Posted by Kingston on December 2, 2009, at 18:20:52
In reply to Re: Add anything to help with the EMSAM wait.... » Kingston, posted by Monica L on December 2, 2009, at 16:52:30
Monica,
Are you stopping the Ritalin all together? If not, actually adding an MAOi to a patient who has been taking a stimulant is the safer route rather than a stimulant to MAOi."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."
The above is an excerpt from my post 2 posts ago towards the bottom and I'll re-post below. This is a convo between some docs in 1995, discussing the use of Ritalin and Dexedrine with Parnate. They all say the same thing: although the combo is considered taboo, they believe it to be safe and extremely beneficial in many cases.
If I were a doctor and you were my patient, I would ask how you responded to the EMSAM to get an idea of how you respond to MAOis? Did you feel tired on it? Difficulty walking up a flight of stairs? Did your blood pressure drop(hypotension)? If so, then I would say you're a prime candidate for stimulant + MAOi therapy and have little to worry about in regards to stopping the Ritilan you are currently taking. I would only recommend that you discuss this all with your doctor and that you lower the stimulant dosage appropriately until you understand how your body reacts to Parnate and whether or not you even need the Ritalin. It may be good to just stop the Ritilan for a while since Parnate is supposed to be stimulating so you may not need a stim unless you are prone to hypotension. Read the following below and show this discussion to your doctor so that he doesn't think you're insane if you do decide to ask to combine Parnate and Ritalin (I would suggest Desoxyn over Ritalin if your BP is normal and you still want the stimulant boost. Desoxyn has little effect on the peripheral nervous system and little effect on blood pressure. It's the safest of all the stimulants aside from having the associated stigma of society's most misunderstood and taboo name-methamphetamine.)
"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."
"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 regiment, 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: "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.
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."
> I've stopped the emsam about a week ago, and want to start Parnate. I see my pdoc tomorrow and hope we would agree that would be best to try next. One problem, I've been taking my ritilan for the past 3 days, 40 mgs. Say I do get prescribed the parnate tomorrow, because I've been taking the ritilan, do you think I can I start the parnate as soon as tomorrow or the next day? Or am I going to have to go through another washout before the parnate is started because of the ritilan I've been taking for the past 3 days?
>
> Thanks
>
> Monica
>
poster:Kingston
thread:926582
URL: http://www.dr-bob.org/babble/20091127/msgs/927847.html