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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 2 to 26 of 26. Go back in thread:
Posted by schleprock on January 6, 2013, at 18:46:16
In reply to Need Advice next Tricyclic Antedepressant to try, posted by reconscout on January 6, 2013, at 18:27:03
You could try going back on nortriptyline and take a low-dose beta-blocker (12.5 mgs of atenolol did it for me)to slow your heartbeat, as well as lower your blood pressure. Dr. Lou Pilder may disagree, though.
Posted by reconscout on January 6, 2013, at 18:52:28
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by schleprock on January 6, 2013, at 18:46:16
Thanks SchlepRock, what a great screen name. So When you added the beta blocker did you have any side effects or new added symptoms / problems? did it effect at all the benefits of your nortriptyline? I did ask my doc to let me try this but for now he seems keen on finding another TCA that will work without the need to augment with a beta blocker :(
Any experience with other TCAs Schlep?
Posted by jono_in_adelaide on January 6, 2013, at 19:21:42
In reply to Need Advice next Tricyclic Antedepressant to try, posted by reconscout on January 6, 2013, at 18:27:03
I agree with Shep - take the nortriptyline along with a low dose beta blocker (say atenolol 25mg)
Most of the tricyclics will leave you groggy and sedated the next day, atleast initialy, nortriptyline and desipramine are the least likely to do this.
I'd start the nortriptyline at 10mg and slwoly build up to an effective dose (which can be between 50 and 150mg per day) Start the atenolol at 12.5mg per day and slowly increase to 25 or 50mg, as well as keeping your heart rate steady, this will also be very helpful for your anxiety.
Posted by reconscout on January 6, 2013, at 19:41:16
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by jono_in_adelaide on January 6, 2013, at 19:21:42
Thanks for the follow up Jono. With the Nortriptyline I was on 10MG for two weeks with great results. Once the heart stuff kicked in I had to take it all the way down to 2.5MG with still some concern. This concerned me and is why I came off of it. Have you tried any of the other energizing TCA's. I plan to push my doc to let me try the beta blocker but I wonder if there is another TCA with a similar profile to nortriptyline that maybe I should try first?
Posted by jono_in_adelaide on January 6, 2013, at 20:08:03
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by reconscout on January 6, 2013, at 19:41:16
The increased heart rate is usualy caused by the tricyclics anticholinergic effect, and unfortunatly, most of the tricyclics have it. Desipramine is the mildest anticholinergic and also the least sedating (so least next day groginess)
It might be worth waiting to see if the side effects you're experiencing with desipramine settle down over the next couple of weeks as your body gets used to the drug.
The other option would be Cymbalta, this is usefull for depression, anxiety and for pain. It shouldnt have any effect on the heart at all.
Posted by reconscout on January 6, 2013, at 20:28:14
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by jono_in_adelaide on January 6, 2013, at 20:08:03
Jono, yah I'm going to give the desipramine a few more days. Do you happen to know which TCA has the 2nd least anticholinergic effects?
Posted by Lou Pilder on January 6, 2013, at 21:03:43
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by jono_in_adelaide on January 6, 2013, at 20:08:03
> The increased heart rate is usualy caused by the tricyclics anticholinergic effect, and unfortunatly, most of the tricyclics have it. Desipramine is the mildest anticholinergic and also the least sedating (so least next day groginess)
>
> It might be worth waiting to see if the side effects you're experiencing with desipramine settle down over the next couple of weeks as your body gets used to the drug.
>
> The other option would be Cymbalta, this is usefull for depression, anxiety and for pain. It shouldnt have any effect on the heart at all.
>
> Friends,
It is written here,[...it (Cymbalta) shouldn't have any effect on the heart at all...].
My friends, this drug could have a great adverse effect on the heart, even heart attack that could lead to death.
I am trying to save lives here by responding to posts such as this, for I consider the allowing of statements that are false that could kill someone if they believed it to be true, to constitute an unsound mental-health practice, for the members could think that the statement is supportive becaue the TOS here states that support takes precedence. I think that warning readers of this site of the danger posted here is supportive and supportive in any forum, unless that forum wants people to die. If that is the case, then death is supportive.
