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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by tom2228 on February 21, 2014, at 13:03:17
Anyone know if protryptyline (Vivactil) is safe with an MAOI?
I currently take:
lithium carbonate 900mg
Lamictal 125mg
Abilify 10mg
Marplan 50mg
Deplin 30mg
Mirapex 0.375mg
Desoxyn 15-20mg
levothyroxine 50mcg (for lithium-induced hypo)but still feeling depressed. main symptoms are apathy, low mood, lack of interest in life and social relationships, feeling flat, anxiety (generalized and social), very neurotic and lack of positive outlook on life and doing the things I need to further my survival. stress, trouble thinking straight and concentrating (perhaps because of interest issues), and irritability, also derealization -- don't always feel like I'm here, like on a strange planet (could be lamictal or depression or BPD)
Meanwhile, diagnoses:
Axis I: Bipolar (I?), ADHD, substance dependence (cannabis and crystal meth, 10 months clean), social anxiety, GAD, some social paranoid
Axis II: borderline, avoidantBeen a week and a half on Abilify as I just switched from 2 weeks of Saphris (was awesome for mood but ran into problems) and 6 months of Latuda. Abilify has taken care of the mania but still a bit irritable/ agitated in background. It has lightened the depression but it is still definitely there.
Abilify has made me extremely sleepy; Saphris was more "sedating" but kept me up and alert all day. Hard to get things done or feel up to it on Abilify. Considering changing to Invega as it's purportedly less sedating and not sure I like the feeling of Abilify, but like the symptom reduction.
Perhaps the Mirapex needs to be brought up as I'm on the lowest dose and it helps. Just avoiding making too many changes at once right now.
Anyway, was considering adding a tricyclic or changing Abilify to or Seroquel (NRI metabolite), but trying to avoid the "bad" type of sedation -- somnolence? -- for me that Abilify produces. I've seen a lot of nortrip with MAOIs on here, but protryptiline is said to be more activating, less sedating. but is it safe?
Any recommendations? Adjustments? Strattera? or is it not good for depression?
Posted by rjlockhart37 on February 21, 2014, at 16:06:30
In reply to protryptiline (Vivactil) safe with MAOI?, posted by tom2228 on February 21, 2014, at 13:03:17
a good thing for you from what you wrote: Geodon, it's someways activating....it's not much of a mind duller like zyprexa and seroquel.....
also you may add Namenda.....enhances cognitive function....
none of those will interfere with MAOI's
Posted by LouisianaSportsman on February 21, 2014, at 16:28:20
In reply to protryptiline (Vivactil) safe with MAOI?, posted by tom2228 on February 21, 2014, at 13:03:17
Hey, Tom!
Wow, I am enthralled by your thread.
Protriptyline should not cause serotonin syndrome nor have any other undesirable interactions with isocarboxazid. It is one of the most benign TCAs to take concomitantly with an MAOI because it is more of an NRI.
I am diagnosed with BP2, ADHD and possibly BPD myself so I relate to the symptoms you described, predominantly the derealization. Ive never really discussed my derealization symptom with anyone. Would you care to divulge more details about what you experience? (I am also prescribed Lamictal [lamotrigine].)
I switched from Abilify (aripiprazole) to Latuda (lurasidone) about three months ago. Lurasidone is a prodigious AAP, but I believe aripiprazole is slightly superior however, it is not superior enough that I would reverberate due to weight gain. Lurasidone is a miracle in terms of being weight neutral. I have had an almost identical to aripiprazole. I did not experience lethargy on neither AAP.
Honestly, if someone came to me asking for an augmentation to their AD for MDD, Id advocate lurasidone due to its side effect profile and dosing compared to aripiprazole.
Invega (paliperidone), indeed, is the least sedating AAP, but its a tough call whether or not you should switch over or not. Have you considered increasing your methamphetamine dosage? Have you considered that, perhaps, the sedation of aripiprazole will diminish over time?
Also, what is the Mirapex (pramipexole) indicated for? I believe that the dosage is too low to be exerting any therapeutic effect on any of your symptomology.
If youre experiencing sedation on aripiprazole, I do not recommend Seroquel (quietapine) therapy as it is notorious for aggrandizing sedation.
Protriptyline is theoretically awesome on paper; however, there is a reason why it is not prescribed more often severe side effects, e.g. via Ask a Patient, Rating: 3.7/10 [10 reviews] http://www.askapatient.com/viewrating.asp?drug=16012&name=VIVACTIL Pamelor (nortriptyline) on this website scored 3.1/10 [100 reviews]. TCAs are definitely hard to swallow.
In terms of Strattera (atomoxetine) it is the worst possible selection, I consider, of any medication, psychoactive or otherwise.
Tom, I may post a follow-up to this post later because I am going to ponder other possible remedies that might be efficacious for symptom alleviation.
Best wishes to you!
