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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 22 of 22. This is the beginning of the thread.
Posted by tensor on April 1, 2013, at 16:14:00
I'm going to add Lamictal to my mirtazapine 30mg, amitriptyline 100mg and clonazepam 2mg, to see if it can prevent this downward spiral with depression and anxiety.
For the first time in my life I'm actually considering MAOIs if the above fails. They are not used here afaik, maybe in special cases I don't know, but my pdoc was aware of them and their issues.
I guess the eternal question is Parnate vs Nardil. Given my history of GAD, SA and TRD I'm sure one is preferred over the other. Which one is harshest on the liver?
I would like to combine it with Remeron for sexual and GI problems. Being a 5HT2A-antagonist it should be protective against serotonin overload.How is it living with MAOI? Do they keep their efficacy or does it usually fade with time? Diet restrictions?
Would like to hear what you have to say.
/tensor
Posted by Tomatheus on April 1, 2013, at 17:26:24
In reply to To MAOI or not to MAOI, posted by tensor on April 1, 2013, at 16:14:00
Tensor,
I personally didn't get a lasting response from the MAOIs that I tried (and I tried them all), but I'm pretty sure at this point that I have idiopathic hypersomnia (and not clinical depression) in addition to the psychosis that begin to manifest itself for me after I tried most of my MAOIs. I think that individuals with depression (especially if the depression is atypical) and anxiety would be more likely to respond to the MAOIs in the long run than I was, although obviously all treatments for depression and anxiety are far from being universally effective. I adjusted to the dietary restrictions rather easily and found that I was able to give up aged cheeses, cured meats, and other foods rather easily when it meant that my energy level was adequate and that I could wake up as easily as anybody else. Unfortunately, as I've said, none of the MAOIs had a lasting effect on me, but when they did work (which was only for three days at a time, except in the case of Nardil), they worked rather well, significantly relieving all of my symptoms.
It's my understanding based on what I've read that Nardil is usually used before Parnate in individuals who experience anxiety as part of their symptomatic profile, given Parnate's reputation as being a more "activating" medication than Nardil is. Also, Nardil inhibits the enzyme GABA transaminase, and Parnate, as far as I know does not, and this may give Nardil and advantage over Parnate when it comes to treating anxiety. I think I've read that Nardil tends to be harsher on the liver than Parnate is, but other members here may have more information on that matter than I do.
All in all, given the symptoms that you list, an MAOI may be worth asking about, assuming that you're comfortable with the risks that MAOIs carry and are committed to restricting what you eat and what medicines you take. Others on this board know more about what psychiatric medications can be taken alongside MAOIs than I do, but I have heard of MAOIs being taken along with Lamictal and clonazepam. Amitriptyline inhibits the reuptake of serotonin and thus should not be taken with an MAOI if my understanding is correct, but I'm not sure about the safety of taking mirtazapine with an MAOI.
Anyway, I hope that you get good results with adding Lamictal to your medication combo, and I wish you luck with getting more responses to your questions from individuals with anxiety and depression. I also hope that my responses have been of some help.
Take care,
Tomatheus
Posted by Tomatheus on April 1, 2013, at 17:40:24
In reply to Re: To MAOI or not to MAOI, posted by Tomatheus on April 1, 2013, at 17:26:24
> Amitriptyline inhibits the reuptake of serotonin and thus should not be taken with an MAOI if my understanding is correct
Actually, I take this back. Information in a post that was just made here (see below) seems to suggest that imipramine and clomipramine are the only tricyclics that pose a significant risk of triggering serotonin syndrome when taken with an MAOI. Of course, taking a tricyclic without significant serotonergic properties alongside an MAOI should only be done with close medical supervision.
Here's a link to the post that I mentioned above:
http://www.dr-bob.org/babble/20130322/msgs/1041496.htmlTomatheus
Posted by vanvog on April 1, 2013, at 18:19:02
In reply to Re: To MAOI or not to MAOI, posted by Tomatheus on April 1, 2013, at 17:40:24
Amitriptyline blocks and prevents the reuptake of norepinephrine not serotonin.
Parnate is less toxic to the liver than Nardil according to Gillman.
Posted by Phillipa on April 1, 2013, at 18:43:28
In reply to Re: To MAOI or not to MAOI, posted by vanvog on April 1, 2013, at 18:19:02
There have been some here that had spontaneous hypertensive Crisis. Check the archives. Tensor I'm sure you remember some? Phillipa
Posted by Tomatheus on April 1, 2013, at 19:00:58
In reply to Re: To MAOI or not to MAOI, posted by vanvog on April 1, 2013, at 18:19:02
> Amitriptyline blocks and prevents the reuptake of norepinephrine not serotonin.
