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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 21 of 21. This is the beginning of the thread.
Posted by busub on June 12, 2015, at 15:38:17
After a very short failed trial of Latuda (akathisia, muscle pain), I finally convinced my pdoc to do a TCA trial. He had been hesitant based on my previous experience on clomipramine (extreme sedation, constipation and sexual side effects), but relented after I sent him an email on my thoughts on nortriptyline. At the appointment though, he threw me a curve ball and prescribed desipramine instead.
I took my first 25mg last night and while I have a little fatigue (much improved over the clomipramine) I feel restless today. Is this normal for TCA's? I was under the impression that this was less of an issue than with the SSRI's. If this is the TCA, how long can I expect it to last?
Last question, anyone else with experience on desipramine? Any input would be appreciated.
Posted by Christ_empowered on June 12, 2015, at 18:45:48
In reply to Desipramine Questions, posted by busub on June 12, 2015, at 15:38:17
hey. It can happen with TCAs. Tofranil (imipramine), the first TCA, was identified as an "antidepressant" when it caused hypomania and full on mania in a lot of hospitalized inpatients.
Anyway...some docs way back when would use the old school antipsychotics for a while to calm things down. I guess these days we have cleaner and safer drugs....maybe a tiny bit of risperdal at night to help you through or something (?). Clearly, I'm no MD...I'm just throwing ideas your way. A benzo, lyrica, neurontin...those are other options, too.
Posted by tom2228 on June 12, 2015, at 21:05:56
In reply to Re: Desipramine Questions, posted by Christ_empowered on June 12, 2015, at 18:45:48
Ok, let's focus on one thing for now -- the desipramine. Most antidepressants have start-up effects that dissipate as the body acclimates to the drug and the therapeutic effects show up. I had a bit of jitteriness/ mild tension/ uncomfortability the first couple days.
Other than that desipramine has been very good to me. In my case Marplan is like the wood that lays the foundation and desipramine lights my fire. My response has been fabulous and it's been one of the more powerful and helpful meds I've
tried. Few sides now except some sweating and dry mouth. I'm on 125mg and I take 75mg at night, 5mg in the morning.I tried nortriptyline which some people prefer and I responded but it had more sides for me and desipramine just works better for my symptoms. Some say nortriptyline is more calming but I find desipramine relaxing albeit it motivating and stimulating. I haven't tried other TCA's but I think it's safe to say that they are different enough, especially compared to the differences between the SSRIs, to warrant giving a fair appraisal to a second TCA. Be patient with yourself and try to make positive life changes and engage yourself in some sort of therapy of you aren't currently. Doing the work, even if it wasn't much at first -- just giving it whatever I could muster -- has made a huge difference and is the fuel that the medications need to work. I wish you strength and patience.
Tom
Posted by busub on June 15, 2015, at 16:18:07
In reply to Re: Desipramine Questions, posted by tom2228 on June 12, 2015, at 21:05:56
Thanks. I'm really struggling today and emailed my pdoc about something to help. In the meantime I'm just zoning out here at work. I hope he gets back to me soon. I just feel so restless.
Posted by SLS on June 16, 2015, at 6:54:30
In reply to Desipramine Questions, posted by busub on June 12, 2015, at 15:38:17
> I took my first 25mg last night and while I have a little fatigue (much improved over the clomipramine) I feel restless today.
I am not surprised. I had the same sort of reaction. It went away within a few days. I hope your reaction follows a similar pattern. Desipramine is one of the most potent and selective reuptake inhibitors or norepinephrine, which is known to be an excitatory neurotransmitter. It might be a good idea to stay at 25 mg/day until the restlessness subsides. Are you taking Prozac, Paxil, or Wellbutrin. These drugs can interfere with TCA metabolism, and requires that the dosage of TCA be reduced by approximately 50%.
- Scott
Posted by Busub on June 16, 2015, at 7:08:20
In reply to Re: Desipramine Questions » busub, posted by SLS on June 16, 2015, at 6:54:30
Not taking anything else. Just took my 5th dose last night and still jittery as ever. It's actually interfering with my sleep it's so strong. I've been waking up at regular intervals through the night unable to fall asleep right away. I pray this ends soon.
Posted by Busub on June 16, 2015, at 7:39:24
In reply to Re: Desipramine Questions » busub, posted by SLS on June 16, 2015, at 6:54:30
> > I took my first 25mg last night and while I have a little fatigue (much improved over the clomipramine) I feel restless today.
>
> I am not surprised. I had the same sort of reaction. It went away within a few days. I hope your reaction follows a similar pattern. Desipramine is one of the most potent and selective reuptake inhibitors or norepinephrine, which is known to be an excitatory neurotransmitter. It might be a good idea to stay at 25 mg/day until the restlessness subsides. Are you taking Prozac, Paxil, or Wellbutrin. These drugs can interfere with TCA metabolism, and requires that the dosage of TCA be reduced by approximately 50%.
