Posted by Kingston on December 2, 2009, at 4:24:05
In reply to Re: Add anything to help with the EMSAM wait...., posted by inanimate peanut on November 28, 2009, at 18:55:23
To be honest, EMSAM is pretty good stuff but it does have the nasty habit of lowering my already low Blood Pressure (98/33) and I'm a 180 lb male. Thus it requires stimulant augmentation; I just can't afford EMSAM--plain and simple so I'm looking to alternatives--Parnate being my final alternative b/f up and moving to Bolivia where I can legally chew coca leaves on a perpetual basis. Apparently you can buy coca leaves on Amazon.com now though so maybe I'll stay.
As for EMSAM, you can safely add a stimulant to MAOIs(see discussion below). A low dose of Desoxyn or Dexedrine to the patch should suffice if it is Dopamine or and increase in BP that you are after. I would go with Desoxyn if you can get a script of it. It can be filled at any local Target pharmacy with a 1-2 day response time. It is the best medication on the market, 70 year efficacy record and quite possibly responsible for World War I. It does tend to make you feel like GOD but it blows all MAOIs out of the pharmaceutical abyss in regards to depression. Side effects are benign: increased narcissism, delusions of grandeur, increased strength, stamina and perceived intellect, propensity towards God Complex: all good things if you are someone suffering from Major Depression/Social Phobia.
Problem is, it's pure methamphetamine HCL(as are all the metabolites of the MAOIs: little known secret but the driving force behind these puppies) but Desoxyn has no guise to hide behind. It's very difficult to get and when you do get it, getting a script for the necessary 30+mg/day to knock out depression with an Ike Turner on Tina-uppercut is virtually impossible. It's not like Adderall or Dex in terms of the 'anxious space cadet effect' that comes with. It doesn't make you shaky or socially awkward. This is largely b/c it brushes your serotonin and opiate receptors. Feels sort of like happiness in a pill and you become supremely confident by defacto. Social Phobia, agoraphobia, depression quickly dissipate into thin smog after minutes of ingestion. Withdrawal?...i've never experienced it from Stims. You want to discuss withdrawal, try weaning off Klonopin; it's a nightmare on Elm street; wish i had never been introduced to this demotivating med that works all to well for just about everything but intellectual function/productivity/motivation. I feel like i'm permanently stoned inside a comfortably numb womb of Novicaine for the brain. They say it's more difficult to kick Klonopin than heroine.
I personally can't take Desoxyn anymore b/c like EMSAM, I can longer afford the exorbitant 500 dollar monthly fee(lost all my money in the stock market last year). I currently take the 6mg EMSAM patch with a 15mg Dexedrine Spansule, 30mg of Lamictal & 1mg of Klonopin(couldn't kick it). The cocktail works decently but I actually came on this site to hear people's thoughts about Parnate.
Rather than increasing my EMSAM dose to 12mg, I'm considering a batch of Parnate. I've been toggling Parnate for about five years now but haven't had the courage to succumb to this beast of a drug which is supposed to be the best when tolerated. Is it really that bad in terms of side effects? I've taken almost every drug known to man and have never once had any 'real' side effects. I think this is b/c I exercise daily and eat healthy by default of having Celiac's disease and having to be on a gluten, casein, lactose free diet. The MAOi diet is nothing compared to what i'm forced to eat. Broccoli and Chicken and that's about it. So yeah, not worried about weight gain. Can't see how an amphetamine based drug like Parnate would cause weight gain anyhow, and if it did, I would welcome it. EMSAM has turned me into a toothpick, albeit a ripped tooth pic. Sexual side effects, ACNE and cognition are my major concerns. One positive effect from EMSAM has been that my libido has skyrocketed and I no longer need Viagra to get it up. I know that Nardil is notorious for phallic Down Syndrome but what about Parnate?
Concerning EMSAM, you have to give this drug time. At least 1 month before passing final judgment. At 6mg, it is pretty much just targeting dopamine(it's major metabolite being methamphetamine). If you have severely low dopamine levels already, than you will need to up the dose. And at higher doses, you get some serotonergic and norepinephrinergic effects that are the hallmarks of Parnate and Nardil.
And as for Parnate, it is KING b/c it is essentially a high dose of amphetamine which is why it helps with depression. Parnate is about as close as you'll will get to street methamphetamine/cocaine which is another reason I think doctors tend to stay away from it; highly addictive and tolerance builds rapidly. Parnate does however, have the added benefits of serotonin and some GABA release(not sure about GABA? although I know Nardil releases GABA in megaton quantities) to quell excessive dopaminergic stimulation. This is what EMSAM lacks and why so many people can't tolerate it. If you get anxious on ESAM, contrary to what seems logical, increasing the dose will actually decrease anxiety due to the onset of both MAO-b and MAO-a effect. At 6mg, you are only getting MAO-b. Why they didn't make a Nardil or Parnate patch boggles the mind?? Probably b/c it would work too well and put the SSRI machine that is raking in billions, out of business.