According to this source (http://www.druglib.com/activeingredient/amitriptyline/), it inhibits the reuptake of both serotonin and norepinephrine. Wikipedia says the same.
I know that the Gillman article that you posted says that imipramine and clomipramine are the only tricyclics that can trigger serotonin syndrome when combined with an MAOI. Maybe the sources referenced in the article might have some information to refute the notion that amitriptyline inhibits the reuptake of both norepinephrine and serotonin, but the sources that I've come across do suggest that amitriptyline blocks serotonin transporters.
Tomatheus
Posted by tensor on April 2, 2013, at 4:23:33
In reply to Re: To MAOI or not to MAOI, posted by vanvog on April 1, 2013, at 18:19:02
> Amitriptyline blocks and prevents the reuptake of norepinephrine not serotonin.
It blocks both, accordingly to Stahl and wikipedia.
http://en.wikipedia.org/wiki/Tricyclic_antidepressant
/tensor
Posted by tensor on April 2, 2013, at 4:32:59
In reply to Re: To MAOI or not to MAOI, posted by Tomatheus on April 1, 2013, at 17:26:24
> Tensor,
>
> I personally didn't get a lasting response from the MAOIs that I tried (and I tried them all), but I'm pretty sure at this point that I have idiopathic hypersomnia (and not clinical depression) in addition to the psychosis that begin to manifest itself for me after I tried most of my MAOIs. I think that individuals with depression (especially if the depression is atypical) and anxiety would be more likely to respond to the MAOIs in the long run than I was, although obviously all treatments for depression and anxiety are far from being universally effective. I adjusted to the dietary restrictions rather easily and found that I was able to give up aged cheeses, cured meats, and other foods rather easily when it meant that my energy level was adequate and that I could wake up as easily as anybody else. Unfortunately, as I've said, none of the MAOIs had a lasting effect on me, but when they did work (which was only for three days at a time, except in the case of Nardil), they worked rather well, significantly relieving all of my symptoms.
>
> It's my understanding based on what I've read that Nardil is usually used before Parnate in individuals who experience anxiety as part of their symptomatic profile, given Parnate's reputation as being a more "activating" medication than Nardil is. Also, Nardil inhibits the enzyme GABA transaminase, and Parnate, as far as I know does not, and this may give Nardil and advantage over Parnate when it comes to treating anxiety. I think I've read that Nardil tends to be harsher on the liver than Parnate is, but other members here may have more information on that matter than I do.
>
> All in all, given the symptoms that you list, an MAOI may be worth asking about, assuming that you're comfortable with the risks that MAOIs carry and are committed to restricting what you eat and what medicines you take. Others on this board know more about what psychiatric medications can be taken alongside MAOIs than I do, but I have heard of MAOIs being taken along with Lamictal and clonazepam. Amitriptyline inhibits the reuptake of serotonin and thus should not be taken with an MAOI if my understanding is correct, but I'm not sure about the safety of taking mirtazapine with an MAOI.
>
> Anyway, I hope that you get good results with adding Lamictal to your medication combo, and I wish you luck with getting more responses to your questions from individuals with anxiety and depression. I also hope that my responses have been of some help.
>
> Take care,
> TomatheusThanks for your thorough answer.
I suspected Nardil would be more suitable for anxious depression. I would only keep Remeron and clonazepam if I were to start Nardil. Did you get to have an antidote to carry around with you for hypertensive crisis, like nifedipine? How fast does bp rise to dangerous levels should you ingest too much tyramine? Did you find the side effects bothersome?/tensor
Posted by tensor on April 2, 2013, at 4:34:52
In reply to Re: To MAOI or not to MAOI, posted by Phillipa on April 1, 2013, at 18:43:28
> There have been some here that had spontaneous hypertensive Crisis. Check the archives. Tensor I'm sure you remember some? Phillipa
IIRC, these are rare and I believe Parnate is more prone to cause this.
/tensor
Posted by Tomatheus on April 2, 2013, at 10:16:03
In reply to Re: To MAOI or not to MAOI » Tomatheus, posted by tensor on April 2, 2013, at 4:32:59
Tensor,
See below for my responses to your questions...
> Did you get to have an antidote to carry around with you for hypertensive crisis, like nifedipine?
No, I didn't. I probably should have at least asked my doctor about getting an antidote medication, but I never did. Then again, the nearest hospital to me isn't very far away. I never had a hypertensive crisis, but of course, they can occur.
