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Dr. Bob is Robert Hsiung, MD,
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Posted by linkadge on November 24, 2013, at 14:23:55
In reply to Safest trycyclics?, posted by Lamdage22 on November 24, 2013, at 10:10:19
it depends on what side effects you are considering.
cardiovascular
genotoxicity
anticholinergic effects
Posted by sigismund on November 24, 2013, at 16:14:02
In reply to Re: Safest trycyclics?, posted by linkadge on November 24, 2013, at 14:23:55
Link, how much does the genotoxicity of trimipramine (and whichever others) matter?
Are they unknown, the probable long term effects?
Posted by linkadge on November 24, 2013, at 17:05:39
In reply to Re: Safest trycyclics? » linkadge, posted by sigismund on November 24, 2013, at 16:14:02
>Link, how much does the genotoxicity of >trimipramine (and whichever others) matter?
I really have no idea how much of a risk this poses. I can just say I stopped clomipramine for this reason - which is unfortunate because it was highly effective.
I just can't see pumping 100s of MG of a genotoxic substance in my body every day and hoping for the best.
I think that doxapin, imipramine, clomipramine, desipramine, and trimipramine are genotoxic. Amitriptyline and nortriptyline (and a few others) are not.
That being said, any risks are probably dose dependent. If you are taking 10mg of trimipramine for sleep, this is probably safer than 300mg of imipramine for depression.
Linkadge
Posted by Phillipa on November 24, 2013, at 17:28:16
In reply to Re: Safest trycyclics?, posted by linkadge on November 24, 2013, at 17:05:39
SSRI's were developed and used to eliminate these risks hopefully. Phillipa
Posted by sigismund on November 24, 2013, at 20:50:00
In reply to Re: Safest trycyclics?, posted by linkadge on November 24, 2013, at 17:05:39
> If you are taking 10mg of trimipramine for sleep, this is probably safer than 300mg of imipramine for depression.
And I am, more or less.
Larry has been taking it, which reassures me somewhat.
It is far better than doxepin for improving sleep.
Posted by ed_uk2010 on November 28, 2013, at 13:14:30
In reply to Safest trycyclics?, posted by Lamdage22 on November 24, 2013, at 10:10:19
> I wonder what they are and if it can be combined with moclobemide.
>
> My doctor told me they are hard on the heart, but im thinking to myself: What do i need heart health for with 50 when i feel like killing myself for 25 and more years?Only non-serotonergic TCAs combine with moclobemide. Others produce symptoms of serotonin toxicity eg. shivering, agitation, sweating, muscle twitching.
Have you ever tried nortriptyline? And do you suffer from any kind of heart or cardiovascular condition?
Posted by Lamdage22 on November 29, 2013, at 10:44:56
In reply to Re: Safest trycyclics?, posted by ed_uk2010 on November 28, 2013, at 13:14:30
No ed,
i dont suffer from that. I do need to take an antipsychotic along with the tricyclic though.
When i was on Lamictal i was normal without antipsychotic. My hope is that this result can be reproduced.
Posted by ed_uk2010 on November 29, 2013, at 14:05:54
In reply to Re: Safest trycyclics?, posted by Lamdage22 on November 29, 2013, at 10:44:56
> No ed,
>
> i dont suffer from that. I do need to take an antipsychotic along with the tricyclic though.
>
> When i was on Lamictal i was normal without antipsychotic. My hope is that this result can be reproduced.
>
>So you had to stop Lamictal?
Nortriptyline is useful for major depression. I'm unsure how it performs in schizoaffective disorder, probably as well as most TCAs.
You would want to start with a low dose and see how you do before increasing. 25mg at night might be sensible. Nort is dangerous in overdose, and it would be a good idea to only get a couple of weeks supply at a time. If you have a history of mania, all TCAs need to be used with great caution.
Ask your doctor for his/her opinion on this.
Posted by Lamdage22 on November 30, 2013, at 4:23:16
In reply to Re: Safest trycyclics?, posted by ed_uk2010 on November 29, 2013, at 14:05:54
I stopped it because i went to university and i felt too stupid.
