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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 5 of 5. This is the beginning of the thread.
Posted by tensor on February 15, 2014, at 2:13:57
Hi Scott!
I have a couple of questions regarding Parnate augmentation, would be grateful if you could look at them. Others are welcome to chime in also.
I can't find the post now, but I read that you had a severe reaction combining Parnate and reboxetine, what was the reaction?
I'm trying to reduce daytime fatigue and I was thinking of adding a small dose of reboxetine in the morning. An alternative would be nortrip, but I don't know if I can add it when I'm at 50mg of Parnate already.
A common friend of ours suggested agomelatine, what do you think about that?
Thanks and I hope you have a nice weekend,
tensor
Posted by SLS on February 15, 2014, at 16:17:59
In reply to SLS, posted by tensor on February 15, 2014, at 2:13:57
> Hi Scott!
Hi Tensor!
> I have a couple of questions regarding Parnate augmentation, would be grateful if you could look at them. Others are welcome to chime in also.
>
> I can't find the post now, but I read that you had a severe reaction combining Parnate and reboxetine, what was the reaction?Actually, my suicidal reaction to reboxetine occurred in the absence of a MAOI. I don't recall if I was taking any other drugs at the time.
> I'm trying to reduce daytime fatigue and I was thinking of adding a small dose of reboxetine in the morning.I've been using Focalin (dexmethyphenidate) to use as a PRN for difficult days. One can add it to a MAOI safely.
> An alternative would be nortrip, but I don't know if I can add it when I'm at 50mg of Parnate already.
I don't see how nortriptyline would represent a greater risk than reboxetine when added to Parnate. Supposedly, one should add the MAOI to ongoing TCA treatment. I don't understand the rationale for this, though. I have not seen any evidence to support this notion. I have added TCA to ongoing MAOI treatment a number of times.
> A common friend of ours suggested agomelatine, what do you think about that?
I don't know what to make of agomelatine. I have seen it reduce rapid-cycling in bipolar 2 disorder. It had no therapeutic effect for me, but I was not taking a MAOI at the time. Perhaps the melatonin M1 an M2 receptor stimulation helps to regulate biological clocks. For depression, my guess is that the 5-HT2c antagonism participates in producing a treatment response.
> Thanks and I hope you have a nice weekend,
Thanks. I have had a difficult few days, both biologically and emotionally. Latuda made me feel significantly worse upon continued treatment and dosage increases, and I have run out of ideas for pharmacotherapy. Perhaps TMS is the next step. I am not feeling terribly optimistic.
> tensor
- Scott
Posted by tensor on February 16, 2014, at 4:59:19
In reply to Re: SLS » tensor, posted by SLS on February 15, 2014, at 16:17:59
> Actually, my suicidal reaction to reboxetine occurred in the absence of a MAOI. I don't recall if I was taking any other drugs at the time.
Okay, I'm sorry to hear you had such a bad reaction.
> > I'm trying to reduce daytime fatigue and I was thinking of adding a small dose of reboxetine in the morning.
>
> I've been using Focalin (dexmethyphenidate) to use as a PRN for difficult days. One can add it to a MAOI safely.Interesting, I have seen suggestions that if you add a stimulant you should start with a small dose and titrate, how does it work when you take it PRN? How large dose do you take?
My concern with adding stims is increased anxiety, but there are drawbacks with every option. Bupropion is also an option, but there is not much information on this combination.> I don't see how nortriptyline would represent a greater risk than reboxetine when added to Parnate. Supposedly, one should add the MAOI to ongoing TCA treatment. I don't understand the rationale for this, though. I have not seen any evidence to support this notion. I have added TCA to ongoing MAOI treatment a number of times.
I don't understand it either, as with much of the information regarding MAOIs, it can be a myth and/or based on outdated/incomplete data. Everything is deemed unsafe unless there is a clinical study that confirms its safety (as it should).
> I don't know what to make of agomelatine. I have seen it reduce rapid-cycling in bipolar 2 disorder. It had no therapeutic effect for me, but I was not taking a MAOI at the time. Perhaps the melatonin M1 an M2 receptor stimulation helps to regulate biological clocks. For depression, my guess is that the 5-HT2c antagonism participates in producing a treatment response.
I have no experience of it, if 5HT2C disinhibits NE and DA it could combat tiredness, but it's a long shot. It could be great for sleep.
> Thanks. I have had a difficult few days, both biologically and emotionally. Latuda made me feel significantly worse upon continued treatment and dosage increases, and I have run out of ideas for pharmacotherapy. Perhaps TMS is the next step. I am not feeling terribly optimistic.