> How fast does bp rise to dangerous levels should you ingest too much tyramine?
According to Sathyanarayana Rao & Yeragani (2009), hypertensive crisis episodes usually occur one to two hours after the intake of the offending food.
> Did you find the side effects bothersome?
For the most part, I didn't find the side effects of Nardil to be bothersome. I gained a little bit of weight on Nardil and experienced some lightheadedness and dizziness upon standing early on during the course of my trial with the medication, but those side effects didn't bother me too much. I also experienced excessive sweating and urinary retention on certain versions of Nardil, but not others, and although I didn't particularly care for those side effects, they never became so unbearable to prompt me to discontinue the medication. About two months into my trial with a slightly altered (enterically encapsulated) version of Nardil that Pfizer markets in the U.S. (which is where I live), I experienced extreme agitation, which along with a sudden loss of effectiveness, did prompt me to discontinue the medication. I suspect that the extreme agitation and the sudden loss of effectiveness that I experienced about two months after I started taking Pfizer's U.S. Nardil may have been brought on by a bad batch of the medication, which other Nardil users in the U.S. have reported, but I guess I can't be 100 percent sure about that.
The main side effect that I experienced on the U.S. version of Parnate (which was made by GlaxoSmithKline at the time) was afternoon drowsiness. Because I was taking classes in the afternoon and evening at the time I took the GlaxoSmithKline Parnate and ended up sleeping through the classes as a result, I did find this particular side effect to be bothersome, and it led me to discontinue the medication. Later, I tried the U.K. version of tranylcypromine (generic Parnate, and that version was made by Goldshield at the time) and did not experience afternoon drowsiness or any other side effects that I could recall.
I don't recall experiencing any side effects when I tried Marplan, but then again, I didn't keep taking the medication for very long because its therapeutic benefits were very short lived for me. I experienced some agitation and what I would describe as slight cognitive impairment when I took oral selegiline, which were somewhat bothersome. I don't know whether or not I would have tolerated the side effects that I experienced on selegiline into the long term, but the fact that my therapeutic benefits on the medication were short lived made the decision to discontinue the drug easy. I think I experienced some agitation from taking moclobemide, but I had been feeling very agitated prior to taking moclobemide and after I stopped taking it, so it was difficult to tell how much more agitated I might have been as a result of taking the medication.
Well, this sums up my responses to your questions. If you have any more questions for me, please feel free to ask.
Tomatheus
==
REFERENCE
Sathyanarayana Rao, T.S., & Yeragani, V.K. (2009). Hypertensive crisis and cheese. Indian Journal of Psychiatry, 51, 65-66. Article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2738414/
Posted by sigismund on April 2, 2013, at 20:26:32
In reply to To MAOI or not to MAOI, posted by tensor on April 1, 2013, at 16:14:00
If Marplan worked for you it would likely have fewer side effects than Nardil.
Might be hard to get hold of though.
Posted by tensor on April 3, 2013, at 3:32:04
In reply to Re: To MAOI or not to MAOI » tensor, posted by Tomatheus on April 2, 2013, at 10:16:03
> Tensor,
>
> See below for my responses to your questions...
>
> > Did you get to have an antidote to carry around with you for hypertensive crisis, like nifedipine?
>
> No, I didn't. I probably should have at least asked my doctor about getting an antidote medication, but I never did. Then again, the nearest hospital to me isn't very far away. I never had a hypertensive crisis, but of course, they can occur.
>
> > How fast does bp rise to dangerous levels should you ingest too much tyramine?
>
> According to Sathyanarayana Rao & Yeragani (2009), hypertensive crisis episodes usually occur one to two hours after the intake of the offending food.
>
> > Did you find the side effects bothersome?
>
> For the most part, I didn't find the side effects of Nardil to be bothersome. I gained a little bit of weight on Nardil and experienced some lightheadedness and dizziness upon standing early on during the course of my trial with the medication, but those side effects didn't bother me too much. I also experienced excessive sweating and urinary retention on certain versions of Nardil, but not others, and although I didn't particularly care for those side effects, they never became so unbearable to prompt me to discontinue the medication. About two months into my trial with a slightly altered (enterically encapsulated) version of Nardil that Pfizer markets in the U.S. (which is where I live), I experienced extreme agitation, which along with a sudden loss of effectiveness, did prompt me to discontinue the medication. I suspect that the extreme agitation and the sudden loss of effectiveness that I experienced about two months after I started taking Pfizer's U.S. Nardil may have been brought on by a bad batch of the medication, which other Nardil users in the U.S. have reported, but I guess I can't be 100 percent sure about that.