I can imagine that tolerance with Parnate is the same as it would be with any stimulant: you get used to it after a while which makes augmenting with Namenda to abate amphetamine tolerance a possibility. Augmentation with Aricept would also boost the effects of any amphetamine based drug in my experience.
Not sure if Parnate will be any cheaper since my insurance isn't covering anything brand name(tapped out at 2000 max) till January and I refuse to take anything but brand; especially with a drug such as Parnate. For ex: I switched from GSK Lamictal that i was getting from overseas for a ridiculously cheap price to generic Lamictal. It felt like i'd been roofied with sugar pills so I was forced to switch back. Generics are just plain garbage and full of fillers that cause more problems than the intended med cures. I try to avoid anything in pill form and instead ask for either liquid, sub-lingual or transdermal. Pills are primitive and for ex: if you have a bowl of fiber, the pill will get absorbed with the fiber and you will defecate it out a-la-stool without it ever getting absorbed. This is the problem with pills and the major reason why I try to stay away from them. Here's another example of why generics are a waste of money: I take a 15mg GSK Dexedrine Spansule and watch my BP go from 110 to 130 in a matter of minutes. I feel it kick after about 15 minutes. If I take 30 mg of Barr (generic) Dex, there is no BP elevation and the cerebral effect is mild. It all has to do with asorbtion which is why I was hoping that my insurance would cover a new form of liquid Dexedrine called Procentra but nope. Without insurance, that has a 1000 dollar price tag. Ridiculous and I certainly can't afford it.
In long winded conclusion, I can imagine that if you're used to a much more potent drug like Parnate or have low dopamine levels, ESMAM would seem like the difference between caffeine and crystal meth; nothing basically; your dopamine threshold levels have habituated to a very high level so you are going to need a more potent drug or combo. Ask your doc about augmenting the patch with a stimulant. Read below. It was once common practice, even with Parnate.
FOUND THIS THREAD ON THE WEB AND THOUGHT IT MIGHT BE APPLICABLE TO EMSAM AS WELL.The commonest reason people do not respond to tranylcypromine (Parnate) is an inadequate dose. When using an MAOI I follow platelet MAO levels and keep increasing the dose is sufficient to reduce those levels almost to zero. This often takes > 60 mg/day of tranylcypromine.
If a month or so on 80 mg/day or so does not lead to a significant improvement, the next thing I usually do is to add a psychostimulant such as methylphenidate or dextroamphetamine to the cocktail. Starting with small doses, the dose is gradually increased until the patient is taking about 30 mg/day of dextroamphetamine, or twice as much methylphenidate.
Date: Fri, 14 Apr 1995 15:06:15 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: MAOIs in high doses and with stimulantsThere are recently been a number of warnings posted there that MAOIs should not be prescribed together with psychostimulants. While that is the conventional wisdom, if universally implemented, it would deprive many severely and intractably depressed people from relief.
In the olden days, the early 1960s, we used to treat some patients with resistant depressions with up to 200 mg/day of tranylcypromine and if that was not effective potentiate it with dextroamphetamine, starting with 2.5 mg once a day and gradually increasing to 15 or 20 mg/day.
Until it was recently withdrawn, a 60ish year old patient of mine was only able to continue in his professional work by taking 170 mg/day of isocarboxazid + 5 mg of dextroamphetamine t.i.d. Since the isocarboxazid became unavailable, he has been doing almost as well on phenelzine 135 mg/day + the dextroamphetamine.
When treating patients with unusually hard to treat syndromes it is often necessary to use combinations [and doses] of medication that are conventionally considered to be contraindicated.
From: "Steven L. Dubovsky" <Steven.Dubovsky@UCHSC.edu>
Date: 15 Apr 95 08:47:17 MST-0700
Subject: MAOIs in high doses and with stimulantsIt is common practice where I come from to combine MAOIs and stimulants for MAOI-induced hypotension and treatment resistance. This is also mentioned in Jan Fawcett's book of a number of years ago. Also, remember Feighner's report of MAOI + TCA + stimulant in ECT-resistant depression. I have tried this a number of times and found it helpful. Since half the caucasian population are (is?) rapid acetylators, higher doses of Parnate are frequently necessary. Other patients are rapid metabolizers of hydrazide MAOIs and need high doses of those. The PDR is a legal, not a medical, document, so I don't think their doses are always reliable.
