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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by jujube on December 8, 2004, at 9:29:50
I am currently on 50 mg of Anafranil, and will beincreasing the dose to 75 mg shortly. I don't know if I will be able to go much higher than 75 mg because of the dizziness I experience as a result of my already low blood pressure. The Anafranil seems to be working ok, but I still need some help with apathy and lack of motivation. To deal with these issues, I will first be trying a couple of natural supplements (DMAE and NADH). If those fail, I will be looking at adding an augmenting med to the Anafranil since I don't want to change ADs again (Anafranil is the 5th AD I have had to try in less than a year).
My question is which would be a better augmenter with the Anafranil - a low dose of Wellbutrin or Provigil? Is there anything else that might be effective as an add-on?
Thanks.
Tamara
Posted by ed_uk on December 8, 2004, at 12:17:21
In reply to TCA Augmentation, posted by jujube on December 8, 2004, at 9:29:50
Hi,
In some cases, dizziness and hypotension due to TCAs can be treated with fludrocortisone. This may allow you to increase the dose of clomipramine. Augmentation might not be necessary. Of course, fludrocortisone can cause side effects too!
Regards,
Ed.
Posted by dove on December 8, 2004, at 13:01:49
In reply to TCA Augmentation, posted by jujube on December 8, 2004, at 9:29:50
Wellbutrin definitely helped with my low blood pressure when I was taking Amitriptyline (Elavil), as did Adderall in addition to helping with lack of motivation and apathy. However, Wellbutrin didn't agree with me in the anxiety department and gave me ceaseless negative feelings which resulted in its discontinuance. Prozac also helped with some of those issues when added to Amitriptyline, although some caution is warranted due to Anafranil's high serotonin affinity. I guess you're looking for more activating agents that can be added to your Anafranil, which leads to meds like Wellbutrin, Adderall, a more energic TCA, Prozac, (Parnate--a MAOI--is activating but contraindicated).
Hopefully, others will post some ideas...
dove
Posted by zeugma on December 8, 2004, at 15:45:57
In reply to Re: TCA Augmentation, posted by dove on December 8, 2004, at 13:01:49
I think Wellbutrin is not a good combination with TCA's because it can block the enzymes that metabolize the TCA. 75 mg Anafranil is not a high dose, but I would be concerned, nontheless, about the combination.
Another reason for concern is that both meds lower the seizure threshold considerably. Anafranil is the most epileptigenic of the tricyclics, and Wellbutrin and maprotiline are considered to be the most epileptigenic meds overall.Again, I think in low doses this would not be a major cause for concern, but if you have any history of seizure disorder this is a strict contraindication.
Provigil also blocks another enzyme that breaks down Anafranil (it's in the PI sheet for Provigil). Again, something to consider: I would definitely pay close attention to possible increased s/e on this combo.
I took Provigil with nortriptyline for a while, and Provigil treated my ADD and narcolepsy symptoms beautifully: I just had too many upsetting side effects to stay on it. So I'm taking nortriptyline with Ritalin instead. Ritalin is no bargain in the side effect department for me, either, and is only modestly effective, but one of the s/e I find aggravating (weight loss) might be desirable for you.
I asked my pdoc about Anafranil months ago. He said the reason he didn't favor it for me was because of the difficulties it can cause for polypharmacy, because it is metabolized by various enzymes (hence more possibility for reactions because many drugs block an enzyme or two). Provigil, from what I read, is not contraindicated with Anafranil: it just needs to be monitored closely.
Posted by jujube on December 8, 2004, at 16:40:52
In reply to Re: TCA Augmentation, posted by zeugma on December 8, 2004, at 15:45:57
Zeugma,
Thank you so very much for the useful information. I know if I were willing/able to go to a higher dose of Anafranil, I would likely not need an augmenter. However, I would have a hard time coping with increased dizziness (dizziness has always been one of the only physical symptoms of anxiety or an anxiety attack for me).
When I was researching Enada NADH on Psychobabble, I can across a thread in which, if I am remembering correctly, you took part. If you don't mind my asking, did you ever try NADH? If so, was it effective?
Thanks.
Tamara
Posted by jujube on December 8, 2004, at 16:45:55
In reply to Re: TCA Augmentation, posted by dove on December 8, 2004, at 13:01:49
Thanks so much for the suggestions. When I was switched to a TCA (after failed tries with Paxil, Prozac, Effexor XR and Celexa), I would have preferred Nortriptyline, which I believe is more activating but also helps with anxiety, but the pdoc wanted to try Anafranil. Oh well, it's not too bad, just not as energizing as I would have liked. Perhaps I should just go back to using Sudafed and drinking copious amounts of coffee on a daily basis.
Tamara
Posted by zeugma on December 8, 2004, at 17:08:55
In reply to Re: TCA Augmentation » zeugma, posted by jujube on December 8, 2004, at 16:40:52
Hi Tamara.
I've never tried Enanda NADH. I can see by your response to dove that you would have preferred nortriptyline as it is more activating. Nortriptyline is a good AD, but would probably help less with OCD symptoms than Anafranil, and is probably less of an anxiolytic, although as you mentioned it does have some antianxiety properties. I remember my pdoc telling me that we could do a mg for mg swap of nortriptyline to clomipramine, if necessary; I don't think the reverse would be possible due to SRI discontinuation syndrome. I definitely got the impression from him that he was happier combining nortriptyline with other meds (such as stimulants), and you can mention that rationale to your pdoc, if you decide to swap and/or augment.
Sorry that this doesn't answer your question, Anafranil vs. nortriptyline is a topic I've mulled over a lot!
Posted by jujube on December 8, 2004, at 19:43:31
In reply to Re: TCA Augmentation » jujube, posted by zeugma on December 8, 2004, at 17:08:55
Thanks Zeugma. Yes, I would have preferred Nortripyline, but I am not unhappy with Anafranil. Although I did not suffer from OCD, I do tend to suffer from extreme anxiety, which can result in ruminating and obsessive thoughts. I did searched Psychobabble after the pdoc prescribed Anafranil for me to see what others' experiences had been with it. I came across a lot of positive information, particularly from a poster named Keith Christie, who had indicated that it was the best AD he had ever been on. If I remember correctly he called it "the bees knees". That's quite an endorsement. I also remember him stating that one of Anafranil's metabolites had an affinity for norephedrine equal to or stronger than Desipramine and nortrityline. So, I will just take it slow and try to increase the dose to the level that I can tolerate.
I had raised Provigil with the pdoc at my last visit, but he was not particularly keen on prescribing it for me. I don't think he's much into augmentation, but I will raise it again if I don't have any success with Enada NADH and DMAE.
Thanks again, and take care.
Tamara
> Hi Tamara.
>
> I've never tried Enanda NADH. I can see by your response to dove that you would have preferred nortriptyline as it is more activating. Nortriptyline is a good AD, but would probably help less with OCD symptoms than Anafranil, and is probably less of an anxiolytic, although as you mentioned it does have some antianxiety properties. I remember my pdoc telling me that we could do a mg for mg swap of nortriptyline to clomipramine, if necessary; I don't think the reverse would be possible due to SRI discontinuation syndrome. I definitely got the impression from him that he was happier combining nortriptyline with other meds (such as stimulants), and you can mention that rationale to your pdoc, if you decide to swap and/or augment.
>
> Sorry that this doesn't answer your question, Anafranil vs. nortriptyline is a topic I've mulled over a lot!
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