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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 agjchs on January 12, 2007, at 17:06:32
Greetings,
I'm new to this board and am at the end of my rope with OCD (I'm 41 years old and have had it since before I was age 2). Have tried Paxil, Prozac, Anafranil (made me more depressed). Have been on Remeron 30mg for a year, and it's the best antidepressant I've ever taken (have taken them for 16 years), but it increased the OCD.
My psychiatrist wants to switch me from Remeron to Luvox (200mg to start, and work up to 400mg). The first night I went without Remeron, I started feeling weird physically and after doing some research on the internet, found out that others had withdrawal symptoms from Remeron and that one should taper off 7.5mg at a time (*none* of which my psychiatrist told me about).
But I have read that taking Remeron and Luvox together can cause serotonin syndrome and can increase Remeron levels by as much as fourfold ("An Overview of Psychotropic Drug-Drug Interactions" by Neil B. Sandson, M.D., Scott C. Armstrong, M.D., and Kelly L. Cozza, M.D.).
I have been tapering off Remeron (was at 22.5mg for two weeks, and am now at 15mg), and was wondering if I could *safely* take a small dose of Remeron (15mg) while "breaking in" Luvox with a small dose (50mg).
Also, I googled this site for Remeron and Luvox, and am pretty spooked by some of the Luvox horror stories I've read.
Thanks in advance for your replies.
Posted by Phillipa on January 12, 2007, at 17:10:04
In reply to can Remeron + Luvox be combined safely?, posted by agjchs on January 12, 2007, at 17:06:32
Well don't be spooked by luvox only ad I can take for depression and OCD withoug side effects. Love Phillipa
Posted by Phillipa on January 12, 2007, at 17:12:46
In reply to Re: can Remeron + Luvox be combined safely? » agjchs, posted by Phillipa on January 12, 2007, at 17:10:04
Oh but the starting dose for luvox is 50mg at bedtime increasing in 50mg increments till l00mg at night. Then 50mg in am. Always the higest dose in pm. I think you need to clarify your doseage with your pdoc. Love Phillipa
Posted by blueberry1 on January 12, 2007, at 19:34:21
In reply to can Remeron + Luvox be combined safely?, posted by agjchs on January 12, 2007, at 17:06:32
Geez. Another lame apathetic pdoc story. Where are the good pdocs hiding?
Ok, so remeron is the best antidepressant you've tried. And he wants to take you OFF it? I'm sorry, but that is mental insanity on display. What are the risks of ongoing OCD compared to the risks of depression? Depression is far more dangerous and life threatening in many ways.
Not being a doctor, I would humbly think a better approach would be leave the remeron in place and add something to it for OCD. A benzo, a ssri, something. It took long enough to find the improvement of depression with remeron, don't say goodbye to that! Does the pdoc somehow think luvox will replace what remeron is doing? Like I said, lame.
Yes, the two drugs can be combined. I used to combine 20mg prozac+30mg remeron.
If you are going to wean off remeron, you might find it easier to cut the 7.5mg chunks in half.I weaned off remeron after several years on it. The last 7.5mg was the hardest. I was cutting it down in tiny chunks. I still do not see any sense in saying goodbye to a drug that has helped your depression.
Posted by yxibow on January 13, 2007, at 3:02:06
In reply to Re: can Remeron + Luvox be combined safely?, posted by blueberry1 on January 12, 2007, at 19:34:21
> Geez. Another lame apathetic pdoc story. Where are the good pdocs hiding?
>
> Ok, so remeron is the best antidepressant you've tried. And he wants to take you OFF it? I'm sorry, but that is mental insanity on display. What are the risks of ongoing OCD compared to the risks of depression? Depression is far more dangerous and life threatening in many ways.
I definately agree and was probably the reason I was switched from Luvox to Cymbalta, but drug interactions are unpredictable and few are challenged between medications except obvious ones such as warfarin, cimetidine, etc...
> Not being a doctor, I would humbly think a better approach would be leave the remeron in place and add something to it for OCD. A benzo, a ssri, something. It took long enough to find the improvement of depression with remeron, don't say goodbye to that! Does the pdoc somehow think luvox will replace what remeron is doing? Like I said, lame.
>
> Yes, the two drugs can be combined. I used to combine 20mg prozac+30mg remeron.
>
> If you are going to wean off remeron, you might find it easier to cut the 7.5mg chunks in half.I weaned off remeron after several years on it. The last 7.5mg was the hardest. I was cutting it down in tiny chunks. I still do not see any sense in saying goodbye to a drug that has helped your depression.One has to look at the P450 potential interactions. Remeron has never been tested other than in the lab as a substrate for 2D6, 1A2, and 3A4. Substrate, meaning that an inducer will increase the level of that medication. It has been noted in the PI that Remeron does have some effect on diazepam, which is at 3A4.
So what does this mean -- due diligence, because Luvox is an inhibitor at 1A2 and definately at 3A4 meaning that it will increase the time Remeron takes to leave your body, if, Remeron is metabolized there, which is unclear.
