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Dr. Bob is Robert Hsiung, MD,
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Posted by SLS on November 20, 2015, at 23:55:05
In reply to Re: HELP sexual dysfunction, posted by Lamdage22 on November 20, 2015, at 11:16:52
> Is there a reason to believe Desipramine will not cause these sexual side effects?
Not really.
I'm going to think about this some more.
Desipramine is more selective for norepinephrine reuptake than is nortriptyline. I don't know how this relates to your case specifically, though. Anorgasmia is usually associated with serotonin reuptake inhibitors, including clomipramine and, to a lesser extent, imipramine. There is an interesting report of anorgasmia resolving once a patient was switched from imipramine to desipramine. The patient was female.
Perhaps NE reuptake inhibitors are problematic for you, though, so I won't make any guarantees. Before committing to making a switch to desipramine, you should wait for more opinions.
Are you totally incapable of achieving orgasm? If you can achieve orgasm at all, perhaps there is a chance that it will improve over time. This is what happened to me with Nardil. It took three months before orgasm approached normalcy.
If you were to switch to desipramine immediately, would you return to nortriptyline if it didn't work?
If it were me, I would continue to test nortriptyline at higher dosages, despite the presence of anorgasmia. I guess it depends upon how many options you have left. Of course, you can always stop taking it whenever you want. I would want the information, though. Most people with severe depression need a minimum of 75 mg/day of nortriptyline. You are almost there. It seems like a waste of the time you have already invested to quit now. I think it makes sense to find out whether or not nortriptyline improves your condition first before switching to another drug. If the anorgasmia begins to improve as nortriptyline begins to work, switching drugs would not be necessary.
It would be interesting to explore the capacity for Remeron to:
1. Reverse anorgasmia via 5-HT2a/c blockade
2. Enhance the antidepressant effects of Effexor or TCA.Good article:
http://www.medscape.com/viewarticle/430614_5
- Scott
Posted by Lamdage22 on November 21, 2015, at 10:55:25
In reply to Re: HELP sexual dysfunction, posted by SLS on November 20, 2015, at 23:55:05
Life is very uncomfortable right now
Posted by Christ_empowered on November 21, 2015, at 12:18:50
In reply to 75mg Nortriptyline induces anorgasmia, posted by Lamdage22 on November 13, 2015, at 10:38:10
can you take wellbutrin?
Posted by SLS on November 21, 2015, at 12:32:09
In reply to Re: HELP sexual dysfunction, posted by Lamdage22 on November 21, 2015, at 10:55:25
> Life is very uncomfortable right now
Upon further thought, I am not convinced that it makes sense for you to switch to desipramine at this juncture. I'm afraid that you might be overly sensitive to NE reuptake inhibitors with respect to anorgasmia. This would be unusual compared to SSRIs, but it is listed as a side-effect of both tricyclics. However, this might be a standard listing for all tricyclics as a class-effect.
It does happen that someone will respond to nortriptyline and not to desipramine. The converse is also true. If you are indicating here that your discomfort is due to your illness, you might as well resume increasing the dosage of nortriptyline. You really do need to find something that helps you immediately. Give nortriptyline more time to see how well it works and then evaluate its side effects. Side effects that appear very early often disappear with continued treatment. Hopefully, your ability to orgasm will return.
- Scott
Posted by SLS on November 21, 2015, at 13:29:26
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by Christ_empowered on November 21, 2015, at 12:18:50
> can you take wellbutrin?
That's a great thought.
If it were me, I would continue to explore nortriptyline right now. Using blood tests can save time in determining the ideal dosage. Lamdage may be very close to responding favorably. Unfortunately, it is hard to know in advance.
Interestingly, a recent study indicates that people with the val66val genotype (2/3 of the population) for BDNF respond better to SSRIs while people with met66val or met66met respond better to tricyclics and SNRIs. Soon, there should be more biomarkers to help determine drug choice. One candidate is the gene promoter of the serotonin transporter.
Discipline and patience are difficult to exercise when you don't like the way you react to a drug at first. I have trouble with this. Of course, the emergence of dangerous or counterproductive reactions will indicate stopping the drug immediately.
- Scott
Posted by Lamdage22 on November 22, 2015, at 2:41:21
In reply to Re: 75mg Nortriptyline induces anorgasmia » Christ_empowered, posted by SLS on November 21, 2015, at 13:29:26
wellbutrin was helpful once.
