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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by SLS on April 12, 2011, at 16:37:48
Pristiq + Wellbutrin
I'm curious if anyone has tried this combination. I know one person who has been responding well to it, although it has only been a few weeks.
I hope it lasts for her.
- Scott
Posted by matthewdavid on April 12, 2011, at 21:44:29
In reply to Pristiq + Wellbutrin anyone?, posted by SLS on April 12, 2011, at 16:37:48
I tried for 6 months, too much norapaniphamine? sorry on the spelling, raised my blood pressure but may work for some. individual had success with each med just not when combined them
Posted by Terry8 on April 12, 2011, at 21:46:48
In reply to Pristiq + Wellbutrin anyone?, posted by SLS on April 12, 2011, at 16:37:48
Yup. It was a good, energizing combo for me with no adverse side effects. Just some appetite suppression and weight loss, which were welcome.
Posted by Bob on April 13, 2011, at 0:51:14
In reply to Pristiq + Wellbutrin anyone?, posted by SLS on April 12, 2011, at 16:37:48
> Pristiq + Wellbutrin
>
> I'm curious if anyone has tried this combination. I know one person who has been responding well to it, although it has only been a few weeks.
>
> I hope it lasts for her.
>
>
> - ScottScott,
Have you ever spent a significant length of time on a therapeutic level of bupropion?
Bob
Posted by SLS on April 13, 2011, at 6:22:41
In reply to Re: Pristiq + Wellbutrin anyone? » SLS, posted by Bob on April 13, 2011, at 0:51:14
> Scott,
>
> Have you ever spent a significant length of time on a therapeutic level of bupropion?
>
> BobHi Bob.
Good thought.
Yes, I have been on Wellbutrin 900 mg for a month or more on an open-label basis before it was finally approved by the FDA. I have tried it several times subsequently; each of which exacerbated my depression moderately. At the time, I thought that Wellbutrin was dopaminergic. That was my reason for trying it. Of course, we have learned since that it is not a potent dopamine reuptake inhibitor.
As an aside, I did respond briefly, but robustly to nomifensine (Merital), a potent DA reuptake inhibitor that is no longer available. If I were to add anything to Pristiq, it would be nortripyline. I tried Effexor in combination with nortriptyliine with partial success. Unfortunately, we stopped titrating nortriptyline at 75mg. We later found that I need 150mg. If I need to change strategies, I would try adding Pristiq 100mg to nortripyline 150mg. Who knows, perhaps the right dosage of Pristiq is 200mg for some people. Clinical experience is sparse at such high dosages. However, it took many years before dosages of Effexor of 300mg and higher were accepted as therapeutic.
- Scott
> > Pristiq + Wellbutrin
> >
> > I'm curious if anyone has tried this combination. I know one person who has been responding well to it, although it has only been a few weeks.
> >
> > I hope it lasts for her.
> >
> >
> > - Scott
>
>
>
> Scott,
>
> Have you ever spent a significant length of time on a therapeutic level of bupropion?
>
> Bob
Posted by Bob on April 13, 2011, at 16:43:57
In reply to Re: Pristiq + Wellbutrin anyone? » Bob, posted by SLS on April 13, 2011, at 6:22:41
>
> > Scott,
> >
> > Have you ever spent a significant length of time on a therapeutic level of bupropion?
> >
> > Bob
>
> Hi Bob.
>
> Good thought.
>
> Yes, I have been on Wellbutrin 900 mg for a month or more on an open-label basis before it was finally approved by the FDA. I have tried it several times subsequently; each of which exacerbated my depression moderately. At the time, I thought that Wellbutrin was dopaminergic. That was my reason for trying it. Of course, we have learned since that it is not a potent dopamine reuptake inhibitor.
>
> As an aside, I did respond briefly, but robustly to nomifensine (Merital), a potent DA reuptake inhibitor that is no longer available. If I were to add anything to Pristiq, it would be nortripyline. I tried Effexor in combination with nortriptyliine with partial success. Unfortunately, we stopped titrating nortriptyline at 75mg. We later found that I need 150mg. If I need to change strategies, I would try adding Pristiq 100mg to nortripyline 150mg. Who knows, perhaps the right dosage of Pristiq is 200mg for some people. Clinical experience is sparse at such high dosages. However, it took many years before dosages of Effexor of 300mg and higher were accepted as therapeutic.