>
> - Scott
>I'm sorry to read this, Scott. You're one of the few guys that have the know-how and courage to try combinations no one else has, making new treatments a viable option for others.
There is also Deep TMS, but I'm not sure how far they have come. Have you tried NMDA antagonists?/tensor
Posted by SLS on February 16, 2014, at 7:43:19
In reply to Re: SLS » SLS, posted by tensor on February 16, 2014, at 4:59:19
> > Actually, my suicidal reaction to reboxetine occurred in the absence of a MAOI. I don't recall if I was taking any other drugs at the time.
>
> Okay, I'm sorry to hear you had such a bad reaction.I found reboxetine to be anxiogenic. I wasn't paralyzed with anxiety, but it did add to the suicidal state I found myself in.
> > > I'm trying to reduce daytime fatigue and I was thinking of adding a small dose of reboxetine in the morning.
> > I've been using Focalin (dexmethyphenidate) to use as a PRN for difficult days. One can add it to a MAOI safely.
> Interesting, I have seen suggestions that if you add a stimulant you should start with a small dose and titrate, how does it work when you take it PRN? How large dose do you take?I was told that I could take Focalin at 20 mg/day (10 mg b.i.d.). Like I said, I have been using it sparingly as a PRN. I don't know if I would build up a tolerance were I to take it daily. Personally, I would think D-amphetamine (Dexedrine) would be smoother than methylphenidate. So, if you find methylphenidate to be anxiogenic, that doesn't guarantee that amphetamine will also produce anxiety.
> My concern with adding stims is increased anxiety, but there are drawbacks with every option. Bupropion is also an option, but there is not much information on this combination. I have added 450 mg/day of bupropion to Parnate. There were no adverse effects other than it worsening my depression to a moderate degree. This occurs with bupropion monotherapy, too.
> > I don't see how nortriptyline would represent a greater risk than reboxetine when added to Parnate. Supposedly, one should add the MAOI to ongoing TCA treatment. I don't understand the rationale for this, though. I have not seen any evidence to support this notion. I have added TCA to ongoing MAOI treatment a number of times.
>
> I don't understand it either, as with much of the information regarding MAOIs, it can be a myth and/or based on outdated/incomplete data. Everything is deemed unsafe unless there is a clinical study that confirms its safety (as it should).
>
> > I don't know what to make of agomelatine. I have seen it reduce rapid-cycling in bipolar 2 disorder. It had no therapeutic effect for me, but I was not taking a MAOI at the time. Perhaps the melatonin M1 an M2 receptor stimulation helps to regulate biological clocks. For depression, my guess is that the 5-HT2c antagonism participates in producing a treatment response.
>
> I have no experience of it, if 5HT2C disinhibits NE and DA it could combat tiredness, but it's a long shot. It could be great for sleep.> > Thanks. I have had a difficult few days, both biologically and emotionally. Latuda made me feel significantly worse upon continued treatment and dosage increases, and I have run out of ideas for pharmacotherapy. Perhaps TMS is the next step. I am not feeling terribly optimistic.
> I'm sorry to read this, Scott. You're one of the few guys that have the know-how and courage to try combinations no one else has, making new treatments a viable option for others.The severe depressive state that I found myself in generated negative thoughts and the beginnings of suicidality. My outlook was pessimistic. I'm better today, and not as pessimistic. I don't have handfuls of treatment ideas, but I might revisit Saphris (asenapine). I don't recall why I discontinued it prematurely. I don't think it made me feel worse. I was probably just impatient.
> There is also Deep TMS, but I'm not sure how far they have come.
One study I came across compared ECT, [shallow] rTMS, and deep TMS. ECT was most effective, but deep TMS was not very far behind. rTMS was only slightly effective by comparison. One weird outcome was that deep TMS at two weeks was better than at four weeks, as there was a higher drop-out rate at four weeks. The authors observed that there were tolerability issues with deep TMS.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3280107/
> Have you tried NMDA antagonists?
I have tried both amantadine and memantine. I didn't feel any better, but I didn't feel any worse.
Thanks for the suggestions.
:-)
- Scott
Posted by Twinleaf on February 16, 2014, at 16:28:11
In reply to Re: SLS, posted by SLS on February 16, 2014, at 7:43:19
I was struck, also, by the high dropout rate with deep TMS in that article. Brainsway describes deep TMS as feeling like sharp tapping - so supposedly it's less painful than regular TMS, which is quite painful at the beginning but becomes quite tolerable as the treatment session progresses
It's very disappointing that Latuda difn't help. Isn't deep TMS available at the center where you are treated? Seems like it should be by now.
This is the end of the thread.
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