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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by tensor on October 31, 2009, at 5:50:40
Hi,
currently taking Remeron 30mg and 300mg of Wellbutrin for depression and 2mg of clonazepam for anxiety. It worked well the first month, but now I have developed a tiredness. I can sleep at day and still have no problems falling asleep at bedtime. At night I easily sleep 8-10hrs and is still tired when I get up for work (if I go to work).
I have tried most of the available meds and taken meds constantly for over ten years. But I don't really know what to do now. Any ideas what to do, dose changes, adding meds etc? Which meds would be safe to add?
Thanks.
Posted by tensor on October 31, 2009, at 5:52:26
In reply to I'm so tired.., posted by tensor on October 31, 2009, at 5:50:40
Posted by delna on October 31, 2009, at 7:06:06
In reply to forgot email notification.. (nm) » tensor, posted by tensor on October 31, 2009, at 5:52:26
Hi,
I really empathize with you about your tiredness issue, it can be so disabling.I'm sure you realize that Remeron is sedating, in itself but since you say you have tried many other drugs, I assume you are on it for a reason.
Personally I have no experience with Remeron but I do with 'stimulating drugs'. So I can suggest an add on.I take Provigil(modafinil) and that is very effective. I have (many times in the past) combined it with 300mg Wellbutrin. This is a safe combination, as far as I know (with antidepressants). No pdoc of mine has ever objected to it. In fact when I start Effexor in several days I will be be adding this exact duo.
Personally, I take up to 400mg of Provigil but the usual dose of 200mg makes a big difference for most people. Alternatively, you can try a conventional stimulant.
I just double-checked in Stahls Prescribers guide to see what he recommends with Remeron and this is what I found.
Not sure you can the see the link without signing up so I am Cut/ pasting here:
Mirtazapine'Best Augmenting Combos for Partial Response or Treatment-Resistance
* SSRIs, bupropion, reboxetine, atomoxetine (use combinations of antidepressants with caution as this may activate bipolar disorder and suicidal ideation)
* Venlafaxine (California rocket fuel; a potentially powerful dual serotonin and norepinephrine combination, but observe for activation of bipolar disorder and suicidal ideation)
* Modafinil, especially for fatigue, sleepiness, and lack of concentration
As far as I know the really stimulating ones are:
Wellbutrin (bupropion)
Provigil (Modafinil)
Reboxetine.
He also mentions using conventional stimulants later on in the chapter (not available online).Maybe others can comment on the other suggested drugs and if they help with fatigue....
So apparently both Wellbutrin and Provigil individually are safe with Remeron. You need to check with your pdoc if it is safe to take BOTH together with Remeron.(But I personally don't see why it should be a problem.)I have no experience with Remeron but as I have mentioned i have taken both Welllbutrin 300mg and Provigil (high doses) together with other antidepressants with no problems nor objections from my (various) pdocs.
Hope that helps somewhat.
Take care
D
Posted by tensor on October 31, 2009, at 7:22:16
In reply to Re: forgot email notification.. » tensor, posted by delna on October 31, 2009, at 7:06:06
> Hi,
> I really empathize with you about your tiredness issue, it can be so disabling.
>
> I'm sure you realize that Remeron is sedating, in itself but since you say you have tried many other drugs, I assume you are on it for a reason.
> Personally I have no experience with Remeron but I do with 'stimulating drugs'. So I can suggest an add on.
>
> I take Provigil(modafinil) and that is very effective. I have (many times in the past) combined it with 300mg Wellbutrin. This is a safe combination, as far as I know (with antidepressants). No pdoc of mine has ever objected to it. In fact when I start Effexor in several days I will be be adding this exact duo.
>
> Personally, I take up to 400mg of Provigil but the usual dose of 200mg makes a big difference for most people. Alternatively, you can try a conventional stimulant.
>
> I just double-checked in Stahls Prescribers guide to see what he recommends with Remeron and this is what I found.