>
> The main side effect that I experienced on the U.S. version of Parnate (which was made by GlaxoSmithKline at the time) was afternoon drowsiness. Because I was taking classes in the afternoon and evening at the time I took the GlaxoSmithKline Parnate and ended up sleeping through the classes as a result, I did find this particular side effect to be bothersome, and it led me to discontinue the medication. Later, I tried the U.K. version of tranylcypromine (generic Parnate, and that version was made by Goldshield at the time) and did not experience afternoon drowsiness or any other side effects that I could recall.
>
> I don't recall experiencing any side effects when I tried Marplan, but then again, I didn't keep taking the medication for very long because its therapeutic benefits were very short lived for me. I experienced some agitation and what I would describe as slight cognitive impairment when I took oral selegiline, which were somewhat bothersome. I don't know whether or not I would have tolerated the side effects that I experienced on selegiline into the long term, but the fact that my therapeutic benefits on the medication were short lived made the decision to discontinue the drug easy. I think I experienced some agitation from taking moclobemide, but I had been feeling very agitated prior to taking moclobemide and after I stopped taking it, so it was difficult to tell how much more agitated I might have been as a result of taking the medication.
>
> Well, this sums up my responses to your questions. If you have any more questions for me, please feel free to ask.
>
> Tomatheus
>
> ==
>
> REFERENCE
>
> Sathyanarayana Rao, T.S., & Yeragani, V.K. (2009). Hypertensive crisis and cheese. Indian Journal of Psychiatry, 51, 65-66. Article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2738414/
>Thank you for your help. That is very good information.
/tensor
Posted by tensor on April 28, 2013, at 15:20:49
In reply to Re: To MAOI or not to MAOI » tensor, posted by Tomatheus on April 2, 2013, at 10:16:03
Tomatheus, how bad was the sexual dysfunction on Nardil?
Again, thanks.
/tensor
Posted by Tomatheus on April 28, 2013, at 15:45:58
In reply to Re: To MAOI or not to MAOI » Tomatheus, posted by tensor on April 28, 2013, at 15:20:49
Tensor,
I remember having a lot of difficulty climaxing (sorry if that's TMI) when I was taking film-coated Nardil, without doing anything to alter the tablets. Interestingly, I remember that problem basically disappearing when I tried taking my Nardil in the enteric capsules that I used. I'm not sure if anyone else had that side effect disappear after going from film-coated Nardil to an "enteric" version of Nardil, but I definitely remember not having problems with sexual functioning after I tried using the enteric capsules.
T.
Posted by SLS on April 28, 2013, at 16:23:24
In reply to Re: To MAOI or not to MAOI » Tomatheus, posted by tensor on April 28, 2013, at 15:20:49
> Tomatheus, how bad was the sexual dysfunction on Nardil?
>
> Again, thanks.
>
> /tensor
I have a great deal of trouble reaching orgasm when I first start taking Nardil. However, I find that it becomes easier over time. It usually takes about 3 months to recover the ability to orgasm, although it still takes more time to achieve it. It can be very frustrating.
- Scott
Posted by tensor on April 29, 2013, at 7:38:56
In reply to Re: To MAOI or not to MAOI » tensor, posted by SLS on April 28, 2013, at 16:23:24
> I have a great deal of trouble reaching orgasm when I first start taking Nardil. However, I find that it becomes easier over time. It usually takes about 3 months to recover the ability to orgasm, although it still takes more time to achieve it. It can be very frustrating.
>
>
> - ScottIs Parnate better in this regard? How would you rate Parnate's anxiolytic qualities?
/tensor
Posted by tensor on April 29, 2013, at 7:41:39
In reply to Re: To MAOI or not to MAOI » tensor, posted by Tomatheus on April 28, 2013, at 15:45:58
> Tensor,
>
> I remember having a lot of difficulty climaxing (sorry if that's TMI) when I was taking film-coated Nardil, without doing anything to alter the tablets. Interestingly, I remember that problem basically disappearing when I tried taking my Nardil in the enteric capsules that I used. I'm not sure if anyone else had that side effect disappear after going from film-coated Nardil to an "enteric" version of Nardil, but I definitely remember not having problems with sexual functioning after I tried using the enteric capsules.
>
> T.Any idea why this is the case?
Are the enteric capsules dosed once-a-day?/tensor
Posted by SLS on April 29, 2013, at 8:32:20
In reply to Re: To MAOI or not to MAOI » SLS, posted by tensor on April 29, 2013, at 7:38:56
> > I have a great deal of trouble reaching orgasm when I first start taking Nardil. However, I find that it becomes easier over time. It usually takes about 3 months to recover the ability to orgasm, although it still takes more time to achieve it. It can be very frustrating.
