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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 30. This is the beginning of the thread.
Posted by ChicagoKat on December 13, 2012, at 11:04:09
Hi,
I was recently on Nardil which had worked for me in the past, but did nothing for me this go-round. *Very* oddly it made me more anxious than I already am.
So I had to fight with the pharmacy over the insurance coverage, but I got my Parnate yesterday.
I was thinking I'd wait a day or two off my Ritalin before I start it. My pdoc is very squeamish about me adding Ritalin while being on Parnate plus Elavil 100mg qhs - it is the ONLY thing that helps me sleep.
OK, here's my question. I've read that Parnate is a more activating MAOI. I need advice on anxiolytics to present to my pdoc next week. I am super-tolerant to benzos, well to Ativan and Klonopin for sure - is there cross-reactivity with a different benzo I've never tried? ie, would valium or librium help? I developed the fastest tolerance in the world to Neurontin; I am on 3600mg tid and it does absolutely nothing for me. Lyrica makes me crazy. AAPs- all of them - make me agitated. Zyprexa even gave me akathisia. Antihistamines give me the paradoxical agitated reaction. I'll have to stay away from trazadone while on an MAOI. And Remeron would not be an option for the same reason, and also b/c now I get paradoxical agitation with it too. Can any of you excellent smart Babblers think of anything else I could try? It would be sad if Parnate actually helped my depression, but I had to stop it b/c of too much anxiety. Thanks so much.
Kat
Posted by Phillipa on December 13, 2012, at 11:16:38
In reply to Anxiety treatment while on Parnate need advice, posted by ChicagoKat on December 13, 2012, at 11:04:09
Kat I had no idea you were tolerant or had paradoxical reactions to so many meds. I honestly don't know. Assuming you have taken ambien, lunesta stuff like that? Best to leave to the maoi experts. So one more day? Hanging in there. Phillipa xxx
Posted by ChicagoKat on December 13, 2012, at 11:21:29
In reply to Re: Anxiety treatment while on Parnate need advice » ChicagoKat, posted by Phillipa on December 13, 2012, at 11:16:38
> Kat I had no idea you were tolerant or had paradoxical reactions to so many meds. I honestly don't know. Assuming you have taken ambien, lunesta stuff like that? Best to leave to the maoi experts. So one more day? Hanging in there. Phillipa xxx
Thanks for posting Phillipa, it's always great to hear from you. Yep, I develop super tolerance to just about everything. And the paradoxical reactions feel like the drugs are turning on me..they are evil!!!! And yep, have been on Ambien, developed tolerance to that too. Lunesta had no effect at all. It's all sooooooo frustrating. But I will hang in ther
Katxxx
Posted by schleprock on December 13, 2012, at 12:56:17
In reply to Anxiety treatment while on Parnate need advice, posted by ChicagoKat on December 13, 2012, at 11:04:09
You should try a beta-blocker. Atenolol and Propranolol helped me in the past (in conjunction with other meds.) I'm trying to go off Lyrica right now and go back to Atenolol; not really having an easy time with it.
Posted by jono_in_adelaide on December 13, 2012, at 16:33:38
In reply to Anxiety treatment while on Parnate need advice, posted by ChicagoKat on December 13, 2012, at 11:04:09
Some benzos (eg Tranxene) produce tolorance at a slower rate to others (Xanax, Ativan) so it might be worth trying Tranxene.
Amitriptyline 100mg/day should have significant anti anxiety efects due to its activity blocking various 5HT receptors, you could even push it to 150mg/day
Buspar would be well worth a try, 15mg-30mg bid
The anxiety you feel at the begining of treatment may well settle after a couple of weeks, so dont abandon Parnate too soon.
Best of luck
Jon
Posted by SLS on December 13, 2012, at 17:27:54
In reply to Anxiety treatment while on Parnate need advice, posted by ChicagoKat on December 13, 2012, at 11:04:09
I hope you don't react to Parnate adversely. As Jono suggested, any activation or "jumpiness" that Parnate might produce early in treatment can disappear. However, with your history of reactions to psychotropics, there are no guarantees.
Thinking outside the box just a bit, you might profit from a mood stabilizer, especially if there is any bipolarity involved in your condition. The three drugs that come to mind as anxiolytics are:
1. Depakote (valproate)
2. Trileptal (oxcarbazepine)
3. Topamax (topiramate)I am particularly impressed with how well some people respond to Trileptal as an antimanic or anxiolytic during benzodiazepine withdrawal.