>
>
> - Scott
>
>
Scott,I am amazed at your recall of all the details of the various treatments you've undergone. Seems like 900mg of bupropion is super high compared to what is FDA approved these days, right? Wellbutrin is a strange med - it gave me one of the best initial responses of any med I've ever taken and then turned into one of the worst poop outs. I was under the impression that the med does affect dopamine in at least modest levels. What is your understanding of the mechanism? I thought the going theory is norepinephrine, dopamine, and some nicotinic actions?
Your response to nomifensine is not unlike my response to pramipexole in that there was an initial robust response that faded away. Interestingly, my current and long time dose of nortriptyline is 70mg... not far from your previously mentioned 75mg. I'm taking it with sertraline at 125mg. I'm not sure I could stand 150mg of nortrip though.
Why would you try nortriptyline with Pristiq? What do you think the augmentation with nortrip is doing? Obviously if you tried Pristiq you'd have to come off of the Nardil. Then it seems that you wouldn't be taking any drug that theoretically directly acts on dopamine?
Posted by SLS on April 13, 2011, at 18:18:49
In reply to Re: Pristiq + Wellbutrin anyone? » SLS, posted by Bob on April 13, 2011, at 16:43:57
> I am amazed at your recall of all the details of the various treatments you've undergone.
I guess my memory for these things is good because so much depends on my finding an effective treatment.
> Seems like 900mg of bupropion is super high compared to what is FDA approved these days, right?
Yes. The original clinical trials for major depression used the higher dosages. When it was discovered that people with bulimia suffered seizures, the drug company decided to withdraw the medication temporarily. The dosage recommendations were refined to dosages that were about half of that originally approved for.
> Wellbutrin is a strange med
For sure. I don't think its efficacy is produced by acting as a dopamine reuptake inhibitor. Preskhorn differs on this point, though.
http://www.preskorn.com/columns/0001.html
> Your response to nomifensine is not unlike my response to pramipexole in that there was an initial robust response that faded away. Interestingly, my current and long time dose of nortriptyline is 70mg... not far from your previously mentioned 75mg. I'm taking it with sertraline at 125mg. I'm not sure I could stand 150mg of nortrip though.
I recommend that you test your blood level of nortriptyline and make treatment decisions based upon the results. You might be a rapid-metabolizer. Effective drug levels range between 50-150 ng/ml.
> Why would you try nortriptyline with Pristiq?
Primarily because I had partial success with combining Effexor and nortriptyline. However, I was underdosed on nortriptyline, so I can justify giving a try to adding either Pristiq or Effexor to the dose of nortriptyline that I now know is therapeutic for me.
> What do you think the augmentation with nortrip is doing?
I can't be sure. Obviously, it is a more potent NE reuptake inhibitor than is Pristiq. However, nortriptyline does other things. For instance, it is an antagonist at 5-HT2a receptors and a calcium channel antagonist.
> Obviously if you tried Pristiq you'd have to come off of the Nardil.
Definitely. It doesn't take much desvenlafaxine to produce a serious serotonin syndrome reaction when given to someone taking a MAOI.
> Then it seems that you wouldn't be taking any drug that theoretically directly acts on dopamine?
This is true. However, the decrease in dopamine turnover produced by an MAOI should be an indicator of an increase in presynaptic stores. In addition, the 5-HT2a receptor antagonism will likely increase dopaminergic activity in the PFC (prefrontal cortex).
Sometimes, I think it is fruitless to try to guess at the clinical result of a specific drug treatment. There is much data, but little understanding.
- Scott
Posted by Bob on April 13, 2011, at 20:06:56
In reply to Re: Pristiq + Wellbutrin anyone? » Bob, posted by SLS on April 13, 2011, at 18:18:49
>
> Sometimes, I think it is fruitless to try to guess at the clinical result of a specific drug treatment. There is much data, but little understanding.
