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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 15 of 15. This is the beginning of the thread.
Posted by TH on July 9, 2019, at 7:18:17
For several months now I have been struggling with a loss of efficacy from my previously effective dose of tranylcypromine. I have an appointment to meet with a psychiatrist who specialises in MAOIs in a few weeks, and a recommendation that increasing the dose is likely to be helpful.
That being said, a rather farfetched idea has been bothering me for a while now, about the possibility of the medication having been improperly stored somewhere along the supply chain. While this idea seems highly unlikely to be behind these issues, it does somewhat seem to fit.
After a strong response of several months to initial treatment with tranylcypromine, the effect had begun to wane. As I live in quite a remote area, I see a doctor in the city, and previously had been filling my prescription there also. At the beginning of February I began filling my prescription at my local pharmacy. While it's hard to pinpoint exactly where things began to fall apart, my internet chat history suggests that by mid-March things had significantly deteriorated. In April, I increased the dose to 40mg daily without significant improvement; the slow decline continued.
This period of March through June was characterised by alternating periods of relative wellness and depression. Suspiciously, the side effects I normally experienced from the medication were now only present during the periods of relative wellness.
At this point, there are no longer significant periods of wellness. I have returned to a more or less consistent state of depression, with a peculiar quirk: periods of side effects appear spontaneously. Just this evening I experienced a transient episode of severe orthostatic hypotension, accompanied with the dry mouth and the sedation I felt during early treatment. Upon standing my blood pressure fell so severely that I felt faint and heard a loud ringing in my ears. By the time I realised what was happening and retrieved my blood pressure monitor I had more or less recovered, however even then my blood pressure was 93/54, and my heart was beating at 133bpm. This is a more significant drop from my normal standing reading of ~130/80 than I had ever experienced during the initial stages of treatment.
These transient episodes of side effects are almost as if the medication has been completely absent from my system and has been suddenly re-introduced, a pattern than would also fit the gradually declining cycles of earlier on.
The fact that this gradually began around the time I switched pharmacies also lends itself to the theory.
I have experimented with dose times and full vs empty stomach and this appears to have no effect. Luckily I had saved all the empty packaging and checked the batch numbers and expiry dates. There was no change in batch number around that time this began, and no medication was near an expiry date.
The datasheet specifies that tranylcypromine should be stored below 25ºC and while this has always been the case on my watch, I am left wondering whether this has been the case with my local pharmacy's supply. While I could find no specific mention of tranylcypromine, brief research suggests that some medications can be very sensitive to their storage conditions.
Although it strikes me as unlikely, does this seem in any way like a plausible explanation, or just the distorted over-analysis of an unwell mind?
Posted by linkadge on July 9, 2019, at 11:49:15
In reply to Improper Medication Handling?, posted by TH on July 9, 2019, at 7:18:17
Hmm. Difficult to say.
You could try skipping a dose to see if there is a noticeable effect. However, if there was something wrong with the storage, you'd think it would only result in a marginal loss of potency.
What dose are you taking? 40mg can be a maintenance dose, but often much higher doses are needed to get to remission.
Are you noticing any insomnia? If not, it might be a sign that insufficient MAO inhibition has been achieved.
Linkadge
Posted by TH on July 9, 2019, at 16:07:03
In reply to Re: Improper Medication Handling?, posted by linkadge on July 9, 2019, at 11:49:15
I experienced a degree of insomnia during the initial treatment period, and during the subsequent intervals of wellness, however this only reduced my normal pattern of oversleeping to a more or less acceptable 7 hours a night.
I'm fairly sure sufficient MAO inhibition was achieved, as indicated by my blood pressure drop during early treatment, by the remission I experienced, and even by the occasional hypertensive crisis from poorly stored food (oops).
It would appear that some medications can experience a severe loss in potency. For example, some sources report a 75% loss of lorazepam exposed to 35°C.
Admittedly it seems unlikely, that such a thing could be behind this, however the "here today, gone tomorrow" nature of the side effects has left me thoroughly confused as to possible causes.
As MAO inhibition recovers slowly, I don't expect missing one dose would reveal much.
In any case, time constraints will mean that my next prescription will have to be filled at an alternative pharmacy, so I suppose time will tell, although if the dosage is also increased at the same time it may be hard to tell what the true cause is. Perhaps I will take a week or two of the new supply at the current dose before increasing?
Posted by TH on July 9, 2019, at 23:16:17
In reply to Re: Improper Medication Handling? » linkadge, posted by TH on July 9, 2019, at 16:07:03
Actually, as I have not cleared my old medication boxes from my dresser, I was just now able to double check the batch numbers.
Beginning in March, I began to receive a mixture of the batch I was initially taking (expiry 09/19) and a new batch (expiry 01/20). As a box only contains 50 tablets, my 30 day supply was always a mixture of old and new batches. Around this time I do remember a slight hold up with refills as there was apparently none in the country and a new source was being urgently sought.
At this point my prescription consists solely of the new batch (expiry 01/20).
While the information sheets show no change to the formulation of the tablets, does it seems possible that this change in batch could be related?
Posted by TH on July 10, 2019, at 0:35:02
In reply to Different Batches!, posted by TH on July 9, 2019, at 23:16:17
https://www.socialanxietysupport.com/forum/f30/gsk-parnate-reformulation-2210965/
The plot thickens! I would be interested to hear from rose45 on the expiry date of her current supply of Parnate also.
