Psycho-Babble Medication Thread 1121427

Shown: posts 1 to 8 of 8. This is the beginning of the thread.

 

TCA + Effexor Combo / Maximum Effexor Dosage

Posted by SLS on December 31, 2022, at 12:48:34

Most importantly, the maximum dosage of Effexor has been determined by clinicians using the drug in their practice and investigators using clinical trials is 300 mg/day - NOT 225 mg/day. If you stop at 225 mg/day when you tolerated it well, not going to 300 mg/day is practically mal-practice in my view. Investigators have used dosages of 600 mg/day when determining the effective dosage range of Effexor - especially in severe or treatment-resistant depression.

https://pubmed.ncbi.nlm.nih.gov/15260908/

https://pdr.net/drug-summary/Venlafaxine-Hydrochloride-Extended-Release-Tablets-venlafaxine-hydrochloride-3520#6

https://www.medicalnewstoday.com/articles/326678#dosage


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There are some interesting reports of adding venlafaxine (Effexor) to an ongoing treatment of clomipramine (Anafranil) or imipramine (Tofranil).

https://pubmed.ncbi.nlm.nih.gov/10830150/

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Generally speaking, clomipramine is considered the most effective tricyclic antidepressant (TCA) in that it will get more people well than any of the others. Amitriptyline is often rated as 2nd and imipramine 3rd.


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- Scott


 

Re: TCA + Effexor Combo / Maximum Effexor Dosage

Posted by SLS on December 31, 2022, at 12:54:13

In reply to TCA + Effexor Combo / Maximum Effexor Dosage, posted by SLS on December 31, 2022, at 12:48:34


A trial of adding low-dosage lithium to an ongoing treatment with Effexor (venlafaxine).


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"Low dosage lithium augmentation in venlafaxine resistant depression: an open-label study"

https://pubmed.ncbi.nlm.nih.gov/22796912/


* Notice the dosages of Effexor used.


--------------------------------------------------------------------


- Scott

 

Re: TCA + Effexor Combo / Maximum Effexor Dosage

Posted by Jay2112 on January 1, 2023, at 20:48:20

In reply to TCA + Effexor Combo / Maximum Effexor Dosage, posted by SLS on December 31, 2022, at 12:48:34

Last time I tried Effexor at 300mg dose I ended up trying to cut my wrists.

Jay

 

Re: TCA + Effexor Combo / Maximum Effexor Dosage Jay2112

Posted by SLS on January 2, 2023, at 11:46:21

In reply to Re: TCA + Effexor Combo / Maximum Effexor Dosage, posted by Jay2112 on January 1, 2023, at 20:48:20

> Last time I tried Effexor at 300mg dose I ended up trying to cut my wrists.
>
> Jay

It is very frustrating to watch someone have a terrible reaction to a treatment that brings others to remission. However, any good doctor would titrate Effexor using a protocol accepted to be ideal for that drug. They consider dosage versus side effects versus therapeutic response. Some people respond to Effexor 75 mg/day, although my guess is that increased severity or treatment-resistance indicates the necessity for using higher dosages.

It's the doctor's responsibility not to blow past the lowest effective dosage for a given individual. With me, 225 mg/day didn't produce any improvement, but I found the drug tolerable. In this circumstance, it is critical to continue to a titrate the dosage to 300 mg/day or higher. If someone doesn't respond to 375 mg/day, it's probably time to reduce the dosage back to 300 mg/day, add Wellbutrin 150-300 mg, low-dosage lithium 300 mg/day +/- 150 mg/day, mirtazepine 45-90 mg/day, or anything else you have on your (or your doctor's) list that is beyond my knowledge.

If you don't respond to Effexor with augmenters, I would consider remaining on low-dosage lithium indefinitely, especially if you receive even the mildest of transient improvements over the first three days. According to published studies testing dosages of lithium 150-600 mg/day, 300 mg/day was the dosage most often found to be effective. For me, there is a narrow therapeutic window:

150 mg/day = No response.
300 mg/day = Remission.
450 mg/day = Relapse.

