![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 7 to 31 of 50. Go back in thread:
Posted by ed_uk2010 on November 28, 2013, at 13:14:30
In reply to Safest trycyclics?, posted by Lamdage22 on November 24, 2013, at 10:10:19
> I wonder what they are and if it can be combined with moclobemide.
>
> My doctor told me they are hard on the heart, but im thinking to myself: What do i need heart health for with 50 when i feel like killing myself for 25 and more years?Only non-serotonergic TCAs combine with moclobemide. Others produce symptoms of serotonin toxicity eg. shivering, agitation, sweating, muscle twitching.
Have you ever tried nortriptyline? And do you suffer from any kind of heart or cardiovascular condition?
Posted by Lamdage22 on November 29, 2013, at 10:44:56
In reply to Re: Safest trycyclics?, posted by ed_uk2010 on November 28, 2013, at 13:14:30
No ed,
i dont suffer from that. I do need to take an antipsychotic along with the tricyclic though.
When i was on Lamictal i was normal without antipsychotic. My hope is that this result can be reproduced.
Posted by ed_uk2010 on November 29, 2013, at 14:05:54
In reply to Re: Safest trycyclics?, posted by Lamdage22 on November 29, 2013, at 10:44:56
> No ed,
>
> i dont suffer from that. I do need to take an antipsychotic along with the tricyclic though.
>
> When i was on Lamictal i was normal without antipsychotic. My hope is that this result can be reproduced.
>
>So you had to stop Lamictal?
Nortriptyline is useful for major depression. I'm unsure how it performs in schizoaffective disorder, probably as well as most TCAs.
You would want to start with a low dose and see how you do before increasing. 25mg at night might be sensible. Nort is dangerous in overdose, and it would be a good idea to only get a couple of weeks supply at a time. If you have a history of mania, all TCAs need to be used with great caution.
Ask your doctor for his/her opinion on this.
Posted by Lamdage22 on November 30, 2013, at 4:23:16
In reply to Re: Safest trycyclics?, posted by ed_uk2010 on November 29, 2013, at 14:05:54
I stopped it because i went to university and i felt too stupid.
Also i thought it made me loose hair.But if it enables me to take less antipsychotics and more antidepressants due to its (in my case) antipsychotic properties i decided its worth it.
Posted by ed_uk2010 on November 30, 2013, at 5:19:27
In reply to Re: Safest trycyclics?, posted by Lamdage22 on November 30, 2013, at 4:23:16
> I stopped it because i went to university and i felt too stupid.
> Also i thought it made me loose hair.Maybe a smaller dose would be suitable?
Posted by Lamdage22 on November 30, 2013, at 5:38:34
In reply to Re: Safest trycyclics?, posted by ed_uk2010 on November 30, 2013, at 5:19:27
Yes perhaps. Thinking like 100mgs.
I do want to take the 300mg Seroquel against depression anyway.
Right now its 700 Seroquel and 15 Zyprexa. Want to reduce that.
With the help of Sarcosine and Lamictal.
Posted by ed_uk2010 on December 1, 2013, at 6:33:55
In reply to Re: Safest trycyclics?, posted by Lamdage22 on November 30, 2013, at 5:38:34
>Right now its 700 Seroquel and 15 Zyprexa. Want to reduce that.
That is rather a lot. Does your doctor feel you may be able to reduce - and do you?
>Lamictal.
I get the impression that cognitive side effects are usually minimal at low doses, but become progressively worse at high doses, especially >200mg/day, but it's minimal. I get the impression that approx. 50mg twice a day (or 100mg once a day) tends to be the lowest dose which is useful.
On another note, do you usually tolerate ADs, or do they induce agitation, manic or psychotic symptoms?
Posted by Lamdage22 on December 3, 2013, at 6:11:16
In reply to Re: Safest trycyclics?, posted by ed_uk2010 on December 1, 2013, at 6:33:55
> >Right now its 700 Seroquel and 15 Zyprexa. Want to reduce that.
>
> That is rather a lot. Does your doctor feel you may be able to reduce - and do you?Yes, we want to discontinue Zyprexa.
>
> >Lamictal.
>
> I get the impression that cognitive side effects are usually minimal at low doses, but become progressively worse at high doses, especially >200mg/day, but it's minimal. I get the impression that approx. 50mg twice a day (or 100mg once a day) tends to be the lowest dose which is useful.Thats good.
>
> On another note, do you usually tolerate ADs, or do they induce agitation, manic or psychotic symptoms?That we are finding out now. I certainly needan AD and balance it with the Seroqudl for example.
Posted by ed_uk2010 on December 3, 2013, at 6:29:32
In reply to Re: Safest trycyclics?, posted by Lamdage22 on December 3, 2013, at 6:11:16
>Yes, we want to discontinue Zyprexa.