>
>
> - Scott
Also, would a beta blocker help? Or would it block the effects of desipramine considering its NRI properties.Would nortriptyline have been gentler? I think my pdoc rx'ed desipramine because of its lower SE profile but man this agitation is no fun.
Posted by Christ_empowered on June 16, 2015, at 8:26:27
In reply to Re: Desipramine Questions, posted by Busub on June 16, 2015, at 7:39:24
maybe a sedative? neurontin, lyrica, even hydroxyzine (maybe...).
For akathisia, some alternative docs use high dose B6.
Posted by busub on June 16, 2015, at 10:41:10
In reply to Re: Desipramine Questions, posted by Christ_empowered on June 16, 2015, at 8:26:27
> maybe a sedative? neurontin, lyrica, even hydroxyzine (maybe...).
>
> For akathisia, some alternative docs use high dose B6.Just got word from pdoc. Still early in trial so he doesn't want to add anything to help cover side effects this early on. Not sure why not, as I wasn't asking for a long term med, just something to ease my symptoms for the time being. He did suggest melatonin or Benadryl to help with the broken sleep for the time being, but that doesn't help for the days. ARGH!
Posted by SLS on June 16, 2015, at 13:03:45
In reply to Re: Desipramine Questions, posted by Busub on June 16, 2015, at 7:39:24
> Also, would a beta blocker help?
>
> Or would it block the effects of desipramine considering its NRI properties.I don't know for sure. For years, there have been reports of propranolol producing depression as a side effect. However, this is still being debated.
> Would nortriptyline have been gentler?In most cases, yes.
You might find nortriptyline very tolerable compared to desipramine. If anything, you might experience some somnolence for a few days.
- Scott
Posted by busub on June 16, 2015, at 13:24:53
In reply to Re: Desipramine Questions » Busub, posted by SLS on June 16, 2015, at 13:03:45
> > Also, would a beta blocker help?
> >
> > Or would it block the effects of desipramine considering its NRI properties.
>
> I don't know for sure. For years, there have been reports of propranolol producing depression as a side effect. However, this is still being debated.
>
> > Would nortriptyline have been gentler?
>
> In most cases, yes.
>
> You might find nortriptyline very tolerable compared to desipramine. If anything, you might experience some somnolence for a few days.
>
>
> - ScottThanks for the help Scott.
Another follow up from Pdoc. Gave me the option to split the pill in half and titrate more slowly. Better than nothing I guess, so I'll be taking 12.5mg/night for the time being. I hope that it helps with the uptick in anxiety.
Not considering nortriptyline at the moment as he wants to give the desipramine an adequate trial. Fair enough.
I don't want to poo poo desipramine completely though. I do notice more energy (low energy has been a big problem lately) when the restlessness/anxiety abates for moments at a time. So that's good. I just hope to sustain that as the restlessness ebbs away.
Posted by SLS on June 16, 2015, at 14:16:12
In reply to Re: Desipramine Questions, posted by busub on June 16, 2015, at 13:24:53
I agree with the course your doctor is taking. Interestingly, older doctors with an abundance of experience with TCAs sometimes report that desipramine responders had done less well with nortriptyline and vice-verse. It is almost as if the two drugs were mutually exclusive in treating MDD to full remission. I don't know how universally true this is, but just in case it is, you should explore desipramine fully before moving on to nortriptyline. If you lose the initial boost of energy as the days pass, I would not look at that as a prognosticator of non-response. It might actually be a good sign. I hope so. It is great that you are so willing to work through these drug trials with patience. It should pay off.
Have you tried Effexor, Pristiq, or Cymbalta?
- Scott
Posted by busub on June 16, 2015, at 14:34:22
In reply to Re: Desipramine Questions » busub, posted by SLS on June 16, 2015, at 14:16:12
I've tried both Effexor and Cymbalta.
I had the same activation issues with Effexor and couldn't get past 112.5mg/day, so I wasn't even getting any NRI action from that dose. That was an 8 week trial.
I later had a Cymbalta trial for 12 weeks and was constantly in a drowsy haze with some weird activation thrown in.