Drugs.com does give the warning of serotonin syndrome between the two, so a balance as noted by the above successful user of two (in her case 2D6, Prozac) may have to be carefully struck by the doctor. I developed mild serotonin syndrome when Robaxin, a completely nonpsychiatric medication for back/neck spasms was added and increased to a higher level. Mild flushing and other uncomfortable but not life threatening things developed and we backed off about 25% of the dose. But when you're dealing with two serotonergic agents, more caution has to be applied. Being in the hospital with cyproheptadine and IVs isn't really a good plan.-- Jay
Posted by Phillipa on January 13, 2007, at 18:49:14
In reply to Re: can Remeron + Luvox be combined safely? » blueberry1, posted by yxibow on January 13, 2007, at 3:02:06
Jay so you've improved so much in OCD that you no longer require luvox but depression is worse hence cymbalta. You think that med is better? And doesn't luvox increse the effects of valium and xanax and not ativan? Why would that be. Thanks Phillipa
Posted by yxibow on January 14, 2007, at 19:12:42
In reply to Re: can Remeron + Luvox be combined safely? » yxibow, posted by Phillipa on January 13, 2007, at 18:49:14
> Jay so you've improved so much in OCD that you no longer require luvox but depression is worse hence cymbalta. You think that med is better? And doesn't luvox increse the effects of valium and xanax and not ativan? Why would that be. Thanks Phillipa
Well... I have OCD for life as anyone does, but the classic presentation of hoarding, washing, etc, is basically gone; the garbage track thoughts when I get anxious are still there, they're hard to fight. You learn the tools of CBT and you apply them later.
Luvox did help me stop worrying 16 hours a day about my disorder; Cymbalta is not as effective at that but it was more clear to my psychiatrist that I was developing MDD, whether it was primary or secondary (depression about my 5+ year condition) was irrelevant so that was the switch.
Whether we later on in the future gently add something like lexapro is still on the table but have to avoid serotonin syndrome.
Correct.. Luvox is an Inhibitor at 3A4. Valium and Xanax are Substrates at CYP-3A4 and thus, the prescribed dose of Luvox will "inhibit" the time that it takes for Valium and Xanax to leave the body, thus increasing the level of Valium or Xanax in the body. The same goes for Versed (which is only a hospital pre-op sedative or conscious sedative for minor surgery) and Halcion (not used much for sleep because of past issues).
The laundry list also goes for inhibition of BuSpar, a variety of calcium channel blockers, Trazodone, Orap, methadone, clarithromycin and related antibiotics, some HIV protease inhibitors, OTC clorpheniramine (although I doubt the dose OTC would matter much).
A fairly good clinically relevant list of P450 interactions can be found athttp://medicine.iupui.edu/flockhart/clinlist.htm
Minor interactions at
http://medicine.iupui.edu/flockhart/table.htm
Posted by Phillipa on January 14, 2007, at 19:30:49
In reply to Re: can Remeron + Luvox be combined safely? » Phillipa, posted by yxibow on January 14, 2007, at 19:12:42
Jay what do you think of cymbalta? It reeved me up badly second go of it. First time nothing so wierd? Love Jan
Posted by yxibow on January 15, 2007, at 0:52:59
In reply to Re: can Remeron + Luvox be combined safely? » yxibow, posted by Phillipa on January 14, 2007, at 19:30:49
> Jay what do you think of cymbalta? It reeved me up badly second go of it. First time nothing so wierd? Love Jan
Well its hard to say since I am on polypharmacy. The higher dose of Valium may cover up some of the intensity of Cymbalta, its hard to say, but I will admit Cymbalta has covered some, but not all of my MDD. There will always be breakthroughs, nothing is perfect. In general, all the serotonergic agents on board tend to give electric shocks when heavily excercising and turning one's head. This is fairly common actually. This has somewhat diminished I think, although its hard to say.
I once accidentally took a dose so I was up to 180mg of it. Didn't feel all that well and was a bit hyped up but I just took the next day's first dose later. It has a fairly wide safety margin, I won't say how much for obvious reasons.
You're taking the Cymbalta and Luvox together? Or you're saying you tried Cymbalta once recently. Together I would say that's a bit too serotonergic unless you manage it carefully. As for taking agents second or third time around -- I never feel exactly the same, I don't know -- I mean I felt the strangest almost psychadelic euphoria when I first took Ambien, never again. I think each time something hits a transmitter in my brain there is a memory or something.
But in general, medically speaking, assuming a lifetime of various degrees of mental/psychobiological illness, it is a moving target, so you may not get the same benefit of a medication the second time around just simply because your chemistry has changed.
Also, Cymbalta is one of those medications that takes quite a long time to take effect so regardless of the initial "rev up" which can be covered by a bit more of your Valium for a short period of time, it may not take its full effect for months and you may not need the additional benzodiazepines later, I can't guarantee anything, its your body.