Here are some links to reported heart attacks and other heart related effects from Cymbalta.
Lou
http://www.ehealthme.com/ds/cymbalta/death
http://www.ehealthme.com/ds/cymbalta/heart+attack
http://www.ehealthme.com/ds/cymbalta/heart+palpitations
http://www.ehealthme.com/ds/cymbalta/rapid+heart+beat
http://www.ehealthme.com/ds/cymbalta/irregular+heart+beat
Posted by SLS on January 6, 2013, at 22:15:04
In reply to Need Advice next Tricyclic Antedepressant to try, posted by reconscout on January 6, 2013, at 18:27:03
> I tried (Nortriptyline)(Pamelor) with awesome results for two weeks. My pain was managed within 3 days. After 1 week my depression was totally gone, My Anxiety was gone, I had more energy, I was motivated, no sexual side effects and I was sleeping all the way through the night. I thought I had found my perfect wonder drug. Problem was after two weeks I started having a pounding heartbeat.
What was your interpretation of this phenomenon?
- Scott
Posted by jono_in_adelaide on January 6, 2013, at 22:33:06
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by reconscout on January 6, 2013, at 20:28:14
It would seem that nortriptyline is in the # 2 spot at about twice the antichiolinergic activity of desipramine
Posted by Phillipa on January 6, 2013, at 22:55:28
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by jono_in_adelaide on January 6, 2013, at 22:33:06
I was also going to suggest cymbalta as it does work for pain experienced this myself. I took pamelor and even l0mg knocked me out. Why do you prefer TCA's? Phillipa
Posted by reconscout on January 6, 2013, at 23:59:09
In reply to Re: Need Advice next Tricyclic Antedepressant to try » reconscout, posted by SLS on January 6, 2013, at 22:15:04
> > I tried (Nortriptyline)(Pamelor) with awesome results for two weeks. My pain was managed within 3 days. After 1 week my depression was totally gone, My Anxiety was gone, I had more energy, I was motivated, no sexual side effects and I was sleeping all the way through the night. I thought I had found my perfect wonder drug. Problem was after two weeks I started having a pounding heartbeat.
>
> What was your interpretation of this phenomenon?
>
>
> - ScottWell Scott, I'm not sure why the heart issues took two weeks to emerge? I have read other posters description of tachycardia coming on 1, 2, or even 3 weeks after start. All I could think is whatever chemical triggered the cardio effects took that long to fully build up in my system. Out of curiousity why do you ask?
Posted by reconscout on January 7, 2013, at 0:10:38
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by Phillipa on January 6, 2013, at 22:55:28
Hi Phillipa,
Well that's a great question. I guess I would prefer to have one drug to address the Pain, depression, anxiety, fatigue, and Insomnia. I've read that TCA's are the most effective class of drugs for treating neuropathic pain. My Rheumy confirmed this and shared that he has seen TCAs mitigate all of my issues in other folks. He recommended Nortriptyline and when I tried it I was skeptical and couldn't believe how well it was working with my body until that two week mark....I've tried a few SSRI's in the past for just depression/anxiety and had really bad results. I'm a little afraid of the dependence and heavy withdrawal that I've read come along with Cymbalta. I also have been taking Norco for going on 5 years now and on a TCA(nortript) I caught a glimpse of being able to reduce my Norco usage by 50 to 75%. All that being said I suppose I am open to other alternatives. I'm just really tired from my long ride on the AD rollercoaster.....
Posted by SLS on January 7, 2013, at 7:50:55
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by reconscout on January 6, 2013, at 23:59:09
> > > I tried (Nortriptyline)(Pamelor) with awesome results for two weeks. My pain was managed within 3 days. After 1 week my depression was totally gone, My Anxiety was gone, I had more energy, I was motivated, no sexual side effects and I was sleeping all the way through the night. I thought I had found my perfect wonder drug. Problem was after two weeks I started having a pounding heartbeat.
