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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 10 to 34 of 77. Go back in thread:
Posted by ZeitGuest on May 25, 2006, at 1:08:23
In reply to Are Family Doctors prescribing EMSAM?, posted by jealibeanz on May 24, 2006, at 6:33:46
I knew it wouldn't fly, but just for the heck of it I asked my general prac doc if he would consider prescribing EMSAM for me. He chuckled condescendingly and said that there was no way he was going to prescribe an MAOI. He did, however, offer to refer me to a pdoc.
Posted by jealibeanz on May 25, 2006, at 11:33:42
In reply to Re: Are Family Doctors prescribing EMSAM? » jealibeanz, posted by Phillipa on May 24, 2006, at 21:56:42
I'm very surprised by these responses. I figured asking would be a stretch, but not out of the question by any means.
Posted by yxibow on May 25, 2006, at 23:03:12
In reply to Re: Are Family Doctors prescribing EMSAM?, posted by jealibeanz on May 24, 2006, at 19:54:21
> Why is it more complex than SSRI's in terms of use? Doesn't the transdermal delivery lessen the concerns of side effects?
Oh goodness its much more complex than SSRIs in terms of use. The transdermal delivery system only in the lowest dose barely lessens the concerns of MAOI effects. Only a psychiatrist who has had training and cases should be giving an MAOI. After the lowest dose, the risk rises to the level of a full on MAOI. These aren't things to be treated lightly, such as hypertensive crises that can, in some unfortunate circumstances, leave someone with a stroke, however unlikely, and I think I've argued my views, and others have on MAOIs -- that isn't the issue here -- its being versed on what is and what isnt a good risk with current and proper medical knowledge of MAOIs in general.
And as far as GPs writing scripts for SSRIs, even then, they should have had some CE credit training for psychiatric medications. Most all psychiatric medications affect what is known as the P450 system, the cytochromes that your liver processes a drug. Mixing the wrong P450 cytochromes could raise or lower the level of other medications in someone's body.
--tidings
Jay
Posted by Jakeman on May 25, 2006, at 23:55:24
In reply to Are Family Doctors prescribing EMSAM?, posted by jealibeanz on May 24, 2006, at 6:33:46
I suspect the Britol-Myers Squibb reps have not made all there rounds yet to all the GP's. They do a presentation and give a case of samples. After they get that info the response to patients may change. It's an old drug, just a different method of delivery.
warm regards, Jake
> Has anyone been prescribed or told of EMSAM from a general practitioner? I know a lot of people on here see pdocs. I'd like to give it a try, but only see my GP.
Posted by cecilia on May 26, 2006, at 1:18:05
In reply to Re: Are Family Doctors prescribing EMSAM? » jealibeanz, posted by yxibow on May 25, 2006, at 23:03:12
Do you really think most pdocs have the slightest clue what meds affect what P450 cytochromes? I guess I'm cynical, but I sure don't think so. Cecilia
Posted by jealibeanz on May 26, 2006, at 1:42:58
In reply to Re: Are Family Doctors prescribing EMSAM?, posted by cecilia on May 26, 2006, at 1:18:05
I know that the cytochromes are part of the electron transport chain involved in the degradation of medications in the liver. Is this necessary when breaking down all medications, or just those that go through the GI tract? Does transdermal delivery avoid processing in the liver?
Posted by jealibeanz on May 26, 2006, at 11:03:25
In reply to Re: Are Family Doctors prescribing EMSAM?, posted by Jakeman on May 25, 2006, at 23:55:24
Is ther a way to contant the company to see if they've begun to market toward GP's, or anyone for that matter through drug reps? I looked on the website for contant info, but couldn't find any.
Posted by Phillipa on May 26, 2006, at 19:47:44
In reply to Re: Are Family Doctors prescribing EMSAM?, posted by jealibeanz on May 26, 2006, at 1:42:58
From my understanding yes. Love Phillipa
Posted by yxibow on May 27, 2006, at 0:43:13
In reply to Re: Are Family Doctors prescribing EMSAM?, posted by jealibeanz on May 26, 2006, at 1:42:58
> I know that the cytochromes are part of the electron transport chain involved in the degradation of medications in the liver. Is this necessary when breaking down all medications, or just those that go through the GI tract? Does transdermal delivery avoid processing in the liver?
No, transdermal delivery does not avoid the processing of what, as was correctly noted, an older drug used in Parkinson's (Eldepryl, selegiline hydrochloride) often in combination with Sinemet (levodopa/carbidopa).