>
> http://stahlonline.cambridge.org/prescribers_drug.jsf?page=0521683505c57_p325-330.html.therapeutics&name=Mirtazapine&title=Therapeutics
>
> Not sure you can the see the link without signing up so I am Cut/ pasting here:
>
>
> Mirtazapine
>
> 'Best Augmenting Combos for Partial Response or Treatment-Resistance
>
> * SSRIs, bupropion, reboxetine, atomoxetine (use combinations of antidepressants with caution as this may activate bipolar disorder and suicidal ideation)
> * Venlafaxine (California rocket fuel; a potentially powerful dual serotonin and norepinephrine combination, but observe for activation of bipolar disorder and suicidal ideation)
> * Modafinil, especially for fatigue, sleepiness, and lack of concentration
>
>
> As far as I know the really stimulating ones are:
> Wellbutrin (bupropion)
> Provigil (Modafinil)
> Reboxetine.
> He also mentions using conventional stimulants later on in the chapter (not available online).
>
> Maybe others can comment on the other suggested drugs and if they help with fatigue....
>
>
> So apparently both Wellbutrin and Provigil individually are safe with Remeron. You need to check with your pdoc if it is safe to take BOTH together with Remeron.(But I personally don't see why it should be a problem.)
>
> I have no experience with Remeron but as I have mentioned i have taken both Welllbutrin 300mg and Provigil (high doses) together with other antidepressants with no problems nor objections from my (various) pdocs.
>
> Hope that helps somewhat.
> Take care
> DHi and thanks for your reply!
Actually modafinil was one of the meds I was thinking about, I used to take it before with Remeron but that was before I started with bupropion. Modafinil worked great, I used to take 200mg in the morning and I have some pills left.
Neither bupropion nor modafinil is used here so my pdoc has really no experience with them so I'm not sure how accurately he could say if it's safe or not. I got these meds through a license from my pdoc. Although bupropion is available as Zyban for quitting smoking.I'm also thinking of adjusting the Remeron dosage, but I don't know if I should go up or down, i.e. 15mg or 45mg.
Thanks.
Posted by delna on October 31, 2009, at 9:36:42
In reply to Re: forgot email notification.. » delna, posted by tensor on October 31, 2009, at 7:22:16
Oh no! that's too bad about the stimulants :(
Maybe a simple dose adjustment will do.
I have no clue but I'm sure others will.
Just a suggestion, if I may be so bold....but maybe you can change the title of your post to something like "Remeron tiredness..dose adjustment?" because right now the thread just says 'forgot email notification..'
It may attract more Remeron users.
Just a suggestion...Hope you get some useful tips
Take Care
D
Posted by Phillipa on October 31, 2009, at 12:21:16
In reply to Re: forgot email notification.. » tensor, posted by delna on October 31, 2009, at 9:36:42
Hi Tensor don't ask why no clue but for some wierd reason remeron at 15mg even combined with benzos didn't maked me tired or sleepy. I took it at bed time and stopped it after a month. Sometimes I wonder if I have an absorption problem or something. Could the tiredness be depression? Just a thought. Phillipa
Posted by X-ray on October 31, 2009, at 12:35:00
In reply to I'm so tired.., posted by tensor on October 31, 2009, at 5:50:40
Hi,
I've just started on a Remeron/Wellbutrin combo myself.
So we are in the same boat.I have always been tired on Remeron,
but this drowsiness has disappeared with Wellbutrin.The reason why you are so tired is clonazepam.
That's crystal clear to me.Have you considered buspirone?
It's a mild drug that has few side effects.I've been on buspirone for 15 years.
This drug does a great job with my anxiety.Lyrica is an option, if you don't like buspirone.
Best regards,
X-ray
Posted by tensor on October 31, 2009, at 14:06:09
In reply to Re: I'm so tired.., posted by X-ray on October 31, 2009, at 12:35:00
> Hi,
>
> I've just started on a Remeron/Wellbutrin combo myself.
> So we are in the same boat.