The following is what I've trialed, in order:
Paroxetine (50mg worked for 18 months, mild activation, tapered off, reinstated, didn't work again)
Sertraline (150mg worked for 12 months, never completely rid of restlessness, then started getting terrible akathisia)
Escitalopram (20mg 6 months, incomplete remission, tried augmentation with Lamictal then Elavil to ease activation)
Venlafaxine (112.5mg 2 months)
Clomipramine (75mg 3 months)
Fluoxetine (10mg 3 months, activating effects never went away)
Duloxetine (60mg 3 months, tried augmenting with burpropion for energy, but too activating)
Vortioxetine (20mg 2 months, chest pain and anger)Citalopram (20 mg6 months, anhedonia, incomplete response, activation)
Mirtazapine (45mg 2 months, sedation, hunger, angry)
Pregabalin (50mg bid 2 weeks, increased depression)
Lurasidone (20mg?? 1 week, akathisia and dystonia in the form of muscle cramping)
DesipramineMy initial diagnosis was GAD, but has since morphed into Dysthymia. My biggest issue with meds is that they all cause this background activation that was tolerable only for paroxetine and sertraline. Ever since it's been unbearable or came with other side effects that made things unbearable when combined. I feel like I'm at my wits end trying to get this sh*t under control and I don't know what to do.
Posted by SLS on June 16, 2015, at 15:30:02
In reply to Re: Desipramine Questions » SLS, posted by busub on June 16, 2015, at 14:34:22
Would you be willing to try Nardil? It seems like the next logical step as a follow-up to desipramine and nortriptyline trials. Nardil is particularly well suited for treating a combination of GAD and depression.
Reuptake inhibitors might be too harsh for you, although Viibryd might be worth a try.
I am getting the impression that Latuda (lurasidone) isn't good for very much when it comes to depression. Abilify would be better, but akathisia-like side effects are often problematic. 2.5 mg/day seems to be the most common dosage used when combined with antidepressants.
Paxil is the one drug that stands out for not working the second time around. It is the worst offender. I wish you had visited this website sooner. :-( Conversely, TCAs are probably the least likely to "poop-out". Given your history, do not ever stop taking an effective treatment. This goes for Nardil, too.
I would consider adding a small amount of lithium (300 mg/day) as an augmenter for depression only.
I don't see Lamictal (lamotrigine) on your list. I know it has a good reputation for treating bipolar depression, but I see people with unipolar depression use it as an augmenter at 200 mg/day. A combination of Lamictal and Abilify works magic for some people. As you know, it takes about a month to titrate Lamictal to a therapeutic dosage. You might consider starting Abilify at 1.0 mg (half a 2.0 mg pill) every other day. It has a long half life (72 hours), so taking it on alternate days will work well. Since you are not in a rush, you can increase the dose gradually if necessary. Perhaps go to 1.0 mg every day, then alternate days at 1.0 mg and 2.0 mg. If you reach 2.0 mg/day without akathisia, that's great. If you develop intolerable akathisia dosing Abilify at 1.0 every other day, I doubt it will be of much use. However, mild akathisia can disappear entirely. It did with me. Just be prepared for some moderate insomnia at first.
If you cannot establish Abilify, try adding N-acetylcystein (NAC) with or without minocycline. Sounds weird, I know, but together, these drugs modulate glutamate neurotransmission and suppress brain inflammation.
Just a few ideas...There are more ideas to be suggested by other posters on Psycho-Babble, so hang in there.
- Scott
Posted by Escapee on June 16, 2015, at 17:31:09
In reply to Desipramine Questions, posted by busub on June 12, 2015, at 15:38:17
> After a very short failed trial of Latuda (akathisia, muscle pain), I finally convinced my pdoc to do a TCA trial. He had been hesitant based on my previous experience on clomipramine (extreme sedation, constipation and sexual side effects), but relented after I sent him an email on my thoughts on nortriptyline. At the appointment though, he threw me a curve ball and prescribed desipramine instead.
>
> I took my first 25mg last night and while I have a little fatigue (much improved over the clomipramine) I feel restless today. Is this normal for TCA's? I was under the impression that this was less of an issue than with the SSRI's. If this is the TCA, how long can I expect it to last?
>
> Last question, anyone else with experience on desipramine? Any input would be appreciated.Hi. For starters don't confuse clomipramine with the other TCAs. Despite its TCA-like chemical structure its effects are that of a very potent SSRI.
Here in UK we have lofepramine and its main metabolite it desipramine. Almost a full NRI. I see people mentioning nortriptyline but that still is a part SRI part NRI. ie, you can still get serotonin syndrome if mixed with other serotonergics. Desipramine has a negligable effect on serotonin. But going on what you say, perhapse Nortriptyline would be a better option by giving a serotonin boost to help with the anxiety/tremmors. tho it might limit you adding other serotonergics if needed.
If you get stuck, and your doctor is willing, imipramine on its own might be worth a try. An old TCA it still remains one of the strongest all-in-one ADs out there.
Just thinking out loud :)
Escapee.
Posted by busub on June 16, 2015, at 18:14:41
In reply to Re: Desipramine Questions » busub, posted by SLS on June 16, 2015, at 15:30:02
Good thoughts Scott.
