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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 2 of 2. This is the beginning of the thread.
Posted by uncouth on March 8, 2016, at 19:29:00
I am currently on 130mg Parnate and started desipramine a month ago. My pdoc is very good but doesn't have a ton of recent experience with combining MAOIs and TCAs so thus far we have been conservative and I have consulted with Dr. Gilman, as well.
I have a partial response to Parnate 130mg, but want to be on an NRI for its purported benefits in terms of reducing the tyramine reaction, for improving cognition, ADHD, motivation, anhedonia symptoms, and to go for the goal of full response. I've been on Strattera in combination with both Nardil (weight gain :( ) and Parnate, which I thought was pretty good, but I didn't see full response nor resolution of some of the social anhedonia I feel nor some of the drug seeking behaviors which I chalk up to continued poor cognitiion, sleep, and incomplete resolution of ADHD / anhedonia symptoms.
So we switched to Contrave (Wellbutrin/Naltrexone) from Strattera in combo with the parnate in the fall, with the intent of aiding weight loss as well as hoping that Wellbutrin combined better with Parnate. Neither effect really occured (didn't lose weight, wasn't any better, possibly worse), so got off of that and switched to desipramine last month.
I have bipolar 2, mostly depression, along with sleep apnea which is fairly well treated if I keep up good sleep hygeine with CPAP and a surgery last year, motivation issues, anhedonia, desire/libido issues, you know the drill...i've been posting on PB for years :)
Overall things are a lot better with Parnate, but I am shooting for full resolution and am still drug seeking which I am hoping an addition to Parnate will help.
So here are the options I want to discuss with my pdoc this week and my questions:
1. Increase desipramine dose? And to what? I have been on 50mg the past month and the side effects have gone away. Dr. Gilman, however, says that in his opinion desipramine is typically dosed 10x more than necessary for full NA transporter inhibition...and that full occupancy of the transporter occurs at 10-50mg. This goes against the guidelines for dose ranges that are effective, but I suspect desipramine may have other known or unknown mechanisms of action independent of NRI that require higher doses.
2. Swap desipramine for nortryptiline. For folks who have been on both, can you describe the difference? What worked better for the more dopamenergic or opioidish type symptoms such as anhedonia, motivation, cognition. Side effect burden? Cardiotoxicity?
3. Swap desipramine for protryptiline. Have never been on protrytiline but curious as to whether anyone can speak to how it compares to desipramine and nortryptiline.
4. Ditch TCAs, go back to strattera. Known quantity.
5. Ditch TCAs, escalate parnate as far as tolerable or until response develops.
Thanks for ideas and feedback.
Posted by SLS on March 9, 2016, at 6:21:22
In reply to Parnate + Desipramine: increase, switch TCA, or..., posted by uncouth on March 8, 2016, at 19:29:00
> I am currently on 130mg Parnate and started desipramine a month ago. My pdoc is very good but doesn't have a ton of recent experience with combining MAOIs and TCAs so thus far we have been conservative and I have consulted with Dr. Gilman, as well.
>
> I have a partial response to Parnate 130mg, but want to be on an NRI for its purported benefits in terms of reducing the tyramine reaction, for improving cognition, ADHD, motivation, anhedonia symptoms, and to go for the goal of full response. I've been on Strattera in combination with both Nardil (weight gain :( ) and Parnate, which I thought was pretty good, but I didn't see full response nor resolution of some of the social anhedonia I feel nor some of the drug seeking behaviors which I chalk up to continued poor cognitiion, sleep, and incomplete resolution of ADHD / anhedonia symptoms.
>
> So we switched to Contrave (Wellbutrin/Naltrexone) from Strattera in combo with the parnate in the fall, with the intent of aiding weight loss as well as hoping that Wellbutrin combined better with Parnate. Neither effect really occured (didn't lose weight, wasn't any better, possibly worse), so got off of that and switched to desipramine last month.
>
> I have bipolar 2, mostly depression, along with sleep apnea which is fairly well treated if I keep up good sleep hygeine with CPAP and a surgery last year, motivation issues, anhedonia, desire/libido issues, you know the drill...i've been posting on PB for years :)
>
> Overall things are a lot better with Parnate, but I am shooting for full resolution and am still drug seeking which I am hoping an addition to Parnate will help.
>
> So here are the options I want to discuss with my pdoc this week and my questions:
>
> 1. Increase desipramine dose? And to what? I have been on 50mg the past month and the side effects have gone away. Dr. Gilman, however, says that in his opinion desipramine is typically dosed 10x more than necessary for full NA transporter inhibition...and that full occupancy of the transporter occurs at 10-50mg. This goes against the guidelines for dose ranges that are effective, but I suspect desipramine may have other known or unknown mechanisms of action independent of NRI that require higher doses.
>
> 2. Swap desipramine for nortryptiline. For folks who have been on both, can you describe the difference? What worked better for the more dopamenergic or opioidish type symptoms such as anhedonia, motivation, cognition. Side effect burden? Cardiotoxicity?
>
> 3. Swap desipramine for protryptiline. Have never been on protrytiline but curious as to whether anyone can speak to how it compares to desipramine and nortryptiline.
>
> 4. Ditch TCAs, go back to strattera. Known quantity.
>
> 5. Ditch TCAs, escalate parnate as far as tolerable or until response develops.
>
> Thanks for ideas and feedback.
If you are looking for an improvement in depression, I think you are squandering an opportunity to attain that goal by discontinuing desipramine prematurely at such a low, subtherapeutic dosage. If all you are interested in is to mitigate a tyramine pressor response, I don't know what the optimum dosage is. Have you seen any studies demonstrating this effect clinically rather than only predicting it theoretically? I'm not sure where to look.Protriptyline was the TCA that I felt worst on. It exacerbated my depression and produced the strongest anticholinergic / pro-noradrenergic side effects. I imagine my reaction was atypical, or else the drug would have no market.
- Scott
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