![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 7 of 7. This is the beginning of the thread.
Posted by Schlepo on November 16, 2018, at 10:24:30
Okay, so I've had something pretty interesting happen during my first few days as an inpatient. There was an apparent nortriptyline shortage when I arrived in the evening. I had plenty of pills in my bag, but I was accused of smuggling opiates and denied access to them. They managed to find 50mg at midnight (my nightly dose is 150mg). I didn't sleep my first night there, but I hadn't slept the past 5 nights either.
Early the next day (8 AM) They were able to give me another 50mg. The Pdoc didn't want me taking more than 150mg in a day, so he prescribed only 100mg the evening (9 PM) of the second day, and I had the best sleep I'd had in years. And I dreamed in perfect clarity as opposed to dream quality on clonazepam (which I had been off a few days.) I'd even felt a little better the following day.
The following evening, I had an episode that was almost, but not quite a panic attack. It was as if I was calm and anxious at the same time, and Amazingly I was able to sleep through it, and slept just as well as the previous evening. My nortriptyline dose that night was the regular 150mg. Then my sleep quality slowly degraded, under a consistent dose of 150mg.
I'm wondering if I can gauge my nortriptyline blood level from these varying events. In general the entire dosage for that period was 100mg less than under normal circumstances. The first night/morning (12AM - 8AM taken together) was only 100mg, as was the dosage following. One could take this as an indication that I would do better on 100mg than 150mg.
On the other hand, the totality of those first three dosages occurred over a 24-hour period (50mg @ 12AM, 50mg @ 8AM, 100mg @ 9PM), 200mg altogether, the most I've taken in the complete space of a day, so maybe 200mg is better for me.
Of course this all depends on the amount of time it takes for nortriptyline to decay in your system, so it's difficult for me to gauge how much was in my system without knowing this. Of course the brief improvement could be due to a number of other factors, as well.
One last thing- could a nortriptyline level test reveal if you're not responding to nortriptyline at all, regardless the dosage?
Posted by SLS on November 17, 2018, at 16:06:55
In reply to Playing Nortriptyline levels by ear..., posted by Schlepo on November 16, 2018, at 10:24:30
You might indeed have to play it by ear.
It would be nice to get a nortriptyline blood level. It would help guide you. However, it does not always predict the right dosage. At 150 mg/day, my blood level was about 150 ng/mL. Apparently, this was too high, even though it was technically within the therapeutic window. I did significantly better once I lowered the dosage to 100 mg/day. It is more likely that someone would respond to 100 mg/day than to 200 mg/day. So, it makes sense to investigate how you feel at 100 mg/day first. No guarantees, of course. At this point in your treatment, you may only need to give a new dosage 7 days to see in what direction things are headed.
Let us know how things go.
Good luck.
- Scott
Posted by Schlepo on November 20, 2018, at 16:39:25
In reply to Re: Playing Nortriptyline levels by ear... » Schlepo, posted by SLS on November 17, 2018, at 16:06:55
> You might indeed have to play it by ear.
>
> It would be nice to get a nortriptyline blood level. It would help guide you. However, it does not always predict the right dosage. At 150 mg/day, my blood level was about 150 ng/mL. Apparently, this was too high, even though it was technically within the therapeutic window. I did significantly better once I lowered the dosage to 100 mg/day. It is more likely that someone would respond to 100 mg/day than to 200 mg/day. So, it makes sense to investigate how you feel at 100 mg/day first. No guarantees, of course. At this point in your treatment, you may only need to give a new dosage 7 days to see in what direction things are headed.
>
> Let us know how things go.
>
> Good luck.
>
>
> - ScottSo I got my test results from an outpatient Pdoc and I think sheshe said my nortriptyline level was 220 (she couldn't give me a copy for some reason). Can this account for an onset of previously controlled depression and anxiety and the reduction of clonazepam efficacy?
Posted by SLS on November 20, 2018, at 21:14:42
In reply to Re: Playing Nortriptyline levels by ear..., posted by Schlepo on November 20, 2018, at 16:39:25
> > You might indeed have to play it by ear.
> >
> > It would be nice to get a nortriptyline blood level. It would help guide you. However, it does not always predict the right dosage. At 150 mg/day, my blood level was about 150 ng/mL. Apparently, this was too high, even though it was technically within the therapeutic window. I did significantly better once I lowered the dosage to 100 mg/day. It is more likely that someone would respond to 100 mg/day than to 200 mg/day. So, it makes sense to investigate how you feel at 100 mg/day first. No guarantees, of course. At this point in your treatment, you may only need to give a new dosage 7 days to see in what direction things are headed.
> >
> > Let us know how things go.
> >
> > Good luck.
> >
> >
> > - Scott
>
> So I got my test results from an outpatient Pdoc and I think sheshe said my nortriptyline level was 220 (she couldn't give me a copy for some reason). Can this account for an onset of previously controlled depression and anxiety and the reduction of clonazepam efficacy?220 is way too high. The top of the window should not exceed 150 ng/mL. The range is generally accepted to be 50-150. However, I have also seen it listed at 70-170. 150 ng/mL was too high for me. Depression will return if one goes too high. Odd. No other TCA displays this behavior. Not even amitriptyline does this, despite nortriptyline being its metabolite.
What will you do?
- Scott
Posted by Schlepo on November 21, 2018, at 16:51:48
In reply to Re: Playing Nortriptyline levels by ear... » Schlepo, posted by SLS on November 20, 2018, at 21:14:42
> > > You might indeed have to play it by ear.
> > >
> > > It would be nice to get a nortriptyline blood level. It would help guide you. However, it does not always predict the right dosage. At 150 mg/day, my blood level was about 150 ng/mL. Apparently, this was too high, even though it was technically within the therapeutic window. I did significantly better once I lowered the dosage to 100 mg/day. It is more likely that someone would respond to 100 mg/day than to 200 mg/day. So, it makes sense to investigate how you feel at 100 mg/day first. No guarantees, of course. At this point in your treatment, you may only need to give a new dosage 7 days to see in what direction things are headed.
> > >
> > > Let us know how things go.
> > >
> > > Good luck.
> > >
> > >
> > > - Scott
> >
> > So I got my test results from an outpatient Pdoc and I think sheshe said my nortriptyline level was 220 (she couldn't give me a copy for some reason). Can this account for an onset of previously controlled depression and anxiety and the reduction of clonazepam efficacy?
>
> 220 is way too high. The top of the window should not exceed 150 ng/mL. The range is generally accepted to be 50-150. However, I have also seen it listed at 70-170. 150 ng/mL was too high for me. Depression will return if one goes too high. Odd. No other TCA displays this behavior. Not even amitriptyline does this, despite nortriptyline being its metabolite.
>
> What will you do?
>
>
> - ScottI'll drop it down to 100mg for now. For about 10 years when things were under control, I alternated nightly between 100mg and 150mg. I was always meaning to go back to that.
Would a high nortriptyline level amplify the effects of hydroxyzine? I had a bad experience with it a few weeks ago.
Posted by SLS on November 21, 2018, at 20:14:05
In reply to Re: Playing Nortriptyline levels by ear..., posted by Schlepo on November 21, 2018, at 16:51:48
> Would a high nortriptyline level amplify the effects of hydroxyzine? I had a bad experience with it a few weeks ago.
What kind of reaction did you have?
- Scott
Posted by Lamdage22 on December 29, 2018, at 3:55:00
In reply to Re: Playing Nortriptyline levels by ear... » Schlepo, posted by SLS on November 21, 2018, at 20:14:05
Its good to have you back SLS. You sound much better
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.