> >
> > What was your interpretation of this phenomenon?
> >
> >
> > - Scott
>
> Well Scott, I'm not sure why the heart issues took two weeks to emerge? I have read other posters description of tachycardia coming on 1, 2, or even 3 weeks after start. All I could think is whatever chemical triggered the cardio effects took that long to fully build up in my system. Out of curiousity why do you ask?My first reaction is to say that it is not a cardiac issue, but, rather, a CNS issue. Research heart palpitations. They very often have nothing to do with the heart.
I suggest that you consider returning to nortriptyline at a dosage of 75 mg/day and have a ECG performed should the palpitations return - just to be safe and ease your mind. I find that for me, mild palpitations are actually a symptom of depression, and that they can temporarily get worse as an antidepressant begins to work or if the dosage is to low. These really aren't "heart palpitations". It is more accurate to just call them "palpitations". That's because it is a sensation rather than a mechanical event located in the heart - although it can be. While you are at 75 mg/day, get a test to assay your blood level of the drug. If it is low and you are a rapid metabolizer, you will likely need 150 mg/day. However, your positive therapeutic response to lower dosages would seem to indicate otherwise.
Please research the causes of chest palpitations. It would be sad if you were to miss a unique opportunity to get well.
Desipramine can be "harsh" when you first begin treatment. Give it time.
- Scott
Posted by reconscout on January 7, 2013, at 11:58:58
In reply to Re: Need Advice next Tricyclic Antedepressant to try » reconscout, posted by SLS on January 7, 2013, at 7:50:55
Thanks Scott,
Wow very well articulated. Your explanation rings true for me as my heart rate/BP did fluctuate more often but not outside of the normal long-term fluctuations I've had. If you don't mind I'd like to ask you a few questions?
1) You mentioned;
"mild palpitations are actually a symptom of depression, and that they can temporarily get worse as an antidepressant begins to work or if the dosage is to low".On that low dose I felt like my mood was very positive. Are you saying chemical depression can be worse internally even if you are feeling upbeat externally? When you've had palpitaions as a symptom of depression were you on a TCA and did you feel like you were'nt depressed? either way it would help me a lot if you could you explain the science behind this?
2)The palpitations you describe, did you feel them under your heart, in your neck and resonating to your ears when you layed down?
3) Did you feel any dull mild chest/lung pain?
Thanks again for the explanation. I feel encouraged.
Posted by reconscout on January 7, 2013, at 12:16:47
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by reconscout on January 7, 2013, at 11:58:58
Hey Scott,
FYI one more thing that leads me to believe you may be right on. I was taking my dose at night. The palpitations would come on heaviest approx 2 hours after I took the med. When they didn't die down I would take a xanax and they would go away completely. To your knowledge if it was some sort of heart Arrhythmia would the xanax have helped? I just read up on palpitations by the way..
Posted by SLS on January 7, 2013, at 13:01:20
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by reconscout on January 7, 2013, at 11:58:58
Funny. I just now stopped in to check out if you had responded to my post. You posted about 30 seconds ago.
> 1) You mentioned;
> "mild palpitations are actually a symptom of depression, and that they can temporarily get worse as an antidepressant begins to work or if the dosage is to low".
>
> On that low dose I felt like my mood was very positive.That's great! The goal is to establish the minimum effective dose. If that ends up being 10 mg/day, so much the better. 75 mg/day of nortriptyline is the most common dosage used for major depressive disorder (MDD). It is likely to be lower for pain disorders without depression. It is not unusual for someone to begin to feel better with a low dosage of nortriptyline during the first week, but need to raise the dosage to maintain a stable response. Just take it one step at a time.
> Are you saying chemical depression can be worse internally even if you are feeling upbeat externally?
No, but that is a great question. I suppose such a thing is conceivable given the complexities of the brain and MDD, but I have never seen that happen.