I have pondered the use of an MAOI but the dietary restrictions would be tough given my Asian heritage. Obviously if it came down to it, I'd give it a go, but it's definitely a last resort.
I've looked at ways to augment medications with a positive effect on my depression that would help with the jitteriness that I experience with the majority of AD's and valproate has come across as a potential add-on, as has lithium. Any thoughts on that? I have tried lamictal as an add on, but the trial was cut short when I was having trouble with the titration. My biggest trouble lies in the fact that my dysthymia presents as low energy, but any type of activation sets my anxiety off. I've become more and more convinced that I'll require polypharmacy, which isn't ideal, but I suppose might be a necessity.
The downside to being fairly functional is there is no hurry to make adjustments. My pdoc knows I'm still working so he's more than happy to let things play out. I understand why, but it makes it hard to digest the waiting game when you're feeling awful start up side effects.
Posted by busub on June 16, 2015, at 18:20:32
In reply to Re: Desipramine Questions » busub, posted by Escapee on June 16, 2015, at 17:31:09
Thanks escapee. My pdoc agrees with me that I'm extremely med sensitive for some reason. My wife is a tiny 5'0" 100 lb woman who took 20mg of amitriptyline with no problems to help control her IBS. The same dose knocked me out like a tranquilizer dart. With that in mind, I'd be hard pressed to imagine doing well on any of the tertiary amine TCA's at therapeutic doses. TBH, I'm a little concerned about not being able to get up to 100mg desipramine.
I've seen a lot of folks from across the pond do well on lofepramine, so I was optimistic about my desipramine trial. I guess between mirtazapine, pregabalin and lurasidone, I forgot what a proper AD titration felt like. UGH.
Posted by Christ_empowered on June 16, 2015, at 18:47:53
In reply to Re: Desipramine Questions » Escapee, posted by busub on June 16, 2015, at 18:20:32
Ever tried a benzo? Like...I dunno...Xanax, maybe the XR version?
Posted by busub on June 16, 2015, at 18:57:43
In reply to Re: Desipramine Questions, posted by Christ_empowered on June 16, 2015, at 18:47:53
I have. Xanax actually precipitated my first ever panic attack when I was prescribed some to take the edge off my GAD (pre-diagnosis).
Since then I've tried Ativan, Klonopin and Valium. They all do the same in that they make me sleepy for the and will calm me down in a pinch, but prn use will give me wicked anxiety as it wears off. I get the same effect if I have a beer or two, the next morning my anxiety will go sky high. If I do take a benzo it's because it's an emergency situation and fully knowing what the next day is going to feel like.
I have taken klonopin on a scheduled basis (1mg bid) during an acute stage of my GAD while I was temporarily hospitalized and during my partial hospitalization program, but after 3 weeks the taper was horrid. This was actually when they ramped me up on the paroxetine. Not gonna lie, it probably disguised a lot of the start up anxiety and withdrawal consisted of 2 days of horridness between drops.
Posted by Christ_empowered on June 17, 2015, at 6:36:22
In reply to Re: Desipramine Questions, posted by busub on June 16, 2015, at 18:57:43
oh man...that's rough. Maybe its a good thing the BZD drugs weren't so great? I mean, I thought maybe a tranquilizer since ADs had been rough on you, but...a life on BZDs can be rough, too.
Anyway, ever tried supplements? I have anxiety+agitation as part of my...well...whatever it is that afflicts me, lol...
...anyway, I take 3 grams niacinamide per day. Mine comes in 1.5 grams time release tablets, so I take one AM and one PM, along with a high potency B complex (B-100) and high dose time release C 2x daily.
That's the core of Hoffer's old school Orthomolecular protocol, and its worked for me. I take a lot of other stuff, too, but the C+B3+B-100= anxiety relief, for me at least. Just throwing that out there, since you've tried so many pharmaceuticals.
Good luck!
Posted by SLS on June 19, 2015, at 13:33:20
In reply to Re: Desipramine Questions » busub, posted by Escapee on June 16, 2015, at 17:31:09
> I see people mentioning nortriptyline but that still is a part SRI part NRI. ie, you can still get serotonin syndrome if mixed with other serotonergics.
It is very possible that I mentioned it. Nortriptyline is heavily weighted towards NE. Compare:
1. Nortriptyline: http://bit.ly/1d6hBke
2. Desipramine: http://bit.ly/1d6ieKDI take Parnate and nortriptyline together. If nortriptyline were truly serotonergic at therapeutic dosages, I would be suffering from serotonin syndrome. I'm not. Serotonin syndrome is weird, though. You never known when it is going to pop-up.
The immediate anxiolytic properties of nortriptyline might be due to its antagonism of serotonin 5-HT2a receptors. Later, NE downregulation may help with anxiety as well. I don't think serotonin reuptake plays a role here.
- Scott
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