It is simply a different method of entry into your bloodstream. A number of medications and chemical substances can enter your bloodstream through your skin -- it is porous.
If you cover too much of your body with Benadryl or Ben-Gay creams you may reach a toxic level inside your system, as the medication goes through the layers of your skin, the outer always being dead, which protects us from some substances being harmful, but not all.
Once the drug is in your bloodstream, it will eventually be metabolized by your liver (or in the case of certain, fewer medications, that bypass the liver route and go through your kidneys, such as Serax -- often through a process known as glucuronidation.)
And as for psychiatrists knowing P450 -- if they dont, they're in serious jeapordy of their license.Its a basic principle -- but I agree, if you are "old school" you may not have been taught all the intricacies which are now routinely taught in medical school, and which if you read a drug monograph or as we call it in the US, a PI, or prescribing information, they will list testing for cytochromes.
This wasn't done routinely until the last decade because the knowledge wasn't out there -- as one who takes polypharmacy (multiple medications), I've had a few curveballs with mixing modern medications with older ones and having to adjust to avoid things like serotonin syndrome.
Posted by jealibeanz on May 27, 2006, at 6:07:32
In reply to Re: Are Family Doctors prescribing EMSAM? » jealibeanz, posted by yxibow on May 27, 2006, at 0:43:13
Right, OK, drugs have to be broken down in the liver when enyering the bloodstream. However, they avoid the stomach. Would this decrease the likelihood of weight gain? Where does insulin come in to play? Does EMSAM involve histamine blockers like the SSRIs/SNRIs (which could be a reason for my weight problems in addition to serotonin, right?)?
Posted by pulse on May 27, 2006, at 15:08:59
In reply to Re: Are Family Doctors prescribing EMSAM?, posted by jealibeanz on May 27, 2006, at 6:07:32
sorry, but Emsam does NOT avoid the gut, far a GI problems. the pharmacist i dislike, of the 2 at my regular drugstore, was right, for once, when he predicted this could - and did happen - to me. oh, boy, did it ever!
another pharmacist at a compounding pharmacy that i'd switched to for a better price on emsam, said same: of course, Emsam thru bloodstream only, can still cause GI problems. i sincerely hope this applies to GI problems/ meds intolerant (not treatment resistant) folks like me - only.
pulse
Posted by pulse on May 27, 2006, at 15:18:04
In reply to Re: Are Family Doctors prescribing EMSAM?, posted by pulse on May 27, 2006, at 15:08:59
forgot to add that yes, my gp (actually an allergy specialist) did (somewhat begrudgingly) prescribe Emsam for me. he has 300 psych. patients, as we have next to no competent p-docs here (revise that to none, imo, at least). he has done much volunteer work at a transitional living place for the seriously mentally ill, so he does know his stuff. he will also work in conjunction with my therapist. all in all, a very good support system.. for me.
sorry, i can't address your questions on weight, insulin, etc.
pulse
Posted by jealibeanz on May 27, 2006, at 19:01:15
In reply to Re: Are Family Doctors prescribing EMSAM?, posted by pulse on May 27, 2006, at 15:08:59
Well then, I don't understand the advantage of transdermal vs. oral selegiline.
Posted by Phillipa on May 27, 2006, at 19:38:11
In reply to Re: Are Family Doctors prescribing EMSAM?, posted by jealibeanz on May 27, 2006, at 19:01:15
Me either I thought it avoided all that mess? Love Phillipa and the high cost for what!!!!!!!
Posted by Iansf on May 27, 2006, at 19:42:07
In reply to Re: Are Family Doctors prescribing EMSAM?, posted by pulse on May 27, 2006, at 15:08:59
Pulse,
You mention getting a better price through a compounding pharmacy. Can you say more about this? Does the compounding pharmacist simply take selegiline and put it onto skin patches of some sort? How much cheaper is it? Thanks.
Ian> sorry, but Emsam does NOT avoid the gut, far a GI problems. the pharmacist i dislike, of the 2 at my regular drugstore, was right, for once, when he predicted this could - and did happen - to me. oh, boy, did it ever!
>
> another pharmacist at a compounding pharmacy that i'd switched to for a better price on emsam, said same: of course, Emsam thru bloodstream only, can still cause GI problems. i sincerely hope this applies to GI problems/ meds intolerant (not treatment resistant) folks like me - only.