Have you tried lamotrigine? If so, did you evaluate 300 mg/day before discontinuing it? This is another drug that can produce a mild response within the first week of treatment. However, its positive effect can become lost when polypharmacy is the mode of treatment. It is important to consider that lamotrigine might not have an all-or-nothing dosage-response curve. For me 200 mg/day gave me a partial improvement when added to my regime. The improvement was persistent and unabated over the course of 8 weeks. When the dosage was raised to 300 mg/day, it "popped". Big improvement. I have remained on both lithium and lamotrigine while continuing to trial other drugs. It has been my observation that the percentage of people responding to 200 mg is much higher than 150 mg/day.


- Scott

 

Re: TCA + Effexor Combo / Maximum Effexor Dosage SLS

Posted by Jay2112 on January 2, 2023, at 16:23:05

In reply to Re: TCA + Effexor Combo / Maximum Effexor Dosage Jay2112, posted by SLS on January 2, 2023, at 11:46:21

> > Last time I tried Effexor at 300mg dose I ended up trying to cut my wrists.
> >
> > Jay
>
> It is very frustrating to watch someone have a terrible reaction to a treatment that brings others to remission. However, any good doctor would titrate Effexor using a protocol accepted to be ideal for that drug. They consider dosage versus side effects versus therapeutic response. Some people respond to Effexor 75 mg/day, although my guess is that increased severity or treatment-resistance indicates the necessity for using higher dosages.
>
> It's the doctor's responsibility not to blow past the lowest effective dosage for a given individual. With me, 225 mg/day didn't produce any improvement, but I found the drug tolerable. In this circumstance, it is critical to continue to a titrate the dosage to 300 mg/day or higher. If someone doesn't respond to 375 mg/day, it's probably time to reduce the dosage back to 300 mg/day, add Wellbutrin 150-300 mg, low-dosage lithium 300 mg/day +/- 150 mg/day, mirtazepine 45-90 mg/day, or anything else you have on your (or your doctor's) list that is beyond my knowledge.
>
> If you don't respond to Effexor with augmenters, I would consider remaining on low-dosage lithium indefinitely, especially if you receive even the mildest of transient improvements over the first three days. According to published studies testing dosages of lithium 150-600 mg/day, 300 mg/day was the dosage most often found to be effective. For me, there is a narrow therapeutic window:
>
> 150 mg/day = No response.
> 300 mg/day = Remission.
> 450 mg/day = Relapse.
>
> Have you tried lamotrigine? If so, did you evaluate 300 mg/day before discontinuing it? This is another drug that can produce a mild response within the first week of treatment. However, its positive effect can become lost when polypharmacy is the mode of treatment. It is important to consider that lamotrigine might not have an all-or-nothing dosage-response curve. For me 200 mg/day gave me a partial improvement when added to my regime. The improvement was persistent and unabated over the course of 8 weeks. When the dosage was raised to 300 mg/day, it "popped". Big improvement. I have remained on both lithium and lamotrigine while continuing to trial other drugs. It has been my observation that the percentage of people responding to 200 mg is much higher than 150 mg/day.
>
>
> - Scott
>

I think it is important to keep a very wide range of options in mind, consideration for individual variables. I think you are missing out on the use of atypical antipsychotics, and other mood stabilizers. In particular, risperidone with it's 5ht2a blockade. 5ht2a is implicated as the 'activating' serotonin receptor. It may be likely responsible for mania, and the activating suicidal responses to serotonin drugs, in particular the SSRI's.(https://pubmed.ncbi.nlm.nih.gov/11870006/) Clozapine also has a strong 5ht2a blockade/antagonism.

I also think Wellbutrin can work well with propranolol...sort-of to balance out the norepinephrine stimulation. IMHO, for an antidepressant effect, there has to be some serotonin effect, and a TCA may be a better angle than Wellbutrin. I found amitriptyline quite effective, and low dose imipramine better than secondary amines. It seems "the more you muck around with (amines), the better the outcome".