I have doubled the 37.5 mg Effexor for now. Anticipating to try Buspar against anorgasmia!
Effexor gives anorgasmia but no erection problems like Nortriptyline.
Nortriptyline is down to 25mg.
I am 26 year old male, not 80 years old!!?
Posted by Christ_empowered on November 22, 2015, at 9:07:38
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by Lamdage22 on November 22, 2015, at 2:41:21
Not sure, but I think Wellbutrin can be used w/ Effexor, too.
Posted by SLS on November 22, 2015, at 9:44:16
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by Christ_empowered on November 22, 2015, at 9:07:38
> Not sure, but I think Wellbutrin can be used w/ Effexor, too.
It can, and it makes for a very effective combination for some people.
- Scott
Posted by Lamdage22 on November 22, 2015, at 11:12:36
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by SLS on November 22, 2015, at 9:44:16
thanks guys, i appreciate your support so much.
Wellbutrin sounds like an option. Its not risk free in terms of psychotic symptoms but maybe my doctor (and me) feel its worth taking the risk.
Posted by Lamdage22 on November 22, 2015, at 11:14:47
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by Lamdage22 on November 22, 2015, at 11:12:36
few things in life are risk free. I will bring it up.
Posted by Christ_empowered on November 22, 2015, at 15:30:44
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by Lamdage22 on November 22, 2015, at 11:14:47
yeah, I really like wellbutrin. I now only very rarely need low dose gabapentin and I almost never need the low dose risperidone I sometimes take/took on top of daily Abilify.
Posted by Lamdage22 on November 23, 2015, at 3:39:42
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by Christ_empowered on November 22, 2015, at 15:30:44
So wellbutrin is not pro-psychotic for you at all?
Posted by Christ_empowered on November 23, 2015, at 6:06:52
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by Lamdage22 on November 23, 2015, at 3:39:42
no, it isn't. At first there was some jittery-ness, but that subsided. I feel mildly stimulated, but nothing too crazy.
Posted by SLS on November 23, 2015, at 8:31:40
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by Christ_empowered on November 23, 2015, at 6:06:52
> no, it isn't. At first there was some jittery-ness, but that subsided. I feel mildly stimulated, but nothing too crazy.
I wish that I would respond to Wellbutrin that way. Instead, it slows me down and makes me feel significantly more dysphoric. I have taken as much as 900 mg/day. A friend of mine is in remission for having combined Wellbutrin with Pristiq. From what I see in others, Wellbutrin is more of an energizer than it is an anti-anhedonic. I would love to hear from others to see if they report the same thing. I think that's why Wellbutrin can augment SNRIs so well. For the right people, Wellbutrin provides improvements in mental energy and cognition while Effexor/Prisiq/Cymbalta yield a brighter mood with a return of interest, pleasure, and reward in doing things. I don't know if Wellbutrin is as effective when combined with SSRIs. I don't know why it shouldn't be.
A clarification request of Lamdage: Your subject line indicates your concern with anorgasmia, not erectile dysfunction. Your posts indicate otherwise. Which is it? These drugs don't necessarily affect both equally. In my estimation, SSRIs tend to produce more anorgasmia than ED. SNRIs, less so. Nortriptyline and desipramine are less likely to produce anorgasmia than ED. There is a better chance of your recovering erectile function with nortriptyline or desipramine than recovering orgasmic function with SSRIs. With me, Nardil produces anorgasmia for the first 2 - 3 months, whereafter I regain function gradually. I don't recall why you keep your dosage of Effexor so low. Generally speaking, with more severe, non-psychotic depressions, 300 mg/day is often necessary. Does your potential for experiencing psychosis factor into your decision to take only 37.5 mg/day? Side effects? as an aside, Luvox is supposed to be better than the other SSRIs for treating psychotic depression. I don't know what its reputation is for producing sexual side effects. However, adding buspirone might help if necessary.
- Scott
Posted by Lamdage22 on November 23, 2015, at 9:15:05
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by SLS on November 23, 2015, at 8:31:40
With Nortriptyline the concern is both anorgasmia and ED, with Venlafaxine its only anorgasmia.
I am trying to recover the anorgasmia with buspar if my doctor will let me.