- Scott
Posted by jono_in_adelaide on December 13, 2012, at 19:24:33
In reply to Re: Anxiety treatment while on Parnate need advice » ChicagoKat, posted by SLS on December 13, 2012, at 17:27:54
Another option might be to switch from amitriptyline to doxepin for sleep - its a more potent 5HT2A blocker, so hits anxiety even better than amitriptyline.
You could also have a benzo to take PRN when anxiety was especialy bad, tolorance shouldnt be a problem under those conditions
The drugs SLS suggested would also be well worth trying. The answer might not be one drug acting alone, but maybe 2 acting by different pathways that add up to good relief
Posted by willyyeee on December 13, 2012, at 20:11:01
In reply to Re: Anxiety treatment while on Parnate need advice » ChicagoKat, posted by SLS on December 13, 2012, at 17:27:54
im on high dose parnate,if i get maniac from it a benzo,mainly klonopin with gabapentin usualy helps,another outstanding med to add to a benzo is phenobarbital
Posted by g_g_g_unit on December 13, 2012, at 23:19:26
In reply to Re: Anxiety treatment while on Parnate need advice » ChicagoKat, posted by SLS on December 13, 2012, at 17:27:54
I'm curious if Parnate becomes more anxiolytic once one exceeds 60mg?
Posted by SLS on December 14, 2012, at 8:32:15
In reply to Re: Anxiety and dose, posted by g_g_g_unit on December 13, 2012, at 23:19:26
> I'm curious if Parnate becomes more anxiolytic once one exceeds 60mg?
If anxiety is an integral component of one's depressive disorder, there is a good chance that it will remit along with the depression once a therapeutic dosage is reached. However, I am not sure what happens in a situation where the appearance of anxiety is the result of Parnate treatment.
How are you doing?
- Scott
Posted by SLS on December 14, 2012, at 8:47:36
In reply to Re: Anxiety treatment while on Parnate need advice, posted by jono_in_adelaide on December 13, 2012, at 19:24:33
> Another option might be to switch from amitriptyline to doxepin for sleep - its a more potent 5HT2A blocker, so hits anxiety even better than amitriptyline.
I believe this is accurate. I didn't know about the 5-HT2a thing, so I looked it up. Also, I have seen the successful use of doxepin to reduce anxiety. Interestingly, the only drug treatment that ever worked for a friend of mine who suffers from an anxious depression (most likely bipolar) was a combination of Nardil + doxepin.
> You could also have a benzo to take PRN when anxiety was especialy bad, tolorance shouldnt be a problem under those conditions
Do you think Xanax (alprazolam) would be a good choice?
IR vs XR?
- Scott
Posted by willyyeee on December 14, 2012, at 15:15:43
In reply to Re: Anxiety and dose, posted by g_g_g_unit on December 13, 2012, at 23:19:26
Actualy im on the high dose treatment of 90 mg,and i find NO DEF NOT,in fact once over the 60 mg it looses its stimulant effect and in my case if i dont use a stimulant i cant get up as if i have cfs,ill be undepressed,however usesless on the counch,addinng a stimulant helps me live with my parnate,might be cause parnate is a gaba re uptake drug as well.
Posted by jono_in-adelaide on December 14, 2012, at 18:15:58
In reply to Re: Anxiety treatment while on Parnate need advice, posted by SLS on December 14, 2012, at 8:47:36
I'd say Xanax or Ativan would be good choices, they act quickly and last for upto 12 hours
When doxepin was first introduced, it was studied as an anxiolytic as well as an antidepressant, 25mg was found to ne = to 5mg of diazepam, but with no tollorance etc. downside is significant sedation in the early days.
If kat took 75mg of doxepin at night for sleep she would get a reasonably anxiolytic effect, and she could push the dose higher if needed, to 150mg at night.
Posted by g_g_g_unit on December 14, 2012, at 19:34:50
In reply to Re: Anxiety and dose » g_g_g_unit, posted by SLS on December 14, 2012, at 8:32:15
>
> How are you doing?
>
>Thank you for asking, but very poorly. In fact, I have all but given up hope and find it incredibly hard to motivate myself to perform very basic day-to-day tasks. I don't know how to get out of this state.
The reason I asked about Parnate is because I had a treatment review with my psychiatrist and realized that very little has helped my depression, other than Parnate, though only once I reached 60mg, and the effect was relatively mild. I suspected higher doses might have been of more benefit, but he wasn't willing to raise it.