> Is Parnate better in this regard?
Definitely.
> How would you rate Parnate's anxiolytic qualities?
Michael Liebowitz did a study in the 1980s that indicated that Parnate was virtually as effective as Nardil in treating social phobia.
Here is a more recent study that seems relevant. Note the difference in the efficacy between 30 mg/day versus 60 mg/day.
http://www.ncbi.nlm.nih.gov/pubmed/20036427
- Scott
Posted by tensor on April 29, 2013, at 8:40:26
In reply to Re: To MAOI or not to MAOI » tensor, posted by SLS on April 29, 2013, at 8:32:20
> > > I have a great deal of trouble reaching orgasm when I first start taking Nardil. However, I find that it becomes easier over time. It usually takes about 3 months to recover the ability to orgasm, although it still takes more time to achieve it. It can be very frustrating.
>
> > Is Parnate better in this regard?
>
> Definitely.
>
> > How would you rate Parnate's anxiolytic qualities?
>
> Michael Liebowitz did a study in the 1980s that indicated that Parnate was virtually as effective as Nardil in treating social phobia.
>
> Here is a more recent study that seems relevant. Note the difference in the efficacy between 30 mg/day versus 60 mg/day.
>
> http://www.ncbi.nlm.nih.gov/pubmed/20036427
>
>
> - ScottThanks. This is becoming a very real choice for me. Would be nice to enjoy the summer for once.
/tensor
Posted by SLS on April 29, 2013, at 9:07:06
In reply to Re: To MAOI or not to MAOI » SLS, posted by tensor on April 29, 2013, at 8:40:26
> > > > I have a great deal of trouble reaching orgasm when I first start taking Nardil. However, I find that it becomes easier over time. It usually takes about 3 months to recover the ability to orgasm, although it still takes more time to achieve it. It can be very frustrating.
> >
> > > Is Parnate better in this regard?
> >
> > Definitely.
> >
> > > How would you rate Parnate's anxiolytic qualities?
> >
> > Michael Liebowitz did a study in the 1980s that indicated that Parnate was virtually as effective as Nardil in treating social phobia.
> >
> > Here is a more recent study that seems relevant. Note the difference in the efficacy between 30 mg/day versus 60 mg/day.
> >
> > http://www.ncbi.nlm.nih.gov/pubmed/20036427
> >
> >
> > - Scott
>
> Thanks. This is becoming a very real choice for me. Would be nice to enjoy the summer for once.
>
> /tensor
You and me both.:-)
- Scott
Posted by tensor on April 29, 2013, at 9:44:19
In reply to Re: To MAOI or not to MAOI, posted by SLS on April 29, 2013, at 9:07:06
> You and me both.
>
> :-)
>
>
> - Scott:-)
A minor issue but regarding the orthostatic hypotension, do you happen to know if certain workout exercises are safe, like squat and deadlift? Would not be nice fainting with a bar on your shoulders.
I'm on nortriptyline 100mg now and the OH is not much of an issue, it's just annoying. IIRC you're on both Parnate and nortriptyline at high doses, how bad is the OH for you?/tensor
Posted by Tomatheus on April 29, 2013, at 10:48:12
In reply to Re: To MAOI or not to MAOI » Tomatheus, posted by tensor on April 29, 2013, at 7:41:39
Tensor,
I'm not completely sure why using the enteric capsules seemed to help with sexual dysfunction, as well as some of the other side effects that I experienced when I took film-coated Nardil. My best guess would be that maybe some phenelzine ends up undergoing chemical degradation in the stomach if the medication doesn't have a coating or capsule to protect it from the acids in the stomach and that some of the byproducts of this chemical degradation may cause the sexual dysfunction and some of the other side effects that emerge when taking film-coated Nardil. That's just a guess, though, and it may or may not be reflective of what's actually happening.
When I put the contents of my Nardil tablets into enteric capsules, I used one capsule for each tablet. I ended up spacing out my Nardil doses when I took them, taking the medication four times a day when I was taking 60 mg and five times a day when I was taking 75 mg. It might be possible to take 30 mg or more at once so you won't have to take as many daily doses of Nardil as I did -- I know I've read of others doing this on this board -- but I would advise discussing your Nardil dosing regimen with a health professional if you end up taking the medication, whether or not you try using the enteric capsules.
I wish you luck with whatever you end up doing medication wise. Feel free to let me know if you have any more questions.
T.
This is the end of the thread.
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