It is a subtle medication and you have to decide whether its worth sticking it out or not. And also I assume you are thinking or are still going to therapy, which is just as important as well, to transition to doing more things with your time.-- tidings
Jay
Posted by agjchs on January 15, 2007, at 13:17:24
In reply to Re: can Remeron + Luvox be combined safely? » Phillipa, posted by yxibow on January 15, 2007, at 0:52:59
Thanks, everyone, for your replies. And thank God there are forums like this so those of us who take psychotropic drugs can tell each other the things our doctors don't tell us.
Posted by Phillipa on January 15, 2007, at 18:19:06
In reply to Re: can Remeron + Luvox be combined safely? » Phillipa, posted by yxibow on January 15, 2007, at 0:52:59
Jay first no I didn't combine the two. But are you saying that cymbalta takes longer to work? First time I think I took it about three to four months. Second time was a whole l0days and part of that may have been the fact that we had just moved here and he asked me how cymbalta had worked. I said fine no side effects. Mine and Greg's gut feeling was neigher of us liked him at all. He prescirbed 30mg for a week then 60 for a week, then 90 for a week than 120mg. I said but the manufacturer says nothing higher than 60 is recommended he brushed me off and said well I see results on l20mg. He scared me to death. Love Jan
Posted by yxibow on January 15, 2007, at 18:37:29
In reply to Re: can Remeron + Luvox be combined safely? » yxibow, posted by Phillipa on January 15, 2007, at 18:19:06
> Jay first no I didn't combine the two. But are you saying that cymbalta takes longer to work? First time I think I took it about three to four months. Second time was a whole l0days and part of that may have been the fact that we had just moved here and he asked me how cymbalta had worked. I said fine no side effects. Mine and Greg's gut feeling was neigher of us liked him at all. He prescirbed 30mg for a week then 60 for a week, then 90 for a week than 120mg. I said but the manufacturer says nothing higher than 60 is recommended he brushed me off and said well I see results on l20mg. He scared me to death. Love Jan
Lilly indeed cannot recommend or disrecommend doses higher than the 60mg in the PI. It is unclear whether doses higher than 60mg are better than doses at 60mg, but if they are tolerable and produce better results they may work for some people. Would it work for me just as well back at 60, I don't know.
If you are sensitive to the medication 30 for a week and 60 for the second week is probably too fast of a move, that is why they made 20s, so you can adjust up to 60 and see how it works over a period of weeks.
The "work" you may have felt the second time was an initial rush from, well... rushing the medication. It doesn't say it will last like that.Yes, I would say 3 to 4 months would not be an uncommon length of time for it to develop all its nuances. Its not a medication to be rushed and neither are SSRIs.
If you can stomach going up to 60, some people do actually start right there, but I have a feeling your anxiety would get the better of you and defeat the purpose of doing that.
Having a good relationship with your doctor and about medications is important. If you are uncomfortable with the way things are being prescribed and you don't think it is right, then speak up. I know it can be intimidating, but that's all I can say on that subject. I don't know your doctor-patient relationship and frankly that is your business to share.
-- Jay
Posted by Phillipa on January 15, 2007, at 19:17:13
In reply to Re: can Remeron + Luvox be combined safely? » Phillipa, posted by yxibow on January 15, 2007, at 18:37:29
Jay he wouldn't talk his initial consult was 20minutes. I took the advise of others here and asked him about the third time if he thought we were a good fit. He said we would when my meds worked. Like I could make them work!!!!!!Then out of the blue he prescrube 80mg of geodon I said no way starting dose 20mg. So he said get a second opinion. Hence end of our so called realationship and why I travel 8 hours total to see my oldpdoc. I need one here but they seem to all be in that big huge group and your're not allowed to switch docs. Love Jan
Posted by yxibow on January 16, 2007, at 1:39:24
In reply to Re: can Remeron + Luvox be combined safely? » yxibow, posted by Phillipa on January 15, 2007, at 19:17:13
> Jay he wouldn't talk his initial consult was 20minutes. I took the advise of others here and asked him about the third time if he thought we were a good fit. He said we would when my meds worked. Like I could make them work!!!!!!Then out of the blue he prescrube 80mg of geodon I said no way starting dose 20mg. So he said get a second opinion. Hence end of our so called realationship and why I travel 8 hours total to see my oldpdoc. I need one here but they seem to all be in that big huge group and your're not allowed to switch docs. Love Jan
Not allowed ? Or they're not taking new patients. I haven't heard of being assigned to "Dr Important #1, #2...".What about county/state mental health agencies ?
I'm sorry that you have to take such a long trip, that shouldn't be necessary and since we don't have that many trains like Europe you're likely to arrive frazzled after all that driving unless you plan properly and take it easy.
-- Jay
Posted by Phillipa on January 16, 2007, at 18:10:47
In reply to Re: can Remeron + Luvox be combined safely? » Phillipa, posted by yxibow on January 16, 2007, at 1:39:24
Jay not allowed. Who you start with you stay with or leave. And I guess google pdocs in Charlotte again. Thanks Phillipa
This is the end of the thread.
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