the usual tolerance set in and it stopped working for me. SO, I am wondering if it would be advisable to consider switching from Nortryptiline to Elavil, which has ALWAYS helped me sleep. Nortryptiline does squat in helping me sleep. So, if you think it's OK, what dose do you recommend, for both starting and tapering up to? I looked it up and it looks like they are both started around the same dose, but that the final treatment doses of Elavil are higher.
I'm curious to hear my Knights in Shining Armors' responses. :D
Kat
Posted by JONO_IN_ADELAIDE on October 4, 2012, at 21:24:28
In reply to A call to my White Knights Jono and SLS for advice, posted by ChicagoKat on October 4, 2012, at 20:38:32
Well, if it was me, I'd stick with the nortriptyline 75mg/day for depression, and consider adding somthing else for insomnia, because i realy dislike the side effects of amitriptyline.
The general concencus is that you need in excess of 125mg per day to get a robust antidepressant response.
If it was me, I'd rather take nortriptyline for the depression and somthing else for sleep, but if you'd found that amitriptylines side effects dont bother you, then it seems logivcal to use it.
Scott might have a better suggestion to offer than me
cheers
Jonathan
Posted by ChicagoKat on October 4, 2012, at 21:45:50
In reply to Re: A call to my White Knights Jono and SLS for advice, posted by JONO_IN_ADELAIDE on October 4, 2012, at 21:24:28
> Well, if it was me, I'd stick with the nortriptyline 75mg/day for depression, and consider adding somthing else for insomnia, because i realy dislike the side effects of amitriptyline.
>
> The general concencus is that you need in excess of 125mg per day to get a robust antidepressant response.
>
> If it was me, I'd rather take nortriptyline for the depression and somthing else for sleep, but if you'd found that amitriptylines side effects dont bother you, then it seems logivcal to use it.
>
> Scott might have a better suggestion to offer than me
>
> cheers
>
> JonathanThanks for the fast reply Jono. I should have mentioned I have tried absolutely everything for sleep and the only thing that works anymore is elavil. I'm just worried that for it to be effective as an antidepressant it will be too high a dose to combine with an MAOI. I used to absolutely hate the side effects, but I've gotten used to them and they no longer bother me.
I'm open to other suggestions for sleep meds, but I mean it when I've tried everything - even thorazine - which just made me wired and agitated.
Thanks again, KISA.
Kat
Posted by phillipa on October 4, 2012, at 22:01:05
In reply to Re: A call to my White Knights Jono and SLS for advice » JONO_IN_ADELAIDE, posted by ChicagoKat on October 4, 2012, at 21:45:50
Haven't seen SLS around at all today. Phillipa
Posted by JONO_IN_ADELAIDE on October 4, 2012, at 22:23:29
In reply to Re: A call to my White Knights Jono and SLS for advice » JONO_IN_ADELAIDE, posted by ChicagoKat on October 4, 2012, at 21:45:50
I dont think there would be any issue combining say 100mg of Elavil with the Nardil, the only issue might be some low blood pressure (but i think you said your BP is normaly high?)
I might retract what I said about needing 150mg/day - thats when its used along, in concert with Nardil you might be able to get away with a lower dose, 75-100mg?
I guess its just going to be a matter of trial and error
What dose of amitriptyline do you need to get a decent nights sleep?
Posted by ChicagoKat on October 4, 2012, at 22:36:58
In reply to Re: A call to my White Knights Jono and SLS for advice, posted by JONO_IN_ADELAIDE on October 4, 2012, at 22:23:29
> I dont think there would be any issue combining say 100mg of Elavil with the Nardil, the only issue might be some low blood pressure (but i think you said your BP is normaly high?)
>
> I might retract what I said about needing 150mg/day - thats when its used along, in concert with Nardil you might be able to get away with a lower dose, 75-100mg?
>
> I guess its just going to be a matter of trial and error
>
> What dose of amitriptyline do you need to get a decent nights sleep?Usually I need 25 - 50mg of elavil to sleep, but some nights I need up to 100mg. I took 25mg about an hour ago; i know, prob a dumb thing to do since i'd already taken my 25 of nortryp. but meanwhile a friend has angered me and i had to have a smoke so now i'll prob never sleep regardless. i actually just took a LOT of gabapentin hoping that helps. i do dumb things like that and get myself in trouble sometimes. but you have no idea how i hate not being able to sleep. but don't worry; i know all the extra gabapentin won't hurrt me; i did the same thing yesterday after hubby and i had a huge fight - and i drank an entire bottle of wine too. white of course, i'm not THAT stupid. but even so i had problems sleeping. i'm starting to think that insomnia is my bigggest problem now, not depression, not anxiety, but insomnia. and anger. i don't deal well with it, obviously. foor one thing it's making me rant to you and i'm very sorry about that. i will shut up now. i appreciate you listening (if you made it this far lol)
Posted by ChicagoKat on October 4, 2012, at 22:37:40
In reply to Re: A call to my White Knights Jono and SLS for advice » ChicagoKat, posted by phillipa on October 4, 2012, at 22:01:05
> Haven't seen SLS around at all today. Phillipa
Thanks Phillipa :)
Posted by JONO_IN_ADELAIDE on October 5, 2012, at 0:27:11
In reply to Re: A call to my White Knights Jono and SLS for advice » JONO_IN_ADELAIDE, posted by ChicagoKat on October 4, 2012, at 22:36:58
Maybe you could take your 45mg Nardil and 75mg nortriptyline for their antidepressant effect, and take 25mg of amitriptyline for sleep?