I've since been in touch with a local depression expert who said that there are certain psychiatrists around here who use high-dose (i.e. >60mg) Parnate.
Posted by SLS on December 14, 2012, at 23:56:49
In reply to Re: Anxiety and dose » SLS, posted by g_g_g_unit on December 14, 2012, at 19:34:50
I am dismayed to hear that you are doing so poorly. I had hoped to hear otherwise.
For me, the difference between Parnate 80 mg/day and 60 mg/day is the difference between response and non-response.
You might want to ask about adding lithium in dosages between 300 - 600 mg/day to augment the Parnate. I find the lower dosages are helpful to lessen the severity of depression and prevent mood lability. Higher dosages of lithium produce flat affect and passivity.
Combining desipramine or nortriptyline with Parnate or Nardil always helps me more than Parnate alone.
How do you react to Lamictal?
- Scott
Posted by SLS on December 14, 2012, at 23:57:36
In reply to Re: Anxiety and dose » SLS, posted by g_g_g_unit on December 14, 2012, at 19:34:50
If you were your own doctor, what would you do?
- Scott
Posted by jono_in-adelaide on December 15, 2012, at 2:53:48
In reply to Re: Anxiety and dose » g_g_g_unit, posted by SLS on December 14, 2012, at 23:57:36
GGG, I'd definatly try the higher dose of parnate with and without nortriptyline- you have nothing to lose and exerything to gain if it works for you. As SLS says, there are other augmenters you can add on as well, lithium, lamactil, a low dose atypical, thyroid...... try and get the name of one of those doctors and get a referal to one of them
Posted by g_g_g_unit on December 15, 2012, at 18:55:53
In reply to Re: Anxiety and dose » g_g_g_unit, posted by SLS on December 14, 2012, at 23:56:49
> I am dismayed to hear that you are doing so poorly. I had hoped to hear otherwise.
>
> For me, the difference between Parnate 80 mg/day and 60 mg/day is the difference between response and non-response.
>
> You might want to ask about adding lithium in dosages between 300 - 600 mg/day to augment the Parnate. I find the lower dosages are helpful to lessen the severity of depression and prevent mood lability. Higher dosages of lithium produce flat affect and passivity.
>
> Combining desipramine or nortriptyline with Parnate or Nardil always helps me more than Parnate alone.
>
> How do you react to Lamictal?
>
>
> - ScottI know. It's sad. There's been a paradigm shift in my thinking -- often I had some way of remaining buoyed or hopeful between drug trials, but I just seemed to have settled into a mood of total dismay and futility.
Parnate helped my depression, but my anxiety was still quite prominent on it (I had a lot of OCD-related obsessions regarding the occurrence of a hypertensive crisis, which suggests it wasn't helping anxiety). However, I have heard some reports that it becomes more calming at higher doses. Looking back I was also very productive on it, and was able to take pleasure in things again, which has been rare for the past 4 years.
I have been in touch with one specialist, and have asked him the name of any psychiatrists he might recommend. Hopefully he gives me a lead ..
Posted by g_g_g_unit on December 15, 2012, at 18:57:29
In reply to Re: Anxiety and dose » g_g_g_unit, posted by SLS on December 14, 2012, at 23:57:36
> If you were your own doctor, what would you do?
>
>
> - ScottCryogenically freeze me until new treatments emerge? =)
Umm .. I don't know, try a higher dose of Parnate, I suppose?
Posted by SLS on December 16, 2012, at 0:34:15
In reply to Re: Anxiety and dose » SLS, posted by g_g_g_unit on December 15, 2012, at 18:57:29
> > If you were your own doctor, what would you do?
> >
> >
> > - Scott
>
> Cryogenically freeze me until new treatments emerge? =)
>
> Umm .. I don't know, try a higher dose of Parnate, I suppose?
That makes sense to me.It would be regrettable if your current doctor were to forgo increasing the dosage of Parnate just a bit more and your always wondering if 80 mg/day would have worked. Would you be able to seek a consultation with a TRD specialist? High dosage Parnate treatment very often employs dosages of 120 mg/day or more. I went up to 150 mg/day. I felt better at 120 mg/day than I did at 80 mg/day.
http://www.ncbi.nlm.nih.gov/pubmed/2710808
http://ajp.psychiatryonline.org/article.aspx?articleid=98116
Something different is happening physiologically at higher dosages.
http://www.ncbi.nlm.nih.gov/pubmed/7931218
- Scott
Posted by jono_in_adelaide on December 16, 2012, at 17:03:21
In reply to Re: Anxiety and dose » g_g_g_unit, posted by SLS on December 16, 2012, at 0:34:15
I hate to suggest it, but why not get a script for 60mg/day, but take it at 80mg/day.