> When you've had palpitaions as a symptom of depression were you on a TCA and did you feel like you were'nt depressed?
No. I palpitations occur with me even when I don't take medication. It is part of my baseline depression.
> either way it would help me a lot if you could you explain the science behind this?
I can't. Well, perhaps I can. The autonomic nervous system (sympathetic + parasympathetic) is often altered in MDD. It becomes imbalanced in a kind of dysautonomia: sympathetic outflow increases while parasympathetic outflow decreases. This produces a kind of "fight or flight" state. Have you ever noticed how palpitation can occur during episodes of fear or anxiety? The heart rate is often increased and can beat more forcefully in this state. A tricyclic can further bias this imbalance at first via NE reuptake inhibition and cholinergic muscarinic receptor blockade. Once the body accomodates to the drug, many of the autonomic effects should decrease in magnitude. Expect an elevated heart rate to persist, though.
You can use a beta-blocker like propranalol to reduce the effects of an overactive sympathetic nervous system. You might then be able to discontinue the propranalol later on after a stable therapeutic response to an antidepressant is established.
> 2)The palpitations you describe, did you feel them under your heart, in your neck and resonating to your ears when you layed down?
Yes.
> 3) Did you feel any dull mild chest/lung pain?
Yes.
> Thanks again for the explanation. I feel encouraged.
When using tricyclic antidepressants, drugs that have a true risk of cardiotoxicity, caution is best. Some doctors will ask that you have a ECG before beginning treatment and again during treatment. I have never had a doctor ask this of me.
If you are concerned, I think it is reasonable for you to get a ECG first and then begin treatment with a beta-blocker afterwards in order to minimize a temporary increase in sympathetic activity produced by a tricyclic. It may be that your heart rate will remain moderately elevated once the the beta-blocker is discontinued, but I would not expect palpitations to persist. Be aware that palpitations might return transiently as a withdrawal rebound can occur when the beta-blocker is discontinued. One would want to taper the beta-blocker.
* Heart rate with desipramine might be higher than it would be with nortriptyline.
- Scott
Posted by SLS on January 7, 2013, at 13:10:18
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by reconscout on January 7, 2013, at 12:16:47
> Hey Scott,
>
> FYI one more thing that leads me to believe you may be right on. I was taking my dose at night. The palpitations would come on heaviest approx 2 hours after I took the med. When they didn't die down I would take a xanax and they would go away completely. To your knowledge if it was some sort of heart Arrhythmia would the xanax have helped? I just read up on palpitations by the way..If I were you, I would be reluctant to add a beta-blocker and complicate matters.
Good idea with the Xanax. I cannot be sure, but I don't think an arrhythmia would disappear with Xanax. That's what beta-blockers and calcium channel blockers are for. I guess it is possible that increases in anxiety can make an existing arrhythmia worse.
- Scott
Posted by reconscout on January 7, 2013, at 16:00:32
In reply to Re: Need Advice next Tricyclic Antedepressant to try » reconscout, posted by SLS on January 7, 2013, at 13:01:20
Hey Scott,
Funny how that works sometimes. I was hoping you'd be checking the site this morning :)
Ok So if I can summarize;
In what you said I heard it is not uncommon for nortriptyline to create a stable response at a low dose where that response becomes unstable as your body further tries to adjust to the medication. You expect increasing the dose would be the solution to the instability I developed at 10mg.
I think you are suggesting it is the nature of a brain in a depressive state to react this way. The combination of the depressed brain and the added new chemical responses by nature create instability The fact that I was no longer feeling depressed may be irrelevant in this discussion as it relates to palpitations. This is why you recommend an increased dosage as opposed to waiting it out at 10mg correct?
You suggested beta blockers as a possible interim solution to the palpitations but expect they should not be necessary long term. This solution has been recommended on other forums by 3 or 4 other folks btw.
It sounds like you would support xanax as another short term solution after hearing my report on its use. My only concern here is when I take xanax too often it stops being effective.