From: Donald Franklin Klein <dfk2@columbia.edu>
Date: Sun, 16 Apr 1995 23:44:11 -0400
Subject: MAOIs with stimulantsMAOIs plus methylphenidate (Ritalin) has not been a problem in my hands although theoretical risk requires discussion with patient, consent, and available nifedipine. Very useful for orthostatic hypotension.
Date: 06 Sep 95 11:38:03 EDT
From: Troy Caldwell <75112.1676@compuserve.com>
Subject: MAOIs with stimulantsNone other than my teacher, John Rush, some years ago referred just such a refractory person to me specifically to try adding a stimulant to her MAOI. This was in the days when doctors could still hospitalize and had authority to do things. Apparently, we private practitioners had a bit more autonomy than the university MDs at that time, so I got the referral.
Social commentary aside, I put the pt in the ICU and added very slowly Dexedrine or Desoxyn to the patient's regimen. It was wonderful -- a grand remission occurred -- and complications were zero. I've tried it since a few times, starting a low doses and titrating gradually upward, and each time no complications arose. Like all treatment efforts, it has been variably effective, but definitely worth trying. Of course, give them nifedipine as an antidote to carry.
Date: Fri, 09 Feb 1996 10:57:43 -0600
From: Kevin Miller <MillerKB@wpogate.slu.edu>
Subject: MAOIs with stimulantsHypotension is a frequent side-effect of MAOIs. If hypotension limits appropriate dosage increases, either based on clinical response, or on not reaching the target dose of about 1 mg/kg in the case of phenelzine (Robinson and Nies), the slow and careful addition of stimulants while monitoring BP makes wonderful sense. The hypotension is treated, the antidepressant effect is augmented, and, if methylphenidate is used, there may be pharmacokinetic effects as well. This is riskier with tranylcypromine given that spontaneous elevations of BP have been noted with this MAOI despite strict dietary adherence. It's also easier to do safely on an inpatient basis.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Sun, 18 Feb 1996 21:43:52 -0500
Subject: MAOIs with stimulantsThere is fortunately a small literature on combining MAOI and stimulant medication: Fawcett, J Clin Psychopharm 1991, 127-132; Feighner, J Clin Psych 1985, 206-209. Also, Clary, J Clin Psych 1990, 226-231, reported in a survey of prescribing habits of Pennsylvania psychiatrists that among those who prescribed MAOIs, use of high doses and combined use of MAOIs with stimulant meds were not unusual.
I have used this combination for the treatment of refractory depression and have at times have found it a great help and at other times useless. I do not remember it being helpful when a patient was not at least partially responsive to either the stimulant or the MAOI alone. However if there is a partial response to one of those meds, then when the two are combined, there can be either an additive or synergistic effect.
I have never had a problem with elevated BP, however I most often add the MAOI to the stimulant rather than the reverse... If I do add a stimulant to an MAOI, I start with 1.25 mg d-amphetamine or equivalent, the idea being that it probably takes at least 5 mg tyramine to precipitate a hypertensive crisis, and since the molecular weights are about the same 1.25 mg amphetamine would be sub-threshold. Starting at that level has not caused any reactions, but I still prefer to start with the stimulant and add the MAOI later.
I find that with time, as more treatment options are available, I use this combination less but there are still some patients for whom nothing else seems to work. The side effects that do cause problems include activation sometimes resembling or identical to dysphoric mania. Stereotypy and choreiform movements including bucco-facial dyskinesia can also occur. These side effects have to watched for closely. If it is essential to continue the regimen, pimozide can usually alleviate the movement disorder.
From: "David A. Kahn" <kahndav@cpmc3.cpmc.columbia.edu>
Date: Wed, 21 Feb 1996 10:31:11 EDT
Subject: MAOIs with stimulantsI'm always in the position of trying to augment an existing MAOI regimen, so it's never seemed feasible to stop the MAOI, start the stimulant, and then restart the MAOI. I just add the stimulant. The only adverse reaction I've encountered is an odd lability of blood pressure on two occasions, where supine blood pressure was somewhat elevated on a tonic basis, together with a worsening of orthostatic hypotension. The supine elevation made it impossible to think of Florinef, etc., so we had to stop the combination. Interestingly, both of these individuals had prior histories of intermittent bordereline essential hypertension which had resolved on the MAOI alone.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Wed, 21 Feb 1996 08:29:48 -0500
Subject: MAOIs with stimulantsBy the way, I do not get signed consent. I do not think that that holds up very well anyway. Well documented clear chart notes indicating the clinical rationale and including what is told to the patient should always be standard practice and especially with atypical treatment modalities such as this.
poster:Kingston
thread:926582
URL: http://www.dr-bob.org/babble/20091127/msgs/927788.html