If i can recover it, i would consider dosages above 100mg. If not, i wont do it
Posted by Lamdage22 on November 23, 2015, at 10:27:04
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by Lamdage22 on November 23, 2015, at 9:15:05
Scott,
my plan with the Venlafaxine is to raise it only if i need to.
That way it will help me get by until say Rapastinel or NRX-1074 reach the market. Or something else that helps me!
Posted by SLS on November 23, 2015, at 12:09:29
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by Lamdage22 on November 23, 2015, at 10:27:04
> Scott,
>
> my plan with the Venlafaxine is to raise it only if i need to.
>
> That way it will help me get by until say Rapastinel or NRX-1074 reach the market. Or something else that helps me!Okay. Now I understand. You are using these drugs as a bridge until something more encouraging to you becomes available. Still, I would be happy to see you feel better.
I'm pretty much doing the same thing. What I'm taking now appears to represent a dead end, but at least I can function. It always comes down to a cost / benefit value judgement. I don't like sacrificing my sex-drive in order to feel better, but it is a compromise that I have been willing to make for the last three years. Once I stabilize on desipramine, I would like to try to remove the culprit, prazosin, from my treatment regime.
- Scott
Posted by Lamdage22 on November 23, 2015, at 13:06:13
In reply to Re: 75mg Nortriptyline induces anorgasmia » Lamdage22, posted by SLS on November 23, 2015, at 12:09:29
If i had to sacrifice only the sex drive, id do it too i think.
Posted by Lamdage22 on November 24, 2015, at 2:22:38
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by Lamdage22 on November 23, 2015, at 13:06:13
I am improved with the ~80mg dose of Effexor. I take 40 b4 bed and 40 in the morning.
Asking my doctor for buspar today!
Posted by SLS on November 24, 2015, at 7:24:57
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by Lamdage22 on November 24, 2015, at 2:22:38
> I am improved with the ~80mg dose of Effexor. I take 40 b4 bed and 40 in the morning.
> Asking my doctor for buspar today!
Please post your progress with the Buspar. I would really like to see it work for you. If the results are unsatisfactory, adding Wellbutrin to Effexor makes sense to me based upon:
1. Wellbutrin is often used to remedy the sexual side effects of serotonin reuptake inhibitors. I don't know what the success rate is.
2. Wellbutrin can be a powerful augmenter of Effexor in producing an antidepressant response.
If it were me (and only me), and Buspar were to remedy the sexual side effects of Effexor 80 mg/day, I would continue to increase the dosage of Effexor with the reasonable expectation that the antidepressant response would progressively improve. Also, if it were me (and only me), and no other drug worked as well as Effexor, I would take it despite any sexual side effects. I want it that bad. Cost versus benefit. For me, the cost would be high, but the benefit would be higher. At the very least, it would be a bridge until new things become available.
I just thought I would share.
- Scott
Posted by Lamdage22 on November 24, 2015, at 7:45:58
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by SLS on November 24, 2015, at 7:24:57
Will do Scott.
I have read about a guy having remission of depression on Lyrica, so i think remission of depression on Buspar is within the realm of "possible".
Sometimes meds can have surprising effects since we all are different.
Posted by Lamdage22 on November 24, 2015, at 8:10:52
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by Lamdage22 on November 24, 2015, at 7:45:58
Scott,
my thought is that if i go on 375mg of Effexor: If it poops out at that dosage, i am f*ck*d.
I didnt feel so much additional effect on higher dosages.
Posted by Lamdage22 on November 24, 2015, at 8:13:36
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by Lamdage22 on November 24, 2015, at 8:10:52
You know what, i will present my doctor with my ideas. He seems like a trustworthy guy.
Posted by SLS on November 24, 2015, at 11:45:23
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by Lamdage22 on November 24, 2015, at 8:10:52
> Scott,
>
> my thought is that if i go on 375mg of Effexor: If it poops out at that dosage, i am f*ck*d.I totally understand that. Still, you might be able to bring the dosage up a little and gain a lot. My impressions might be wrong, but it seems that SNRIs don't poop-out as often as the SSRIs, particularly Paxil. Nardil can poop-out, too.
> I didnt feel so much additional effect on higher dosages.
You know yourself best. As you indicated, each person has a unique brain biology.
