![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 5 of 5. This is the beginning of the thread.
Posted by NKP on December 29, 2022, at 4:21:13
My psychiatrist has me on 225 mg/day venlafaxine, 150 mg/day bupropion (to counteract anhedonia and sexual side-effects of the venlafaxine), and 200 mg/day lamotrigine.
The side-effects of the venlafaxine are still a problem, even with the bupropion. It also causes me to sweat excessively, something that bupropion will not help with.
So I'm considering either (i) reducing the dose of the venlafaxine, or (ii) to ask my general practitioner to replace the venlafaxine with 50 mg/day of sertraline. Both of these options would be done without the blessing of my psychiatrist, as it takes weeks to get an appointment with him.
I doubt that my GP would agree to (ii) anyway, because in the past he was reluctant to interfere with what my psychiatrist was doing when I asked him for medication changes.
Back when I used 50 mg/day of sertraline, I had zero side-effects from it.
Would you say that venlafaxine is a better antidepressant than sertraline? Especially when combined with bupropion? Considering that bupropion has norepinephrine reuptake inhibition too?
To be fair however, the venlafaxine seemed to fix my cognitive problems better than sertraline did, so that's possibly a reason to stay on it.
My psychiatrist said that the next step would be to increase the bupropion to 300 mg/day if the 150 mg/day doesn't do the trick.
One problem that I see here, is that bupropion increases serum levels of venlafaxine, thus indirectly worsening the venlafaxine side-effects at the same time as directly counteracting them.
My psychiatrist seems to not want to mess with what's working. He said that he'd rather add things than remove things. He was very averse to even reducing the dose of my venlafaxine when I asked him about this ("maybe some day, but we're not there yet"), and when I suggested replacing the venlafaxine with sertraline and flupentixol, he was basically like "no way, forget about it".
What should I do?
Posted by SLS on December 29, 2022, at 9:09:03
In reply to Fixes for venlafaxine side-effects, posted by NKP on December 29, 2022, at 4:21:13
It is my observation that Effexor should not be abandoned until 300 mg/day is reached and allowed 2 weeks to demonstrate an improvement.
It is also my observation that the sweet-spot for Wellbutrin dosage is 300 mg/day - not 150 mg/day
You might miss something if you don't combine Wellbutrin 300 mg/day with Effexor 300 mg/day. I would be surprised if 300 mg/day of Wellbutrin doesn't work better than 150 mg/day. Allow any tolerable side effects upon a dosage increase a couple of weeks to mitigate.
What are your thoughts on this?
- Scott
Posted by SLS on December 29, 2022, at 13:47:34
In reply to Fixes for venlafaxine side-effects, posted by NKP on December 29, 2022, at 4:21:13
Sorry. I forgot to respond.
> Would you say that venlafaxine is a better antidepressant than sertraline?
Yes.
> Especially when combined with bupropion?
Yes.
> Considering that bupropion has norepinephrine reuptake inhibition too?
From what I have seen written over the years, the norepinephrine and dopamine reuptake inhibition by bupropion are minimal compared to the magnitude of reuptake inhibition by other antidepressants of NE and/or 5-HT. Of course, that doesn't mean that reuptake inhibition should be ignored. I am dubious of its importance, though.
Nitric oxide is now considered to be a neurotransmitter, and I think should be looked at more closely when evaluating the mechanisms of action of bupropion. Bupropion has remained an enigma from its inception.
How long have you been taking these drugs? Is there a possibility that the side-effects may yet mitigate?
As I indicated, I don't think you should abandon treatment with venlafaxine and bupropion until dosages of both drugs reach 300 mg/day. I think Pristiq (desvenlafaxine) is milder with respect to side effects. However, my guess is that fewer people respond to this active metabolite of Effexor. I think the way to look at this is that you either need the parent compound, venlafaxine (Effexor), or you don't. If you need only the active metabolite, you might be able to respond equally well to both Pristiq and Effexor, but the side effects might be milder with Pristiq.
Try not to let side effects cause you to abort this trial prematurely.
- Scott
Posted by Jay2112 on December 30, 2022, at 15:18:02
In reply to Fixes for venlafaxine side-effects, posted by NKP on December 29, 2022, at 4:21:13
> My psychiatrist has me on 225 mg/day venlafaxine, 150 mg/day bupropion (to counteract anhedonia and sexual side-effects of the venlafaxine), and 200 mg/day lamotrigine.
>
> The side-effects of the venlafaxine are still a problem, even with the bupropion. It also causes me to sweat excessively, something that bupropion will not help with.
>
> So I'm considering either (i) reducing the dose of the venlafaxine, or (ii) to ask my general practitioner to replace the venlafaxine with 50 mg/day of sertraline. Both of these options would be done without the blessing of my psychiatrist, as it takes weeks to get an appointment with him.
>
> I doubt that my GP would agree to (ii) anyway, because in the past he was reluctant to interfere with what my psychiatrist was doing when I asked him for medication changes.
>
> Back when I used 50 mg/day of sertraline, I had zero side-effects from it.
>
> Would you say that venlafaxine is a better antidepressant than sertraline? Especially when combined with bupropion? Considering that bupropion has norepinephrine reuptake inhibition too?
>
> To be fair however, the venlafaxine seemed to fix my cognitive problems better than sertraline did, so that's possibly a reason to stay on it.
>
> My psychiatrist said that the next step would be to increase the bupropion to 300 mg/day if the 150 mg/day doesn't do the trick.
>
> One problem that I see here, is that bupropion increases serum levels of venlafaxine, thus indirectly worsening the venlafaxine side-effects at the same time as directly counteracting them.
>
> My psychiatrist seems to not want to mess with what's working. He said that he'd rather add things than remove things. He was very averse to even reducing the dose of my venlafaxine when I asked him about this ("maybe some day, but we're not there yet"), and when I suggested replacing the venlafaxine with sertraline and flupentixol, he was basically like "no way, forget about it".
>
> What should I do?The sweating can be couter acted by a) clonidine, and/or propranolol plus, (or) b) small extra dose of amitriptyline (anticholinergic effect counteracts sweating).
Switching to sertraline will likely increase your sweating as it is a stronger serotonin binder than venlafaxine.
Jay
Posted by NKP on January 5, 2023, at 9:47:17
In reply to Re: Fixes for venlafaxine side-effects » NKP, posted by SLS on December 29, 2022, at 13:47:34
> Nitric oxide is now considered to be a neurotransmitter, and I think should be looked at more closely when evaluating the mechanisms of action of bupropion. Bupropion has remained an enigma from its inception.
Interesting. What does nitrous oxide do?
> As I indicated, I don't think you should abandon treatment with venlafaxine and bupropion until dosages of both drugs reach 300 mg/day.
I'm considering asking my doctor to increase my dose of bupropion to 300 mg/day. I still feel tired all the time, and don't enjoy previously enjoyable activities, like listening to music. I think that this is due to the venlafaxine, but it's probably not a good idea to reduce my venlafaxine dose.
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.