You also have to take into consideration, as expert psychopharmacologist Dr. Peter Kramer explains, that psychiatry is still very much an art form, as no two individual psyche's are the same. We may respond in some ways similar to drugs and therapy, but no two exactly the same.

Jay

 

Re: TCA + Effexor Combo / Maximum Effexor Dosage Jay2112

Posted by SLS on January 2, 2023, at 19:44:25

In reply to Re: TCA + Effexor Combo / Maximum Effexor Dosage SLS, posted by Jay2112 on January 2, 2023, at 16:23:05

> I think you are missing out on the use of atypical antipsychotics, and other mood stabilizers.


olanzapine
ziprazidone
aripiprazole
sulpiride
asenapine
aripiprazole
lurasidone
risperidone


carbamazepine
oxcarbazepine
tiagabine
pregabalin
gabapentin
lamotrigine
topiramate
levetiracetam
valproate


I haven't seen anyone on PB report their having tried lumateperone (Caplyta). Perhaps it would be worth considering for those people who failed to respond to lurasidone for depression.

Keep an eye out for zuranolone.


- Scott

 

Re: TCA + Effexor Combo / Maximum Effexor Dosage Jay2112

Posted by undopaminergic on January 3, 2023, at 10:58:09

In reply to Re: TCA + Effexor Combo / Maximum Effexor Dosage SLS, posted by Jay2112 on January 2, 2023, at 16:23:05

>
> I think it is important to keep a very wide range of options in mind, consideration for individual variables. I think you are missing out on the use of atypical antipsychotics, and other mood stabilizers. In particular, risperidone with it's 5ht2a blockade. 5ht2a is implicated as the 'activating' serotonin receptor. It may be likely responsible for mania, and the activating suicidal responses to serotonin drugs, in particular the SSRI's.(https://pubmed.ncbi.nlm.nih.gov/11870006/) Clozapine also has a strong 5ht2a blockade/antagonism.
>

In fact, clozapine was the first so-called atypical antipsychotic, with a lower incidence of extrapyramidal side effects (including tardive dyskinesia) but due to its potentially lethal hematological adverse effects, there was a lot of effort to develop "workalikes" to replace it. It was thought that the high ratio of serotonin 5-HT2A antagonism was one of the main characteristics of an atypical antipsychotic, so a lot of them have been developed (eg. olanzapine and quetiapine are notable). However, amisulpride does not fit into this model, as it has an "atypical" profile but no affinity for 5-HT2A.

-undopaminergic

 

Re: TCA + Effexor Combo / Maximum Effexor Dosage

Posted by SLS on January 3, 2023, at 12:35:29

In reply to Re: TCA + Effexor Combo / Maximum Effexor Dosage Jay2112, posted by undopaminergic on January 3, 2023, at 10:58:09

> >
> > I think it is important to keep a very wide range of options in mind, consideration for individual variables. I think you are missing out on the use of atypical antipsychotics, and other mood stabilizers. In particular, risperidone with it's 5ht2a blockade. 5ht2a is implicated as the 'activating' serotonin receptor. It may be likely responsible for mania, and the activating suicidal responses to serotonin drugs, in particular the SSRI's.(https://pubmed.ncbi.nlm.nih.gov/11870006/) Clozapine also has a strong 5ht2a blockade/antagonism.
> >
>
> In fact, clozapine was the first so-called atypical antipsychotic, with a lower incidence of extrapyramidal side effects (including tardive dyskinesia) but due to its potentially lethal hematological adverse effects, there was a lot of effort to develop "workalikes" to replace it. It was thought that the high ratio of serotonin 5-HT2A antagonism was one of the main characteristics of an atypical antipsychotic, so a lot of them have been developed (eg. olanzapine and quetiapine are notable). However, amisulpride does not fit into this model, as it has an "atypical" profile but no affinity for 5-HT2A.
>
> -undopaminergic

I would say that olanzapine (Zyprexa) is the drug closest to clozapine (Clozaril).


- Scott


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