Posted by LouisianaSportsman on February 21, 2014, at 17:46:30
In reply to Re: protryptiline (Vivactil) safe with MAOI?, posted by LouisianaSportsman on February 21, 2014, at 16:28:20
Hey, Tom! I am in a bit of a rush, but I wanna get my thoughts out real fast like I said I would. This is not going to be written in the prose I like.
Just sharing my thoughts on what Id do in terms of your medications:
1.I would leave Desoxyn as is and augment with Vyvanse (lisdexamphetamine) at 50mg. which is ~= 22.5mg. of Dexedrine over an extended period of time which would probably feel like 15mg. of Desoxyn, but you have to consider that it would be time-released. Id dose: Vyvanse 50mg., Desoxyn 5-10mg. QAM; and as a booster, Desoxyn 10-15mg. QPM. For some reason, people seem to report that Vyvanse is smooth, and it seems to be good for people with treatment resistant depression.
2.I would titrate the Lamictal to the more common therapeutic dosage of 200mg.
3.I would change Mirapex to Mirapex ER with a target dose of 1.5mg.
4.I would go ahead and max out Marplan to 60mg.
5.I would order a blood test to have your lithium levels checked and adjust dosage accordingly.
6.I would titrate properly and prescribe Oxtellar XR (oxcarbazepine) with a target dosage of 1,200mg. This an extended-release version of Trileptal (Tegretol). It is effective for some bipolar patients, but I am worried about mania since you said that lithium induced it.
7.I would increase the Abilify to 15mg. This is the suggested dose on the PI sheet and it is good because of the addition of oxcarbazepine. Perhaps it would block potential mania. Lethargy would hopefully be resolved by Vyvanse.
8.Since you wanted a TCA and because it does make sense, Id add-on desipramine and not nortrip. I like it because its a metabolite of Tofranil (imipramine) which might be the best TCA for anxiety and that seems to be one of your issues right now. Id go for a target dose of 100mg.
9.I cannot make an educated opinion about Deplin and levothyroxine, honestly.Basically, Id make your meds look like this:
Abilify (aripiprazole) 15mg.
Deplin (levomefolic acid) 30mg.
Desoxyn (methamphetamine) 20mg.
Lamictal (lamotrigine) 200mg.
Levothyroxine 50mcg
Lithobid ER (lithium carbonate) 900mg.
Marplan (isocarboxazid) 60mg.
Mirapex ER (pramipexole) 1.5mg.
Norpramin (desipramine) 100mg.
Oxtellar XR (oxcarbazepine) 1,200mg.
Vyvanse (lisdexamphetamine) 50mg.Let me know what you think, bud.
Posted by LouisianaSportsman on February 21, 2014, at 21:54:24
In reply to Re: protryptiline (Vivactil) safe with MAOI?, posted by LouisianaSportsman on February 21, 2014, at 17:46:30
For some reason, I thought you had tried Lyrica. I think I was reading about Lyrica at the time. I HIGHLY SUGGEST LYRICA OVER OXTERLLAR XR!!! It would be a great remedy for your anxiety and other issues. Also, if you haven't tried bupropion-- it would be MUCH BETTER than desipramine.
I actually prefer this. I made some changes and removed some drugs as you might notice:
Abilify (aripiprazole) 15mg.
Aplenzin (bupropion hydrobromide) 348mg.
Desoxyn (methamphetamine) 20mg.
Lamictal (lamotrigine) 200mg.
Lithobid ER (lithium carbonate) 900mg.
Lyrica (pregabalin) 300mg.
Marplan (isocarboxazid) 60mg.
Mirapex ER (pramipexole) 2.25mg.
Vyvanse (lisdexamphetamine) 50mg.^^^ now, that is a good cocktail :)
What medications have you tried, Tom?
Posted by LouisianaSportsman on February 21, 2014, at 21:57:16
In reply to Re: protryptiline (Vivactil) safe with MAOI?, posted by LouisianaSportsman on February 21, 2014, at 21:54:24
I also did not suggest a benzodiazepine because I thought there must be a reason why you're not currently on one now? You might want to consider one, such as Klonopin (clonazepam).
The only reason I included oxcarbazepine earlier was because I was trying to suggest something that you have never tried.
Best wishes!
Posted by Christ_empowered on February 22, 2014, at 7:37:38
In reply to Re: protryptiline (Vivactil) safe with MAOI?, posted by LouisianaSportsman on February 21, 2014, at 21:57:16
Abilify works for me, but some people HATE it. I think being on Lithium w/ a neuroleptic makes things harder.
Ummm...maybe up the Desoxyn a tad bit and switch to a single dose of Seroquel xr at night? Or forget about an antipsychotic, maybe? I just think Seroquel xr because the eps+td for Seroquel is low and the xr is more tolerable.
There's also older APs to consider, cuz there aren't that many atypicals (in comparison). I was thinking low dose loxapine, or maybe amoxapine with the maoi (?) .
Good luck!