>
> pulse
Posted by jealibeanz on May 27, 2006, at 19:42:25
In reply to Re: Are Family Doctors prescribing EMSAM? » jealibeanz, posted by Phillipa on May 27, 2006, at 19:38:11
This doesn't make much sense to me. Surely, the patch was not created to people could wear a sticker instead of swallowing a pill.
Posted by Phillipa on May 27, 2006, at 21:02:31
In reply to Re: Are Family Doctors prescribing EMSAM?, posted by jealibeanz on May 27, 2006, at 19:42:25
For more money? It makes no sense. Love Phillipa
Posted by yxibow on May 27, 2006, at 22:00:48
In reply to Re: Are Family Doctors prescribing EMSAM?, posted by jealibeanz on May 27, 2006, at 19:42:25
> This doesn't make much sense to me. Surely, the patch was not created to people could wear a sticker instead of swallowing a pill.
No, it was created in hopes (I think) of avoiding severe MAOI problems, but in the end, as the monograph reads, that only is with the lowest dose with caveats to protect their behinds. When you need more than that, it does seem to me to be maybe not a zero sum gain but not much of a notch down from just generic selegeline (I think its generic now).
Posted by cecilia on May 28, 2006, at 0:59:05
In reply to Re: Are Family Doctors prescribing EMSAM?, posted by yxibow on May 27, 2006, at 22:00:48
I think the goal with Emsam (besides making big bucks) was hopefully to decrease the MAO side effects and food interactions. No way of administration is going to completely eliminate them. People in the hospital getting pain meds via IV instead of orally still get GI side effects. Cecilia
Posted by pulse on May 28, 2006, at 18:05:08
In reply to Re: Are Family Doctors prescribing EMSAM? » pulse, posted by Iansf on May 27, 2006, at 19:42:07
No, sorry, I realized too late that my post might give folks the impression that you've now asked about.
It was just a coincidence that the lowest priced Emsam in my area happened to be at a compounding pharmacy. They did not compound my Emsam. The price there was still quite high at $427 for 30 of the lowest dose patches.
Perhaps it could be done with selegiline (?), but I did ask about compounding Wellbutrin, and the "active ingredient" i.e. (Wellbutrin itself) would still HAVE to remain - thus no help for the even more severe GI problems (than Emsam) that Wellbutrin causes me.
I would then have to assume compounding would not take away any of the bad side-effects that never diminish for some - like me- no matter what those particular side-effects are...if they are inherent to the med itself, and not from gelatin, binders. etc.
pulse
Posted by pulse on May 28, 2006, at 18:14:36
In reply to Re: Are Family Doctors prescribing EMSAM?, posted by cecilia on May 28, 2006, at 0:59:05
For me, though, when I've very rarely had to take antibiotics, my GP will order in a anti-biotic shot, administer that, and I have NO GI side-effects whatsoever...plus I'm virtually well in 3 days vs. the standard 10.
pulse
Posted by Donna Louise on May 29, 2006, at 6:43:17
In reply to Re: Are Family Doctors prescribing EMSAM? » cecilia, posted by pulse on May 28, 2006, at 18:14:36
It seems to me that I read somewhere that by transdermal delivery some of the unwanted type metabolites that result in first past gut metabolism in the liver are not created. Maybe one of the more amphetamine type metabolites?? I will see if I can find where I read that.
At any rate, for me, I have had no side effects from the patch, maybe I wouldn't from oral administration either. I guess another plus with transdermal delivery is the slow and steady plasma state. no ups and downs. What do I know, just that I like it. May need to go to 9mg though for more depression relief.Donna
Posted by crazy777girl on May 30, 2006, at 6:17:33
In reply to Re: Are Family Doctors prescribing EMSAM? » cecilia, posted by pulse on May 28, 2006, at 18:14:36
I think, in part, it (the Rx of transdermal delivery) may be the illusion (delusion?) that we are merely swallowing one less pill. Call me crazy.
A.> For me, though, when I've very rarely had to take antibiotics, my GP will order in a anti-biotic shot, administer that, and I have NO GI side-effects whatsoever...plus I'm virtually well in 3 days vs. the standard 10.
>
> pulse
Posted by SFY on May 30, 2006, at 10:38:05
In reply to delivery difference, posted by Donna Louise on May 29, 2006, at 6:43:17
> It seems to me that I read somewhere that by transdermal delivery some of the unwanted type metabolites that result in first past gut metabolism in the liver are not created. Maybe one of the more amphetamine type metabolites?? I will see if I can find where I read that.