In terms of most side effects, 75mg of nortriptyline is ~ equal to 12.5-25mg amitriptyline, the combo shouldnt be a problem.... result, good control of depression, a sound nights sleep, and minimised side effects
Posted by SLS on October 5, 2012, at 4:58:08
In reply to A call to my White Knights Jono and SLS for advice, posted by ChicagoKat on October 4, 2012, at 20:38:32
I like Jono's ideas.
I see nothing wrong with using the 25 mg dose of amitriptyline at night for sleep. If, however, you need 100 mg to sleep, I think crossing-over to amitriptyline makes sense. For me, I always need a full therapeutic dose of TCA when added to MAOI. If you do switch from nortripyline to amitriptyline, you might need 150 mg/day or higher in combination with Nardil to glean a persistent antidepressant effect. It is likely that the anticholinergic side effects of amitriptyline will lessen over time. After being on imipramine for an extended period of time, I hardly knew that I was taking it.
If nothing else works, you could try taking a combination of triazolam (Halcion) and lorazepam (Ativan). I found this extremely effective when taking a combination of Parnate and desipramine; and later, Nardil. There was very little, if any, hangover the next morning. I woke up clear-headed. It was very clean in my experience. It didn't feel yucky. Triazolam is the most potent BZD for sleep.
1. Nowadays, I doubt that you could find a doctor to prescribe triazolam, let alone in combination with another BZD.
2. Behavioral disinhibition is possible with triazolam, as it is with Xanax. It is an infrequent occurrence.
3. Amnestic phenomena can occur with triazolam, much like those that occur with of Ambien.
- Scott
Posted by ChicagoKat on October 5, 2012, at 7:36:12
In reply to Re: A call to my White Knights Jono and SLS for advice » ChicagoKat, posted by SLS on October 5, 2012, at 4:58:08
> I like Jono's ideas.
>
> I see nothing wrong with using the 25 mg dose of amitriptyline at night for sleep. If, however, you need 100 mg to sleep, I think crossing-over to amitriptyline makes sense. For me, I always need a full therapeutic dose of TCA when added to MAOI. If you do switch from nortripyline to amitriptyline, you might need 150 mg/day or higher in combination with Nardil to glean a persistent antidepressant effect. It is likely that the anticholinergic side effects of amitriptyline will lessen over time. After being on imipramine for an extended period of time, I hardly knew that I was taking it.
>
> If nothing else works, you could try taking a combination of triazolam (Halcion) and lorazepam (Ativan). I found this extremely effective when taking a combination of Parnate and desipramine; and later, Nardil. There was very little, if any, hangover the next morning. I woke up clear-headed. It was very clean in my experience. It didn't feel yucky. Triazolam is the most potent BZD for sleep.
>
> 1. Nowadays, I doubt that you could find a doctor to prescribe triazolam, let alone in combination with another BZD.
>
> 2. Behavioral disinhibition is possible with triazolam, as it is with Xanax. It is an infrequent occurrence.
>
> 3. Amnestic phenomena can occur with triazolam, much like those that occur with of Ambien.
>
>
> - ScottThank you my knights for all that useful information. I shall think upon it. You may now go back to guarding the castle keep.
(I'm such f*ck*ng nerd sometimes lol)
Posted by ChicagoKat on October 5, 2012, at 11:44:35
In reply to Re: A call to my White Knights Jono and SLS for advice » ChicagoKat, posted by SLS on October 5, 2012, at 4:58:08
> I like Jono's ideas.
>
> I see nothing wrong with using the 25 mg dose of amitriptyline at night for sleep. If, however, you need 100 mg to sleep, I think crossing-over to amitriptyline makes sense. For me, I always need a full therapeutic dose of TCA when added to MAOI. If you do switch from nortripyline to amitriptyline, you might need 150 mg/day or higher in combination with Nardil to glean a persistent antidepressant effect. It is likely that the anticholinergic side effects of amitriptyline will lessen over time. After being on imipramine for an extended period of time, I hardly knew that I was taking it.
>
> If nothing else works, you could try taking a combination of triazolam (Halcion) and lorazepam (Ativan). I found this extremely effective when taking a combination of Parnate and desipramine; and later, Nardil. There was very little, if any, hangover the next morning. I woke up clear-headed. It was very clean in my experience. It didn't feel yucky. Triazolam is the most potent BZD for sleep.