>
>
> - Scott
>
Couldn't have made a better point. However, for I think people like you and I need a rational basis for the treatments we want to try, otherwise it ends up seeming even more hopeless. I know a relative that just does what the doctor says and never, ever questions anything. In fact, she will not even discuss any aspects of the meds. I guess it's just too depressing for her but I can't operate like that - I'm just not wired for it.Bob
Posted by SLS on April 14, 2011, at 5:36:21
In reply to Re: Pristiq + Wellbutrin anyone? » SLS, posted by Bob on April 13, 2011, at 20:06:56
>
> >
> > Sometimes, I think it is fruitless to try to guess at the clinical result of a specific drug treatment. There is much data, but little understanding.
> >
> >
> > - Scott
> >
>
>
> Couldn't have made a better point. However, for I think people like you and I need a rational basis for the treatments we want to try, otherwise it ends up seeming even more hopeless. I know a relative that just does what the doctor says and never, ever questions anything. In fact, she will not even discuss any aspects of the meds. I guess it's just too depressing for her but I can't operate like that - I'm just not wired for it.
>
> Bob
>
>
You are right.
- Scott
Posted by mtdewcmu on April 14, 2011, at 17:11:33
In reply to Re: Pristiq + Wellbutrin anyone? » Bob, posted by SLS on April 13, 2011, at 18:18:49
> > Seems like 900mg of bupropion is super high compared to what is FDA approved these days, right?
>
> Yes. The original clinical trials for major depression used the higher dosages. When it was discovered that people with bulimia suffered seizures, the drug company decided to withdraw the medication temporarily. The dosage recommendations were refined to dosages that were about half of that originally approved for.What was it like at 900mg? It's a strange tale that it was originally intended to be used at such high doses, but now suddenly 300mg is good enough, just because it doesn't cause seizures. Maybe we are missing out on what are supposed to be the true effects.
> > Wellbutrin is a strange med
>
> For sure. I don't think its efficacy is produced by acting as a dopamine reuptake inhibitor. Preskhorn differs on this point, though.
>
> http://www.preskorn.com/columns/0001.html
>My understanding (no reference handy) is that bupropion is a DRI, and hydroxybupropion, the metabolite, is an NRI. Hydroxybupropion accumulates over the first week or so until there is more of it than bupropion. Unfortunately, there is no way to separate out just bupropion. I have been taking WB for over a year and I see no reason to doubt that it's in fact a DRI. It's just that it gets overwhelmed by NE as the metabolites accumulate. Over at erowid.org there are stories by people claiming to have gotten high from WB. They take large doses in a short time period, so it would mostly affect DA.
I stopped it for a few days and when I restarted it, the effects were best the first day. I could concentrate pretty well on work that day.
> Sometimes, I think it is fruitless to try to guess at the clinical result of a specific drug treatment. There is much data, but little understanding.
>I absolutely agree. Psychiatry is voodoo. It's a lot like the days when all diseases were explained in terms of the four humors, blood, phlegm, yellow bile, and black bile. The treatment for almost everything was bloodletting. Not too different than treating all mental illness by jacking up serotonin and hoping for the best. Of course, there are proven (if not understood) treatments for psychosis, ADHD, and bipolar mania. But any treatment for MDD is basically a shot in the dark.
I think you ought to give Wellbutrin another shot. The effects may be different if you are mixing it with different other drugs. Especially if the other drug reduces anxiety.
Posted by mtdewcmu on April 14, 2011, at 17:13:36
In reply to Re: Pristiq + Wellbutrin anyone?, posted by mtdewcmu on April 14, 2011, at 17:11:33
Actually, now that I think about it, it might be possible to deliberately block the enzyme that converts bupropion to its active metabolite. Then you might be able to get bupropion by itself. But that is advanced stuff.
Posted by floatingbridge on April 15, 2011, at 18:47:41
In reply to Pristiq + Wellbutrin anyone?, posted by SLS on April 12, 2011, at 16:37:48
Scott, now that I am off of it, I realize pristiq did far more than I gave it credit. And relatively transparent. (2¢)
Good luck to your friend. And you, too.
fb
Wellbutrin didn't help me at the time, (somulence) but my objectivity was pretty low. I was also taking max reccomended amount, 450? My doc worried about strokes.
Posted by Bob on April 17, 2011, at 1:43:47
In reply to Re: Pristiq + Wellbutrin anyone?, posted by mtdewcmu on April 14, 2011, at 17:11:33
This is the end of the thread.
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