OK, good. I'm sure you already know (and so I don't want to offend), but it will need to be very gradual, particularly the final stages. Zyprexa can be difficult to discontinue.
>That we are finding out now. I certainly need an AD and balance it with the Seroquel for example.
OK, so were you thinking of introducing an AD at some point in the next few months, once your other meds are more stable? That makes sense. I was wondering whether you've reacted badly to SSRIs like Lexapro since you're asking about tricyclics?
Take care,
ed_uk
Posted by Lamdage22 on December 3, 2013, at 8:58:45
In reply to Re: Safest tricyclics? » Lamdage22, posted by ed_uk2010 on December 3, 2013, at 6:29:32
Lexapro can prolong QT intervall.
I took Sertraline and got akathisia from it.Doc said other SSRI either prolong QT or make even more akathisia.
Posted by Lamdage22 on December 3, 2013, at 9:01:13
In reply to Re: Safest tricyclics?, posted by Lamdage22 on December 3, 2013, at 8:58:45
> Lexapro can prolong QT intervall.
> I took Sertraline and got akathisia from it.
>
> Doc said other SSRI either prolong QT or make even more akathisia.Antipsychotics are said to prolong qt as well, thats why.
Posted by ed_uk2010 on December 3, 2013, at 13:04:16
In reply to Re: Safest tricyclics?, posted by Lamdage22 on December 3, 2013, at 8:58:45
>Lexapro can prolong QT interval.
True, but probably less so than any of the major tricyclics. Overall, it seems that tricyclics are considerably more likely to cause cardiac arrhythmias than other ADs, including all SSRIs. QT prolongation is dose-dependent, so anyone at risk should avoid high doses and overly complex med combinations.
Amitriptyline in particular tends to cause QT prolongation, which is part of the reason that it is very toxic in overdose.
Posted by ed_uk2010 on December 3, 2013, at 13:06:28
In reply to Re: Safest tricyclics?, posted by Lamdage22 on December 3, 2013, at 9:01:13
>Antipsychotics are said to prolong qt as well, thats why.
Most do yes, Seroquel and Zyprexa are not terribly bad in this respect but the effect may be increased by the combination. Perhaps you could initiate an AD once you've tapered off Zyprexa and started Lamictal.
Posted by Lamdage22 on December 4, 2013, at 3:37:28
In reply to Re: Safest tricyclics?, posted by ed_uk2010 on December 3, 2013, at 13:06:28
Thanks, i will keep that in mind.
Its good to know that other SSRIs are still an option.
Posted by ed_uk2010 on December 4, 2013, at 8:59:11
In reply to Re: Safest tricyclics?, posted by Lamdage22 on December 4, 2013, at 3:37:28
> Thanks, i will keep that in mind.
>
> Its good to know that other SSRIs are still an option.
>Zoloft, Celexa and Lexapro have the fewest drug interactions amongst the SSRIs, which is useful if you're on multiple meds. Given your previous reaction to Zoloft, a low starting dose of any SSRI would be essential eg. Lexapro 5mg in the morning, or Celexa 10mg in the morning. You could even take less for the first few days if you prefer, just to make sure you're OK with it, and then increase up to a more normal dose over a period of a few weeks. No more than 40mg of Celexa or 20mg of Lexapro should be taken per day. Some people do take higher doses off-label, but it's not safe when you're on other drugs which may prolong the QT interval.
After an initial low starting dose, 'standard' therapeutic doses are 20mg Celexa or 10mg Lexapro, but individual adjustment may be needed. To be honest, it might be best not to exceed these doses while taking Seroquel, unless it's unavoidable. I do not think it would be a good idea to take either Celexa or Lexapro while still on two antipsychotics, since the effect on the QT interval may be additive. Once you've tapered off Zyprexa you have more options. It is possible (thought not entirely clear) than Lexapro may be slightly more effective than Celexa. It is unfortunately a lot more expensive, and not everyone prefers it. Overall, they are very similar meds.
Zoloft has no effect on the QT interval, but it sounds like you tolerated it badly so I guess it's a no-go.
Prozac and Paxil have very little, if any, cardiac effects, but they do have a lot of drug interactions which can make med combinations awkward. I do not believe that either of these drugs interact greatly with Seroquel, however. On the other hand, they do tend to cause slightly more side effects than Celexa or Lexapro.
Have you considered mirtazapine (Remeron)? It may be a useful AD. It does not appear to prolong the QT interval and it may improve depression and insomnia when coming off Zyprexa. You could consider starting Remeron after (very slowly) reducing your dose of Zyprexa.
Any idea what your doc thinks about all this? Stopping Zyprexa is a major event because there is a risk of relapse and withdrawal anxiety/insomnia.