Sure the script would run out early, but by that time,you'd have proved that it worked, or proved that it didnt. If it did work, you'd have a convincing story to justify to your doctor for continuing on 80mg.
Also, adding nortriptyline would be well worth trying, other addons would be low dose atypicals, lythium and thyroid hormone in various combinations. If your doc isnt willing to give you nortriptyline for a trial, there are other avenues to obtaining it.
Just keep trying GGG, never give up, as well as the virtualy infinate different combinations of existing drugs, there are new drugs in the pipeling as well, you never know when remission is just around the corner
Posted by g_g_g_unit on December 17, 2012, at 2:50:33
In reply to Re: Anxiety and dose » g_g_g_unit, posted by SLS on December 16, 2012, at 0:34:15
> > > If you were your own doctor, what would you do?
> > >
> > >
> > > - Scott
> >
> > Cryogenically freeze me until new treatments emerge? =)
> >
> > Umm .. I don't know, try a higher dose of Parnate, I suppose?
>
>
> That makes sense to me.
>
> It would be regrettable if your current doctor were to forgo increasing the dosage of Parnate just a bit more and your always wondering if 80 mg/day would have worked. Would you be able to seek a consultation with a TRD specialist? High dosage Parnate treatment very often employs dosages of 120 mg/day or more. I went up to 150 mg/day. I felt better at 120 mg/day than I did at 80 mg/day.
>
> http://www.ncbi.nlm.nih.gov/pubmed/2710808
>
> http://ajp.psychiatryonline.org/article.aspx?articleid=98116
>
> Something different is happening physiologically at higher dosages.
>
> http://www.ncbi.nlm.nih.gov/pubmed/7931218
>
>
> - ScottYes, I've e-mailed two TRD specialists .. both have confirmed that they are aware of the therapeutic benefits of exceeding 60mg/day, but were rather vague on addressing whether or not they specifically prescribed higher doses? I guess that implies that they do ..
That said, I'm wondering if a retrial is worth the hassle. I remember 60mg helping my mood somewhat, as well as drive, motivation, etc., but it made me agitated and had no effect (or possibly worsened) my OCD. I felt overstimulated in general, but 60mg was the minimum I needed for an anti-depressant response.
Have you ever heard of, say, 80mg+ helping anxiety where lower doses didn't, or even worsened it?
Posted by SLS on December 17, 2012, at 6:10:22
In reply to Re: Anxiety and dose » SLS, posted by g_g_g_unit on December 17, 2012, at 2:50:33
> Have you ever heard of, say, 80mg+ helping anxiety where lower doses didn't, or even worsened it?
No.
:-(
What about Marplan (isocarboxazid)?
What else are you taking right now?
I forget - how do amphetamine and methylphenidate affect you?
- Scott
Posted by jono_in_adelaide on December 17, 2012, at 21:28:59
In reply to Re: Anxiety and dose » g_g_g_unit, posted by SLS on December 17, 2012, at 6:10:22
Marpan was withdrawn in Australia many years ago - the manufacturers decided that sales were so low, it wasnt worth the bother of marketing it.
Could you cousider a trial of Parnate in higher doese, with or without nortriptyline for antidepressant effect, and a benzo to counter the anxiety?
Posted by SLS on December 17, 2012, at 23:18:02
In reply to Re: Anxiety and dose, posted by jono_in_adelaide on December 17, 2012, at 21:28:59
> Marpan was withdrawn in Australia many years ago - the manufacturers decided that sales were so low, it wasnt worth the bother of marketing it.
Marplan had been withdrawn from the US market for the same reason in 1994. Afterwards, some people were granted a supply of the drug under a compassionate use program. It was then reintroduced in 1999. Marplan has always been considered to be a "weaker" Nardil. However, there is a minority of people that responds better to Marplan than to Nardil. The side effects for Marplan are more forgiving than those of Nardil. I really don't know what place Marplan has in psychiatry. However, I am sure that there are people who pray that it always remain available.
I tried Marplan once. I experienced a very small improvement that lasted for less than a week. I was surprised that it worked at all. For me, it had no side effects.
- Scott
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