Well thanks again for the support Scott. I am still giving Desipramine a fair shake, currently on day 4. I am really sensitive and very in touch with my body. I kind of get the sense that this drug is not going to be enough to cover all of the symptoms I'm trying to address.(N Pain, Depression, Anxiety, Fatigue, Insomnia) I am falling asleep easier on it but am still waking up 3 to 5 times per night. I also typically will not put up with a drug that leaves me feeling disconnected or out of my body. I usually can tell in the first few days if a drug is going to fit with me or not. I think this drug my be too narrow focused but I want to give it a good week to make that decision.
Posted by jono_in_adelaide on January 7, 2013, at 16:52:13
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by reconscout on January 7, 2013, at 16:00:32
Can i just check, was the OP complaining of palpitations or tachicardia?
I seem to have taken it as tachicardia, where as Scott seems to have taken it as palpitations (or was it both)
Neither is dangerous, even if they are a bit unplesant. I also agree with Scott, adding one drug to counter the side effects of another is bad practice, so if you could tolorate the side effects without the betablocker, then do it by all means, they might settle in time, but, if you find that nortriptyline gives stellar releif, but you cantr tolorate the cardiac side effects, I think a low dose of atenolol would be justified for the improvment in your life it allowed.
Posted by jono_in_adelaide on January 7, 2013, at 16:59:02
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by jono_in_adelaide on January 7, 2013, at 16:52:13
As always, Scots advice was well thought out and reasoned - I'd give what he said some very serious thought.
Posted by reconscout on January 7, 2013, at 17:44:59
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by jono_in_adelaide on January 7, 2013, at 16:52:13
Thanks for the one up Jono, It was heart pounding, not for sure but it seems to be palpitations.
Posted by schleprock on January 7, 2013, at 20:30:47
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by SLS on January 7, 2013, at 13:10:18
I was under the impression that nortriptyline dosage (for mdd/anxiety?) was to be determined through bloodwork and monitoring for the "therapeutic window".
Also, there was just a report on the news stating that studies suggested taking beta-blockers help prevent the onset of dementia and Alzheimer's.
By the way, my pdoc was skeptical when I mentioned the use of alpha-blockers for treating depression. Couldn't really get him to really explain the differences between alphas and betas. He's pretty much a big supporter of buspirone. Bringing up my buspirone dilemmas to the community will have to wait until another thread.
He also immediately shot down Latuda as an option for treatment.
Posted by SLS on January 7, 2013, at 21:19:54
In reply to Re: Need Advice next Tricyclic Antedepressant to try » SLS, posted by schleprock on January 7, 2013, at 20:30:47
> I was under the impression that nortriptyline dosage (for mdd/anxiety?) was to be determined through bloodwork and monitoring for the "therapeutic window".
The dosage can be worked with to some degree by using the statistical mode, which happens to be 75 mg/day. It is my observation that people seem to fall into one of two categories: slow metabolizers and extensive metabolizers. slow metabolizers tend to respond to 50 - 75 mg/day, while extensive metabolizers respond to 150 mg/day. I wouldn't bother with getting blood levels at 75 mg/day unless there is an inadequate clinical response or intolerable side effects. Nortriptyline is perhaps the only antidepressant for which it is possible to actually lose a response if the dosage is increased beyond its therapeutic window. A responder at 75 mg/day can be a non-responder at 100 mg/day.
> Also, there was just a report on the news stating that studies suggested taking beta-blockers help prevent the onset of dementia and Alzheimer's.
Yes. I saw that. I don't know what to make of it, though. Is it a neurochemical effect or a mechanical effect?
> By the way, my pdoc was skeptical when I mentioned the use of alpha-blockers for treating depression.
Well, prazosin has been shown to reduce both anxiety and depression in the PTSD patients that were studied. So far, I don't think non-PTSD patients have been studied methodically.