>
> 1. Nowadays, I doubt that you could find a doctor to prescribe triazolam, let alone in combination with another BZD.
>
> 2. Behavioral disinhibition is possible with triazolam, as it is with Xanax. It is an infrequent occurrence.
>
> 3. Amnestic phenomena can occur with triazolam, much like those that occur with of Ambien.
>
>
> - ScottScott...I just want to make sure, if I took 150mg/day of elavil with 45mg/day of nardil, that it would be safe?
Thanks for the rec of benzos, but they are pretty much out for me. I have developed too much tolerrance to them which does not go awawy.
Thanks,
Kat
Posted by SLS on October 5, 2012, at 13:33:01
In reply to Re: A call to my White Knights Jono and SLS for advice » SLS, posted by ChicagoKat on October 5, 2012, at 11:44:35
> Scott...I just want to make sure, if I took 150mg/day of elavil with 45mg/day of nardil, that it would be safe?
Been there, done that...
It was safe enough for me. Hopefully, it will be for you, too.
The only thing I can think of that would be unsafe about this combination is the possibility that it would precipitate serotonin syndrome. You should get familiar with its signs and symptoms, just in case. I really don't see it happening, though.
Because of its anti-cholinergic, central pro-adrenergic, and peripheral NE alpha-1 antagonism, adding amitriptyline to Nardil might produce some problematic hypotension, tachycardia, and urinary retention that will need to be remediated pharmacologically. These things are less of a problem when the dosage of Nardil is kept below 60 mg/day. Let's see what happens and take it one step at a time.
Good luck!
- Scott
Posted by ChicagoKat on October 5, 2012, at 15:29:00
In reply to Re: A call to my White Knights Jono and SLS for advice » ChicagoKat, posted by SLS on October 5, 2012, at 13:33:01
> > Scott...I just want to make sure, if I took 150mg/day of elavil with 45mg/day of nardil, that it would be safe?
>
> Been there, done that...
>
> It was safe enough for me. Hopefully, it will be for you, too.
>
> The only thing I can think of that would be unsafe about this combination is the possibility that it would precipitate serotonin syndrome. You should get familiar with its signs and symptoms, just in case. I really don't see it happening, though.
>
> Because of its anti-cholinergic, central pro-adrenergic, and peripheral NE alpha-1 antagonism, adding amitriptyline to Nardil might produce some problematic hypotension, tachycardia, and urinary retention that will need to be remediated pharmacologically. These things are less of a problem when the dosage of Nardil is kept below 60 mg/day. Let's see what happens and take it one step at a time.
>
> Good luck!
>
>
> - ScottThanks for your thoughts Scott. I've had serotonin syndrome (prozac + robitussin DM, dumb me), so I know the signs and symptoms. and i have some thorazine in case i should ever get it again.
my biggest worry autonomic-wise is reflex tachycardia. how the heck can i treat that when the only options i can think of are beta blockers or non-dihydropyridine calcium channel blockers, both of which will obviously just make the hypotension worse. do you know of anything else i could take?
Lastly, I really wonder how much a TCA, no matter which one i go with is gonna help me. They've never helped in the past, so why should they now? my pdoc did mention a sort of catalyst effect they have when used with MAOIs, but i didn't ask him about the mechanism of that. do you have any other arguments in their favor when combined with MAOIs, despite the fact they've never helped on their own?
Thanks as always, you are the best.
Kat
Posted by jono_in_adelaide on October 5, 2012, at 18:29:37
In reply to Re: A call to my White Knights Jono and SLS for advice » ChicagoKat, posted by SLS on October 5, 2012, at 13:33:01
Good luck Kat, and sweet dreams!
Posted by ChicagoKat on October 5, 2012, at 19:58:58
In reply to Re: A call to my White Knights Jono and SLS for advice, posted by jono_in_adelaide on October 5, 2012, at 18:29:37
> Good luck Kat, and sweet dreams!
Thanks Jono, and sweet dreams to you to....whenever the hell it is you go to sleep, probably sometime next week you guys are so ahead of us time wise.
Posted by SLS on October 6, 2012, at 0:29:53
In reply to Re: A call to my White Knights Jono and SLS for advice » SLS, posted by ChicagoKat on October 5, 2012, at 15:29:00
> Thanks as always, you are the best.
> KatActually, my vote is for Jono.
:-)
- Scott
Posted by ChicagoKat on October 6, 2012, at 9:43:53
In reply to Re: A call to my White Knights Jono and SLS for advice » ChicagoKat, posted by SLS on October 6, 2012, at 0:29:53
> > Thanks as always, you are the best.
> > Kat
>
> Actually, my vote is for Jono.
>
> :-)
>
>
> - ScottYou are too modest!!! :) But in my eyes, it's a tie; I love to hear from each of you equally, but for slightly different reasons, but it comes out completely equal. :D
>
This is the end of the thread.
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