Maybe you can print out the article I cited about strategies to remedy sexual side effects. It was written in 1998, so it probably is not comprehensive. It still has some value, though. I would add mirtazapine (Remeron) to the list as a possibility because it hits the same receptors that mianserin and yohimbine do.
If you get really frustrated, you can try vilazodone (Viibryd) or vortioxetine (Brintellix) instead of Effexor. Sexual side effects are supposed to he less frequent with these drugs.
- Scott----------------------------------------------------
http://www.medscape.com/viewarticle/430614_5
Medscape Psychiatry & Mental Health eJournal [TM]
Treatment of Antidepressant-Induced Sexual DysfunctionMichael J. Gitlin, MD
DisclosuresMedscape Psychiatry & Mental Health eJournal. 1998;3(3)
References
A variety of antidotes have been reported to treat SSRI-induced sexual dysfunction effectively; however, virtually all the data on these agents are derived from open case reports and case series. Insofar as sexual function improvement may be responsive to placebo effects, it is impossible to estimate the true efficacy of these antidotes.[27]
Most of these antidotes either have serotonin-blocking properties (especially 5HT-2 antagonistic effects) or augment catecholamine activity, especially that of dopamine. The antiserotonergic antidotes are cyproheptadine, buspirone, nefazodone, and mianserin. Medications enhancing dopaminergic tone include amantadine, bupropion, and stimulants, with yohimbine showing noradrenergic effects. Among the reported antidotes, the only 2 without antiserotonergic effects or catecholaminergic activity are gingko biloba and urecholine.
Cyproheptadine is an antihistamine with antiserotonergic properties that has been reported for over a decade to reverse antidepressant-induced sexual dysfunction. Only case reports and case series attest to its efficacy.[13,42-44] Effective doses range from 2mg to 16mg. In the most recent and largest case series, 12 of 25 patients described improvement in sexual function when treated with cyproheptadine (mean dose, 8.6mg).[13] Anorgasmia is the sexual side effect most often reported to be alleviated by cyproheptadine. Cyproheptadine is effective when taken either on an as-needed basis (typically, 1 to 2 hours before intercourse) or on a regular basis.
However, cyproheptadine's utility is often limited by its potential side effects. Excessive sedation and the reversal of the therapeutic effect of the antidepressant are major problems that limit its usefulness. Effectively treated depression and bulimic symptoms have been reported to reemerge soon after cyproheptadine was started.[42,45-48] This reversal of therapeutic effects is itself reversible upon discontinuation.
Buspirone is a serotonin-IA partial agonist typically prescribed to treat persistent anxiety. One case series reported that buspirone reversed both decreased sexual interest and orgasmic dysfunction caused by SSRIs.[49] Most patients using buspirone to treat sexual dysfunction take it daily. The dosage is the same as that used for anxiety (15mg to 60mg daily). The mechanism of action of buspirone in treating sexual dysfunction may be reduction of serotonergic tone via stimulation of presynaptic autoreceptors or the alpha-2 antagonist effects of one of buspirone's major metabolites, 1-pyrimidinylpiperazine.
Nefazodone and mianserin are antidepressants with strong postsynaptic blocking properties. In one case report, nefazodone 150mg taken 1 hour prior to sexual activity completely reversed sertraline-induced anorgasmia.[50] Mianserin, an antidepressant with 5HT-2 and alpha-2 adrenergic antagonist properties, is available in many countries but not in the US. It has been reported to reverse serotonin reuptake inhibitor-induced sexual dysfunction in 9 of 15 patients.[51] Mirtazapine is similar in its biological activity to mianserin and might also be effective in reversing sexual side effects. No case reports or case series have yet been published attesting to this, although clinicians have described such an effect. The putative capacity of mianserin and mirtazapine to reverse sexual side effects can be attributed either to their serotonergic activity or presynaptic alpha-2 activity.