My personal theory regarding prazosin involves its ability to antagonize NE alpha-1b receptors in the frontal cortex, hippocampus, and amygdala. Tricyclics do not affect these receptors.
http://www.dr-bob.org/babble/20120202/msgs/1009565.html
Depression seems to be associated with hyperactivity, rather than hypoactivity, in several brain regions. That's why DBS works. DBS interferes with neurotransmission, thus reducing activity rather than stimulating it.
> Couldn't really get him to really explain the differences between alphas and betas.
You could really test him by asking him what are the three subtypes of NE alpha-1 receptors: NE alpha-1a/b/d. There is no "c" :-).
> He's pretty much a big supporter of buspirone.
At least someone is. There are people who report fantastic results for anxiety, but it may not begin working for two or three weeks. I haven't seen anyone report success when using buspirone as an augmentor of antidepressants for treating depression, but I'm sure it can. For me, it would probably be a bad drug because I react badly to NE alpha-2 antagonists. Although the buspirone parent molecule does not do this, its 1-PP metabolite does.
> Bringing up my buspirone dilemmas to the community will have to wait until another thread.
Now, you have me in suspense.
> He also immediately shot down Latuda as an option for treatment.
What exactly is your diagnosis or symptom?
- Scott
Posted by reconscout on January 7, 2013, at 22:30:10
In reply to Re: Need Advice next Tricyclic Antedepressant to try » schleprock, posted by SLS on January 7, 2013, at 21:19:54
Hey Chris, In case you missed it, I'd love to hear your response to my last post.....
Posted by reconscout on January 23, 2013, at 18:13:05
In reply to Re: Need Advice next Tricyclic Antedepressant to try, posted by reconscout on January 7, 2013, at 22:30:10
Hey Folks. I though I would post my progress for those of you who may also be benefiting from this topic.
So I ended up coming off the desipramine over 2 or days. I started back up with the Nortriptyline.
Day One - I took 10 MG of Nortryptyline. This time around I did not sleep through the night, I woke up prob 6 times but I think that was likely more a result of the past drugs still in my system. Already felt depression and anxiety starting to lift.
Day 2 - 10 MG I slept a little bit better but was feeling some heavier withdrawals head, stomach, etc...from coming off the Desipramine. Anxiety and depression lifted further. mild fog started in.
Day 3 - 10 MG mild withdrawal from the desipramine slept most of the way through the night only 2 wake-ups. further lift of anxiety and depression. mild fog.
Day 4 - same sleep pattern prob peaked anxiety depression benefit. mild fog.
Day 5-7 - same sleep pattern mildly decreasing anxiety and depression benefit. got some palpitations (this leads me to believe you're suspicians were accurate Chris) xanax kept them in check. mild fog lifted. Had a strange heavy depression on Day 6 only.
Day 7 - switched to 15 MG - Slept all the way through the night. anxiety and depression turned around towards the positive direction again.
Day 8 - mild fog came back, still sleeping well. continued positive improvement.
Day 9 - minor constipation, some other digestive side effects, mild fog, continued mood improvement.
Day 10, 11 - constipation gone, fog reducing, stable mood, most positive yet, a little manic
Day 12 - Solid Sleep, fog reducing, Heavy depression Anxiety,
My day 12 is today. This Depression on day 6 is right on track with what happened my first time around. I expect my day 6 and 7 of each new dose or in this runs case day 11 and 12 is my brains attempt to push extremes in order to find balance. If things go as they have in the past I expect to have a very well balance day tomorrow. Let's keep our fingers crossed guys.
Thanks everyone for your support. I chose to not go with a beta blocker unless I absolutely need it. So far my palpitations have not been a big issue. I think my original palpitations when I started Nortriptyline the first time were largely aggravated by my anxiety about them. This time around I am paying them less attention and not allowing myself to get anxious around them and the result is they are less frequent and mostly short lived. Additionally I've been watching my resting heart rate and it has not really gone outside of my normal fluctuations more than 5 or 6 beats per minute. I have noticed a more aggressive response while taking an energy drink or other heavy energy products. Not sure what to make of this I will run it by my doctor when I talk to him next.
This is the end of the thread.
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