Posted by tom2228 on February 24, 2014, at 22:06:11
In reply to Re: protryptiline (Vivactil) safe with MAOI?, posted by Christ_empowered on February 22, 2014, at 7:37:38
First of all, thanks to eveyone for the speedy and lengthy replies, they have been helpful for me as well as having a forum to sift through my mind's contents
rjlockhart:
> a good thing for you from what you wrote: Geodon, it's someways activating....it's not much of a mind duller like zyprexa and seroquel.....
>
> also you may add Namenda.....enhances cognitive function....
>
> none of those will interfere with MAOI'swas on Geodon, up to 80mg for a month this summer in the hospital -- hate it. stimulation was at times "cool" but I felt like it "cracked out" my mania, along w/ cognitive impairment and sedation that I couldn't tolerate. I believe Geodon is contraindicated w/ MAOIs b/c it has SRI (as well as NRI) properties -- I've seen at least 1 case report of fatal serotonin syndrome w/ Geodon and an MAOI.
Luisiana sportsman ---
Wow, that would be so many changes at once. I frequently debate doing things slowly to figure out what's doing what -- I am on a lot of meds after all -- and doing something more like acute care where you change up a lot at once and hope for the best -- as I've been desperate lately.re: Vyvanse been on Vyvanse, not sure I would like it with the Desoxyn. I find my ADHD/ cognition get worse with too much of a stim, and Desoxyn hits the bar pretty well. Would be on dexamphetamine as my 2nd line, but not my cup of tea in general
Thanks for your suggestion about desipramine -- I think I'd rather try that first as it's lower on the muscarinic side-effects. already having trouble urinating with abilify (idk why) on top of the other stimulating meds.
Would take bupropion except it's a potent inhibitor of the CYP 2D6 isoenzyme and would not gel with the desoxyn (or abilify for that matter) -- that was one of the main problems I had with Saprhis unfortunately it just builds up in my system, messes up dosing, and makes me start to feel high -- not good for being in recovery from crystal
Used to take and really liked Ativan -- did a fantastic job on my anxiety where I could just feel OK!!! no longer on it as trying to use other methods to deal with the underlying problems, as well benzos are disinhibiting for me and screw with my priorities -- was conducive to drug use in the past (tho not benzo abuse). might be ok in the future but can do without it for now. nervous about lyrica for same reason -- need to keep my inhibitions for now, I guess. would add it later if necessary -- trying to use neuroleptics to help w/ things and not mask the agitation/irritability/anxiety that is from bipolar, and treat that at the root instead. although ativan did a good for my mood stability actually.
Been on trileptal twice -- does something vivid to my mind, but gives me a lot of anxiety. basically makes me see things so differently and feel so responsible over my life and behavior that I can't breathe, it's almost suffocating. wasn't helping the cycling so we swapped for lamictal this fall.
lamictal is staying at 125mg for a while. it kicked in for mood stabilization/ borderline at 100mg and better now at 125mg. I won't go higher (at least not for now, or so quickly) b/c I get this nasty cognitive impairment that freaked the sh*t out of me 6 years ago on 200mg of the stuff -- first mood stabilizer. o, the early days
What's your beef with strattera? (lol) curious as to why it's not good as an AD as an NRI
Christ_empowered -- ya I've been fluctuating the past week and a half between hating and liking Abilify. hated it this morning but liking it tonight, lol -- I just don't feel as serious about life as I usually am (not good) -- like lack of interest in things including
socializing. Thinking of asking on Saturday for maybe 25mg of desipramine to be taken twice daily for these issues. like I said I liked what Saphris did, and recognized the noradrenergic feeling as something my mood has been missing for years now -- my hypothesis is because of the MAOI suppressing NE function over time. I wonder sometimes if being on Marplan for years (except Nardil and Parnate this fall) is the actual problem instead of the stuff that keeps getting added on top of it.But tonight the cognitive issues w/ Abilify seem better, and I notice I'm functioning more. So I'm going to stick with the Abilify for now, and wait until l adjust more if I need to up to 15mg. If Abilify doesn't work out I'm going to ask for Invega -- I keep debating whether to ask for it this appointment though -- been desperate to get things right.
CE you're right that the lithium w/ neuroleptic makes things tougher; I notice a dip in between the morning and night lithium doses that is in some ways an improvement and in other ways rougher going to stick with both for now.
In the meantime I've upped pramipexole (AM taking the ER actually) to 0.75 two days and it seems to be doing something nice, same with lamictal xr to 125mg (from 100mg) a week ago. Would keep upping the pramipexole but I feel there's something missing (NE?) that I don't want to mask before addressing it. using the pramipexole for bipolar depression and to offset some cognitive effects of neuroleptics (latuda when started it) and of bipolar/ depression in general. like the effect (on-paper) on neurogenesis and neurotrophism.
Posted by tom2228 on February 24, 2014, at 22:07:18
In reply to Re: protryptiline (Vivactil) safe with MAOI?, posted by tom2228 on February 24, 2014, at 22:06:11
will try to post more frequently and in less huge chunks working through the anxiety of expressing myself/ importance of social support and issues functioning
thanks to everyone
This is the end of the thread.
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