Amantadine, a dopamine agonist, is used both as an antiviral agent and as a treatment for Parkinson's disease. It has been shown in a number of small case series to reverse anorgasmia.[13,52-54] Reported effective doses have ranged between 100mg to 400mg taken either on a daily or as-needed basis. In the most recent case series, 8 (42%) out of 19 patients with SSRI-induced sexual dysfunction improved with amantadine 200mg daily.[13] Given dopamine's consistent effect as a neurotransmitter involved in sexual arousal, a number of other dopamine agonists have been explored as treatments for sexual side effects.[2,55,56]
Bupropion is another commonly touted antidote for SSRI-induced sexual dysfunction.[57,58] It is assumed that the mechanism of action by which bupropion reverses sexual side effects is its weak dopamine agonism. The evidence for bupropion's efficacy is scant, except for unpublished, anecdotal reports, one case report,[57] and a case series[58] in which 31 (66%) of 47 patients showed improvement when bupropion was added to the regimen along with the serotonergic antidepressant. Most patients (18/31) with a successful outcome responded to as-needed use of bupropion 75mg to 150mg. Libido, arousal, and orgasmic difficulties were all effectively reversed. Fifteen percent of treated patients stopped taking bupropion because of its stimulation side effects. It is unclear whether bupropion doses need to be somewhat lower than usual when added to fluoxetine or paroxetine, to compensate for pharmacokinetic interactions resulting in increased bupropion levels.[59]
Stimulants, such as methylphenidate, D-amphetamine, and pemoline, are reported to reverse a variety of sexual side effects caused by SSRIs or MAOIs.[60-62] Low doses of 10mg-25mg of methylphenidate or D-amphetamine have been effective. One should add stimulants to an MAOI with extreme caution because of the risk of a hypertensive episode. However, use of an MAOI/stimulant combination has been shown to be safe in a case series.[63] SSRI/stimulant combinations show no similar risks.
Yohimbine is available with or without a prescription (and with unclear purity) in health food stores. It is an alkaloid from the bark of Corynanthe yohimbi (family, Rubiaceae) and has been used for decades to reverse erectile dysfunction.[64-66] Its efficacy in treating sexual dysfunction may be associated with its ability to block presynaptic alpha-2 adrenergic sites, leading to enhanced adrenergic tone.[65] A variety of sexual side effects have been reported to be alleviated by yohimbine in doses ranging from 2.7mg to 16.2mg daily, prescribed either on a regular 5.4mg 3 times daily basis or on an as-needed basis with single doses up to 16.2mg.[13,67-69] In the largest case series, 17 (81%) of 21 patients showed improvement of sexual side effects when treated with yohimbine (mean dose, 16.2mg).[12]
Typical side effects associated with yohimbine include anxiety, nausea, flushing, urinary urgency, and sweating. Yohimbine has been the subject of the only double-blind, placebo-controlled study to evaluate treatment of sexual dysfunction occurring as a drug side effect.[27] Unfortunately, the placebo effect was marked, showing a minimal drug-placebo difference with yohimbine given at a dose of 5.4mg 3 times daily. Yohimbine is also available in lower potency without a prescription. The purity, potency, and safety of these preparations, however, are unknown.
Bethanechol is a cholinergic agonist that has occasionally been useful in reversing sexual dysfunction associated with TCAs and MAOIs.[70-73] Typical doses are 10mg to 20mg as needed or 30mg to 100mg daily in a divided dose. Potential side effects with bethanechol include diarrhea, cramps, and diaphoresis. No reports have evaluated or suggested the efficacy of bethanechol for treating SSRI-induced sexual side effects.
Gingko biloba is an herbal extract reported to reverse a variety of sexual dysfunctions associated with antidepressants. Information about gingko's ability in this regard is derived from the experience of 1 clinician presenting a large case series.[74] The response rate was greater than 80%, with doses ranging from 60mg twice daily to 120mg twice daily (mean daily dose, 207mg). Reported side effects include gastrointestinal upset, lightheadedness, and stimulation effects. Because gingko may inhibit platelet-activating factor, caution should be used in considering its use by any patient with a bleeding diathesis. The mechanism by which gingko might alleviate sexual dysfunction is unknown.
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Posted by Lamdage22 on November 24, 2015, at 12:41:03
In reply to Re: 75mg Nortriptyline induces anorgasmia, posted by SLS on November 24, 2015, at 11:45:23
Oh i tried Brintellix. I wanted to kill myself so badly on day 2 that i stopped. First time i ever had suicidal thoughts from a med.
I felt euthymic today. Almost a little euphoric because of a positive outlook. Needless to say i am pleased with Effexor! Maybe my brain chemistry changed.
I am thinking to go to professional school for two years and work in pharmacies one day. I like the contact with people. I like to be there for people. It could give me more of a sense of a purpose.
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Dr. Bob is Robert Hsiung, MD,
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