> At any rate, for me, I have had no side effects from the patch, maybe I wouldn't from oral administration either. I guess another plus with transdermal delivery is the slow and steady plasma state. no ups and downs. What do I know, just that I like it. May need to go to 9mg though for more depression relief.
>
> DonnaI posted this below in another thread that may have been overlooked:
EMSAM does deliver selegiline directly into the blood thereby significantly reducing its exposure to the GI tract. But because blood flows to all internal organs including the liver, intestines, and stomach there will be some selegiline exposure which explains why some people are having GI tract-related side effects.
According to one study:
Transdermal delivery of selegiline provides several pharmacological advantages over oral delivery. First, it sufficiently reduces exposure of the gastrointestinal tract to the drug to limit inhibition of intestinal MAOA activity. Thus, adequate gastrointestinal MAOA enzyme is left
intact to metabolize dietary tyramine. Second, transdermal administration of selegiline circumvents first-pass hepatic metabolism, which results in sustained high plasma levels of the parent compound with a concomitant decrease in metabolite formation. This provides sufficient brain concentrations of selegiline to produce an antidepressant effect, presumably involving substantial MAOA as well as MAOB inhibition. This also may permit the expression of additional pharmacological properties of selegiline other than MAO inhibition previously observed in vitro. At the same time, there is less exposure to L-methamphetamine and L-amphetamine metabolites than observed with oral selegiline.http://ajp.psychiatryonline.org/cgi/content/full/159/11/1869
The EMSAM drug insert clearly states that at least 1 in 100 users may experience GI-related side effects such as "Constipation, flatulence, anorexia, gastroenteritis, vomiting."
Posted by Iansf on May 30, 2006, at 11:53:05
In reply to Re: delivery difference, posted by SFY on May 30, 2006, at 10:38:05
Again, my question: wouldn't sublingual delivery work in the equivalent manner? Liquid forms of selegiline meant for sublingual delivery are available. If 6mg of selegiline delivered suglingually turns out to be equivalent to 6mg delivered transdermally, then what you achieve with Emsam can be achieved at less than a sixth the price with liquid preparations. This may not be an issue for those whose insurance pays for Emsam, but it is for those of us without insurance.
So does anyone know if 6mg suglingual and 6mg transdermal are equivalent? (And please forget 6mg oral - I know that's not equivalent, and that's not part of the question.) Thanks.
Ian
> > It seems to me that I read somewhere that by transdermal delivery some of the unwanted type metabolites that result in first past gut metabolism in the liver are not created. Maybe one of the more amphetamine type metabolites?? I will see if I can find where I read that.
> > At any rate, for me, I have had no side effects from the patch, maybe I wouldn't from oral administration either. I guess another plus with transdermal delivery is the slow and steady plasma state. no ups and downs. What do I know, just that I like it. May need to go to 9mg though for more depression relief.
> >
> > Donna
>
> I posted this below in another thread that may have been overlooked:
>
> EMSAM does deliver selegiline directly into the blood thereby significantly reducing its exposure to the GI tract. But because blood flows to all internal organs including the liver, intestines, and stomach there will be some selegiline exposure which explains why some people are having GI tract-related side effects.
>
> According to one study:
>
> Transdermal delivery of selegiline provides several pharmacological advantages over oral delivery. First, it sufficiently reduces exposure of the gastrointestinal tract to the drug to limit inhibition of intestinal MAOA activity. Thus, adequate gastrointestinal MAOA enzyme is left
> intact to metabolize dietary tyramine. Second, transdermal administration of selegiline circumvents first-pass hepatic metabolism, which results in sustained high plasma levels of the parent compound with a concomitant decrease in metabolite formation. This provides sufficient brain concentrations of selegiline to produce an antidepressant effect, presumably involving substantial MAOA as well as MAOB inhibition. This also may permit the expression of additional pharmacological properties of selegiline other than MAO inhibition previously observed in vitro. At the same time, there is less exposure to L-methamphetamine and L-amphetamine metabolites than observed with oral selegiline.
>
> http://ajp.psychiatryonline.org/cgi/content/full/159/11/1869
>
> The EMSAM drug insert clearly states that at least 1 in 100 users may experience GI-related side effects such as "Constipation, flatulence, anorexia, gastroenteritis, vomiting."
>
>
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