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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 14 of 14. This is the beginning of the thread.
Posted by CGDR2 on January 19, 2013, at 14:20:47
Hey guys,
I'm currently on 200mg of Clomipramine, which seems to be working very well. I'm a heavy smoker, in case that dose seems a bit high!
Thing is, while my depression is definitely heading towards remission, there's no way I'm strong enough to stop yet. I was on Phenelzine for a while last year, and the side effects kept me stuck at 45mg, which wasn't enough for my depression. I ended up wasting a lot of time, because rather than admitting the Phenelzine wasn't enough, and trying a new drug, I simply carried on taking it until things got worse.
Blah blah blah; what I'm asking is, has anyone had any good experiences augmenting Clomipramine? My Pdoc is fantastic, but generally likes to hear my ideas, so it seems worthwhile going in armed with some extra knowledge. My main condition is MDD.
Thanks a lot, look forward to hearing from you,
(Previous Drug History, in chrono. order: Citalopram, Fluoxetine, Sertraline, Mirtazapine, Lofepramine, Tranylcypromine, Phenelzine, Imipramine (all failed for one reason or another)
Posted by tensor on January 19, 2013, at 15:59:52
In reply to Clomipramine - Augmentation options?, posted by CGDR2 on January 19, 2013, at 14:20:47
> Hey guys,
>
> I'm currently on 200mg of Clomipramine, which seems to be working very well. I'm a heavy smoker, in case that dose seems a bit high!
>
> Thing is, while my depression is definitely heading towards remission, there's no way I'm strong enough to stop yet. I was on Phenelzine for a while last year, and the side effects kept me stuck at 45mg, which wasn't enough for my depression. I ended up wasting a lot of time, because rather than admitting the Phenelzine wasn't enough, and trying a new drug, I simply carried on taking it until things got worse.
>
> Blah blah blah; what I'm asking is, has anyone had any good experiences augmenting Clomipramine? My Pdoc is fantastic, but generally likes to hear my ideas, so it seems worthwhile going in armed with some extra knowledge. My main condition is MDD.
>
> Thanks a lot, look forward to hearing from you,
>
> (Previous Drug History, in chrono. order: Citalopram, Fluoxetine, Sertraline, Mirtazapine, Lofepramine, Tranylcypromine, Phenelzine, Imipramine (all failed for one reason or another)Mirtazapine comes first to my mind. It should not be anything that are an SRI. Clomipramine is such a strong SRI. Can be used with bupropion with caution. Then there are lithium (great results with TCAs) stims and the AAPs. Do you have a favorite candidate? I would love to elaborate on this but I'm so tired I have to go to bed.
'night
tensor
Posted by CGDR2 on January 19, 2013, at 17:37:13
In reply to Re: Clomipramine - Augmentation options? » CGDR2, posted by tensor on January 19, 2013, at 15:59:52
> Mirtazapine comes first to my mind. It should not be anything that are an SRI. Clomipramine is such a strong SRI. Can be used with bupropion with caution. Then there are lithium (great results with TCAs) stims and the AAPs. Do you have a favorite candidate? I would love to elaborate on this but I'm so tired I have to go to bed.
>
> 'night
> tensorMirtazapine was one of the things I was thinking of, same as Buproprion. I'm already on a low dose of Chlorpromazine and occasional Flupentixol, so I think that rules out Lithium.
I was actually wondering about SSRIs - I know that some people have mixed Clomipramine with SSRIs, and I was wondering if they had seen any benefit?
Thanks for your post
Posted by tensor on January 20, 2013, at 2:30:17
In reply to Re: Clomipramine - Augmentation options?, posted by CGDR2 on January 19, 2013, at 17:37:13
> Mirtazapine was one of the things I was thinking of, same as Buproprion. I'm already on a low dose of Chlorpromazine and occasional Flupentixol, so I think that rules out Lithium.
>
> I was actually wondering about SSRIs - I know that some people have mixed Clomipramine with SSRIs, and I was wondering if they had seen any benefit?
>
> Thanks for your postI know fluvoxamine is used in combination with clomipramine, it makes clomipramine more serotonergic due to a metabolic change. I would stay away from strong SSRIs like paroxetine. The thing is, clomipramine itself is a strong serotonin reuptake inhibitor.
/tensor
/tensor
Posted by SLS on January 20, 2013, at 6:24:22
In reply to Re: Clomipramine - Augmentation options? » CGDR2, posted by tensor on January 20, 2013, at 2:30:17
> I know fluvoxamine is used in combination with clomipramine, it makes clomipramine more serotonergic due to a metabolic change.
Hmm. Interesting. I didn't know that. You are right, of course.
Which metabolic route (enzyme) is responsible for this? I know that CYP3A4 is inhibited by fluvoxamine, but that should not affect a TCA, should it? Is clomipramine different than the other TCAs in this regard?