Posted by Lamdage22 on December 5, 2013, at 2:10:03
In reply to Safest trycyclics?, posted by Lamdage22 on November 24, 2013, at 10:10:19
Im thinking about aurorix though after cymbalta.
Posted by Lamdage22 on December 5, 2013, at 4:25:22
In reply to Safest trycyclics?, posted by Lamdage22 on November 24, 2013, at 10:10:19
I read that paxil induces suicidality. I want it to do the opposite :(
Posted by phidippus on December 5, 2013, at 17:07:39
In reply to Safest trycyclics?, posted by Lamdage22 on November 24, 2013, at 10:10:19
Most TCAs are fine on the heart, but if large doses are applied, they can cause QT problems which can lead to death.
Posted by Lamdage22 on December 7, 2013, at 5:58:33
In reply to Re: Safest trycyclics? » Lamdage22, posted by phidippus on December 5, 2013, at 17:07:39
Since Sertraline worked instantly and remarkably, does that mean there is a good chance that another Ssri works as well?
Sertraline gave me horrible akathisia.
So far i had Effexor and it worked minimally. Currently im on Cymbalta and it doesnt work yet.
Posted by ed_uk2010 on December 8, 2013, at 2:03:15
In reply to Re: Safest trycyclics?, posted by Lamdage22 on December 5, 2013, at 2:10:03
> Im thinking about aurorix though after cymbalta.
Aurorix is a novel one. You'll need to wait until Cymbalta is fully out of your system before starting it, or else severe side effects will occur. Since Cymbalta is a short-acting drug, it is normally fully out of your body within 4 days after your very last dose. Your doctor may advise leaving a gap of one week for increased safety. Remember, the dose of Cymbalta often needs to be reduced gradually to prevent withdrawal symptoms.
Posted by ed_uk2010 on December 8, 2013, at 2:08:08
In reply to Paxil suicide thoughts, posted by Lamdage22 on December 5, 2013, at 4:25:22
> I read that paxil induces suicidality. I want it to do the opposite :(
This is nothing specific to Paxil. Some people react this way to all SSRIs and sometimes other ADs such as Effexor. The risk is much higher in children and moderate in people under the age of 25. It is much less common in people over 25, except that agitation can also in some bipolar or schizoaffective pts on antidepressants. You may have experienced this before with other meds.
People who suffer from anxiety may feel restless and agitated if the starting dose of an AD is too high. This is most common in people who have panic attacks, in which case the starting dose should be half the usual starting dose.
Of course, anyone can potentially react badly to any medication. It's not easy to predict. The best way is to avoid high initial doses of meds which you have not previously taken, especially if you are on other psych meds as well.
Posted by ed_uk2010 on December 8, 2013, at 2:13:42
In reply to Re: Safest trycyclics?, posted by Lamdage22 on December 7, 2013, at 5:58:33
> Since Sertraline worked instantly and remarkably, does that mean there is a good chance that another Ssri works as well?
What dose did you take and were you on other meds at the same time? High doses of sertraline are more likely to cause restlessness. 25mg is a suitable starting dose for anyone at risk.
Escitalopram (Lexapro/Cipralex) and citalopram (Celexa) seem to have a somewhat lower risk of 'overstimulation' than sertraline.
Since you've not responded well to Effexor and Cymbalta, Aurorix may turn out to work for you, since it works in a different way. Aurorix is not usually a very potent antidepressant, but it can work for some people. It does not prolong the QT interval.
I can't remember whether you said you'd tried mirtazapine (Remeron/Zispin)as an AD. This medication may work for you when SSRIs haven't. It does cause weight gain.... but less than Zyprexa!
Posted by Lamdage22 on December 8, 2013, at 3:10:32
In reply to Re: Safest trycyclics? » Lamdage22, posted by ed_uk2010 on December 8, 2013, at 2:13:42
Thanks Ed for your insight!
I am still trying Cymbalta.. im at half the effective dosage so it remains to be seem if i respond.
I thought about trying Paxil next and then Moclobemide.
Im concerned about Moclobemide pooping out.
Posted by ed_uk2010 on December 8, 2013, at 11:19:33
In reply to Re: Safest trycyclics?, posted by Lamdage22 on December 8, 2013, at 3:10:32
>I'm concerned about moclobemide pooping out.
There's always a risk but I'm not aware of a special problem with moclobemide.
Posted by Lamdage22 on December 9, 2013, at 4:35:36
In reply to Re: Safest tricyclics?, posted by ed_uk2010 on December 8, 2013, at 11:19:33
Moclobemide appears to be "effective for at least one year", just like ssri and tricyclics.
It sucks that it isnt more. But i will use 5-htp if it loses efficacy.
Go forward in thread:
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.