Posted by PeterMartin on July 10, 2019, at 2:47:24
In reply to Re: Different Batches!, posted by TH on July 10, 2019, at 0:35:02
I took Package but on for a month or so. I can't remember, but is there more than one manufacturer of it at the moment? I know Nardil has 2 (Gavis/Greenstone). I have had wide variations in response to different manufacturers with some meds like Lamictal. The 2 different Nardil brands felt different to me also.
If there's a different generic you could ask your pharmacy to order in that would probably be worth a try.
Posted by PeterMartin on July 10, 2019, at 2:48:03
In reply to Re: Different Batches!, posted by PeterMartin on July 10, 2019, at 2:47:24
Parnate* (not "package") autocorrect fail.
Posted by TH on July 10, 2019, at 5:45:19
In reply to Re: Different Batches!, posted by PeterMartin on July 10, 2019, at 2:48:03
It would be nice if this were an option, however our health system appears to only fund one brand of Tranylcypromine. It would be possible to import a different brand with a valid prescription, however it would mean paying the full cost out of pocket. If you are at all interested, our government's pharmaceutical schedule is available here: https://www.pharmac.govt.nz/tools-resources/pharmaceutical-schedule/
Posted by linkadge on July 10, 2019, at 8:25:35
In reply to Re: Improper Medication Handling? » linkadge, posted by TH on July 9, 2019, at 16:07:03
If there was an effect of temperature, it would also be a function of time. In other words, how long does lorazepam need to be exposed to 35 degree temps to lose that much potency.
When I took parnate, there was an immediate stimulant like effect with each dose (which wore off a bit with time). However, if I missed a dose, I would notice it.
Linkadge
Posted by rose45 on July 10, 2019, at 14:38:40
In reply to Re: Improper Medication Handling?, posted by linkadge on July 10, 2019, at 8:25:35
Hi TH, Ive only just seen these messages.
When parnate stopped working after I stupidly decreased it, mine were from a different batch, and Im afraid I didnt make a note of the manufacturer. My pharmacist is having trouble getting hold of parnate these days. Im not too sure why.... but I have to give him plenty of notice as he seems to be having trouble getting it, which is scary.
My present batch is from mercury pharmaceuticals lot 1102015 exp 6/20
but its not working as psychiatrists are trying to figure out how to deal with the situation.
I also consulted a private psychiatrist who specialises in maois and it was a bit of a disaster....
In my experience, I did feel that parnate was working less well some months after starting on it, and I also consulted a private psychiatrist at the time. But I did not increase the dose and slowly things got better again. ...in my experience, a lot has to do with what is happening in your life.
Posted by rose45 on July 10, 2019, at 14:41:48
In reply to Re: Improper Medication Handling?, posted by rose45 on July 10, 2019, at 14:38:40
What do you think about the posts on reddit, re.
crushing the tablets and mixing with water? Its worth a try.
Posted by TH on July 10, 2019, at 17:34:33
In reply to Re: Improper Medication Handling?, posted by rose45 on July 10, 2019, at 14:41:48
Suspiciously, mine are from mercury pharmaceuticals also.
It's highly likely that this whole idea around the new batches is irrelevant, but I can't help feeling like it fits what's happening. It's not unbelievable either seeing as the same thing happened to many people when Nardil was reformulated.
As for crushing them, I hadn't seen the Reddit post and would appreciate a link if you have it, however I had been thinking about that idea myself already, as well as the possibility of adding the tablets to an extra pill like some people have tried with Nardil, incase absorption should be lower in the GI tract rather than higher. Even sublingual administration is an option.
While I don't want to change anything so near my appointment, these are all options I may resort to exploring if nothing else is effective.
Posted by TH on July 11, 2019, at 20:37:37
In reply to Re: Improper Medication Handling?, posted by rose45 on July 10, 2019, at 14:41:48
> What do you think about the posts on reddit, re.
> crushing the tablets and mixing with water? Its worth a try.This morning I had a very close look at the packaging and tablets. I noticed that the plastic packaging has a small bump in the bottom of every pill compartment. Sometimes when ejecting a pill from the foil, this bump will pierce or indent the casing, however other times it will not.
Unable to contain my curiousity, I cut both tablets of my afternoon dose in half, exposing the inner pill, before taking them. The familiar sensation of the medication entering my system occurred much sooner and more noticeably; more like what I would feel when the treatment was effective.
I don't know if this will translate into a return of useful therapeutic effect, but I think I will continue splitting my pills for at least a few weeks to gauge the result.
Posted by rose45 on July 12, 2019, at 4:20:33
In reply to Pill packaging and absorption rates » rose45, posted by TH on July 11, 2019, at 20:37:37
TH, I read the post on Reddit, but cant find it now... Your packaging must be different to mine. Mine come in a bottle with the pills loose . I am trying to suck the pill and then bite it into little pieces - but eventually hve to swallow .... I take them all in the morning..... havent done the mixing with water, because I dont understand how you can really absorb them under the tongue, without swallowing at all - but they stopped working for me many months ago... Im still waiting to see a psychiatrist on the nhs, as the private one was so expensive, and didnt really come up with any different solutions. But I am a difficult case, and really desperate now.
Posted by TH on July 12, 2019, at 6:02:38
In reply to Re: Pill packaging and absorption rates, posted by rose45 on July 12, 2019, at 4:20:33
I'd just like to add that in no way can I advise anyone else to tamper with their medication in any way. I would hate to be responsible for some unforseen occurrence.
Am I to understand that you have been chewing your medication like this for some time now?
I will do my best to photograph what I have described tomorrow morning.
This is the end of the thread.
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