I hope you slept well.
- Scott
Posted by tensor on January 20, 2013, at 6:34:40
In reply to Re: Clomipramine - Augmentation options? » tensor, posted by SLS on January 20, 2013, at 6:24:22
> > I know fluvoxamine is used in combination with clomipramine, it makes clomipramine more serotonergic due to a metabolic change.
>
> Hmm. Interesting. I didn't know that. You are right, of course.
>
> Which metabolic route (enzyme) is responsible for this? I know that CYP3A4 is inhibited by fluvoxamine, but that should not affect a TCA, should it? Is clomipramine different than the other TCAs in this regard?Fluvoxamine inhibits CYP1A2. Which is the enzyme breaking down clomipramine to desmethyl-clomipramine (which is a strong NE reuptake inhibitor.) This results in higher clomipramine levels and stronger serotonin action.
/tensor
> I hope you slept well.
Thanks, I did :-)
Posted by SLS on January 20, 2013, at 7:57:10
In reply to Re: Clomipramine - Augmentation options? » SLS, posted by tensor on January 20, 2013, at 6:34:40
As always, thank you.
- Scott
Posted by Phillipa on January 20, 2013, at 9:25:35
In reply to Re: Clomipramine - Augmentation options? » SLS, posted by tensor on January 20, 2013, at 6:34:40
Seems fluvoximine effects a lot of other classes of meds also like benzodiazapines. Makes them stronger I was told. Phillipa
Posted by CGDR2 on January 20, 2013, at 17:15:27
In reply to Re: Clomipramine - Augmentation options? » tensor, posted by Phillipa on January 20, 2013, at 9:25:35
So do people have any opinions on Luvox + Clomipramine? Seems I've seen that around in a few places
Posted by jono_in_adelaide on January 20, 2013, at 17:39:52
In reply to Clomipramine - Augmentation options?, posted by CGDR2 on January 19, 2013, at 14:20:47
Low dose atypical antipsychotic (say risperidone 1mg at bedtime) might be usefull
Posted by jono_in_adelaide on January 20, 2013, at 17:41:49
In reply to Re: Clomipramine - Augmentation options?, posted by jono_in_adelaide on January 20, 2013, at 17:39:52
Bupropion might also be a goer, but under no circumstances should you take an SSRI or SNRI with clomipramine, it can result in serious seretonin toxicity.
What are your residual symptoms that you'd like the augmenter to treat?
Posted by tensor on January 21, 2013, at 1:53:52
In reply to Re: Clomipramine - Augmentation options?, posted by CGDR2 on January 20, 2013, at 17:15:27
> So do people have any opinions on Luvox + Clomipramine? Seems I've seen that around in a few places
Yes, but that is for severe and/or treatment-resistant OCD, nothing I would take for MDD. As I pointed out earlier and also by jono_in_adelaide, combining an SSRI with clomipramine can result in way to much serotonergic activity.
Basically, it's redundant to combine these two. I have had som luck combining clomipramine with Remeron, it's a powerful combination. I you were to choose bupropion, it would be prudent to lower your clomipramine dosage because bupropion inhibits (to some extent) the breakdown of clomipramineRemeron has some nice features, it blocks 5-HT3 which may revese nausea and other GI s/e. Several antiemetics work this way. It may also reverse sexual s/e of ADs, atleast for SSRIs, I found that it wasn't quite strong in this regard for clomipramine.
/tensor
Posted by CGDR2 on January 22, 2013, at 13:46:58
In reply to Re: Clomipramine - Augmentation options?, posted by jono_in_adelaide on January 20, 2013, at 17:39:52
To answer those last questions:
Residual symptom is depression; I'm not depressed at the moment, and if anything, I'd be hyperthymic. Problem is, I know that my remission is not stable, as a few unkind words could make me feel hopeless. I just want to make sure the remission is as strong as possible.
As for Risperidone, I actually forgot to mention; I tried that as well. It made me feel... urgh, which was odd. I replace it with Flupenthixol for day-time anxiety, and that works a charm. Also tried Seroquel, and don't really want to be on three antipsychotics!
I also want to quit smoking, so I was thinking Buproprion would be perfect.
Many thanks again,
Posted by tensor on January 23, 2013, at 0:48:18
In reply to Re: Clomipramine - Augmentation options?, posted by CGDR2 on January 22, 2013, at 13:46:58
> I also want to quit smoking, so I was thinking Buproprion would be perfect.
>
> Many thanks again,
>Ok, but read this:
http://www.drugs.com/interactions-check.php?drug_list=440-0,702-0You don't want a two-fold increase of clomipramine.
It's possible to check plasma levels of clomipramine.
/tensor
This is the end of the thread.
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