>
> I have always been tired on Remeron,
> but this drowsiness has disappeared with Wellbutrin.
>
> The reason why you are so tired is clonazepam.
> That's crystal clear to me.
>
> Have you considered buspirone?
> It's a mild drug that has few side effects.
>
> I've been on buspirone for 15 years.
> This drug does a great job with my anxiety.
>
> Lyrica is an option, if you don't like buspirone.
>
> Best regards,
> X-ray
>
>Interesting, this combo seems to be rare.
I have taken clonazepam for 8-9 years for social phobia and it still works great, far better than anything I tried before it. I have planned and actually begun to wean myself off clonazepam but the returning symptoms have convinced me I still need it.
I have been on Remeron even longer, since -98, with only a couple of months off it, I have a pretty good idea how it affects me.
When I started bupropion two months ago it energized me from the first pill, but has now kind of lost its "momentum". Maybe I need to reinstate cipralex or something. I actually switched cipralex for bupropion, perhaps I felt so good when I started bupropion because of the cipralex that was still in my body?
Also, discontinuing clonazepam is out of the question as long as I take bupropion. I know my pdoc is reluctant to mix three antidepressants, and honestly I don't like the idea either. I have been working six weeks now after a long sick leave, and I really would like to work now.Thanks.
Posted by tensor on October 31, 2009, at 14:11:02
In reply to Re: forgot email notification.., posted by Phillipa on October 31, 2009, at 12:21:16
> Hi Tensor don't ask why no clue but for some wierd reason remeron at 15mg even combined with benzos didn't maked me tired or sleepy. I took it at bed time and stopped it after a month. Sometimes I wonder if I have an absorption problem or something. Could the tiredness be depression? Just a thought. Phillipa
Hi,
yes, unfortunately it could be depression, but I don't have the typical depressive thought patterns. I'm simply tired, I think. It could be the darkness or perhaps an infection but it has lasted for a couple of weeks now.
Thanks.
Posted by X-ray on October 31, 2009, at 15:01:59
In reply to Re: I'm so tired.. » X-ray, posted by tensor on October 31, 2009, at 14:06:09
From Stahls Essential Psychopharmacology Online:
BUPROPION
Best Augmenting Combos for Partial Response of Treatment-Resistance
Benzodiazepines for residual anxiety.
Mirtazapine, modafinil for residual symptoms of depression.So maybe modafinil could do the trick?
X-ray
Posted by tensor on October 31, 2009, at 17:12:56
In reply to Re: I'm so tired.., posted by X-ray on October 31, 2009, at 15:01:59
> From Stahls Essential Psychopharmacology Online:
>
> BUPROPION
>
> Best Augmenting Combos for Partial Response of Treatment-Resistance
>
> Benzodiazepines for residual anxiety.
> Mirtazapine, modafinil for residual symptoms of depression.
>
> So maybe modafinil could do the trick?
>
> X-ray
>Yeah it probably would, I haven't taken it for a while, gonna call my pdoc on monday and see what he says.
Thanks.
Posted by Phidippus on October 31, 2009, at 18:00:09
In reply to I'm so tired.., posted by tensor on October 31, 2009, at 5:50:40
Remeron can be very sedating. CLonazepam is also sedating. You could go down on the CLonazepam and the Remeron and I wonder if udjusting the Wellbutrin up would help. You could also ad a stimulant.
P
Dexedrin 45 mg
Geodon 80 mg
Keppra 1000 mg
Lexapro 20 mg
Gabitril prn
Tramadol prn
Posted by tensor on November 1, 2009, at 13:20:59
In reply to Re: I'm so tired.., posted by Phidippus on October 31, 2009, at 18:00:09
I actually took 100mg of modafinil today and it worked great, I got alot of things done. Gonna take it tomorrow too and discontinue bupropion. Will likely increase Remeron to 45mg in an attempt to keep anxiety away. SSRIs simply don't work for my anxiety.
/tensor
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