Also i thought it made me loose hair.But if it enables me to take less antipsychotics and more antidepressants due to its (in my case) antipsychotic properties i decided its worth it.
Posted by ed_uk2010 on November 30, 2013, at 5:19:27
In reply to Re: Safest trycyclics?, posted by Lamdage22 on November 30, 2013, at 4:23:16
> I stopped it because i went to university and i felt too stupid.
> Also i thought it made me loose hair.Maybe a smaller dose would be suitable?
Posted by Lamdage22 on November 30, 2013, at 5:38:34
In reply to Re: Safest trycyclics?, posted by ed_uk2010 on November 30, 2013, at 5:19:27
Yes perhaps. Thinking like 100mgs.
I do want to take the 300mg Seroquel against depression anyway.
Right now its 700 Seroquel and 15 Zyprexa. Want to reduce that.
With the help of Sarcosine and Lamictal.
Posted by ed_uk2010 on December 1, 2013, at 6:33:55
In reply to Re: Safest trycyclics?, posted by Lamdage22 on November 30, 2013, at 5:38:34
>Right now its 700 Seroquel and 15 Zyprexa. Want to reduce that.
That is rather a lot. Does your doctor feel you may be able to reduce - and do you?
>Lamictal.
I get the impression that cognitive side effects are usually minimal at low doses, but become progressively worse at high doses, especially >200mg/day, but it's minimal. I get the impression that approx. 50mg twice a day (or 100mg once a day) tends to be the lowest dose which is useful.
On another note, do you usually tolerate ADs, or do they induce agitation, manic or psychotic symptoms?
Posted by Lamdage22 on December 3, 2013, at 6:11:16
In reply to Re: Safest trycyclics?, posted by ed_uk2010 on December 1, 2013, at 6:33:55
> >Right now its 700 Seroquel and 15 Zyprexa. Want to reduce that.
>
> That is rather a lot. Does your doctor feel you may be able to reduce - and do you?Yes, we want to discontinue Zyprexa.
>
> >Lamictal.
>
> I get the impression that cognitive side effects are usually minimal at low doses, but become progressively worse at high doses, especially >200mg/day, but it's minimal. I get the impression that approx. 50mg twice a day (or 100mg once a day) tends to be the lowest dose which is useful.Thats good.
>
> On another note, do you usually tolerate ADs, or do they induce agitation, manic or psychotic symptoms?That we are finding out now. I certainly needan AD and balance it with the Seroqudl for example.
Posted by ed_uk2010 on December 3, 2013, at 6:29:32
In reply to Re: Safest trycyclics?, posted by Lamdage22 on December 3, 2013, at 6:11:16
>Yes, we want to discontinue Zyprexa.
OK, good. I'm sure you already know (and so I don't want to offend), but it will need to be very gradual, particularly the final stages. Zyprexa can be difficult to discontinue.
>That we are finding out now. I certainly need an AD and balance it with the Seroquel for example.
OK, so were you thinking of introducing an AD at some point in the next few months, once your other meds are more stable? That makes sense. I was wondering whether you've reacted badly to SSRIs like Lexapro since you're asking about tricyclics?
Take care,
ed_uk
Posted by Lamdage22 on December 3, 2013, at 8:58:45
In reply to Re: Safest tricyclics? » Lamdage22, posted by ed_uk2010 on December 3, 2013, at 6:29:32
Lexapro can prolong QT intervall.
I took Sertraline and got akathisia from it.Doc said other SSRI either prolong QT or make even more akathisia.
Posted by Lamdage22 on December 3, 2013, at 9:01:13
In reply to Re: Safest tricyclics?, posted by Lamdage22 on December 3, 2013, at 8:58:45
> Lexapro can prolong QT intervall.
> I took Sertraline and got akathisia from it.
>
> Doc said other SSRI either prolong QT or make even more akathisia.Antipsychotics are said to prolong qt as well, thats why.
Posted by ed_uk2010 on December 3, 2013, at 13:04:16
In reply to Re: Safest tricyclics?, posted by Lamdage22 on December 3, 2013, at 8:58:45
>Lexapro can prolong QT interval.
True, but probably less so than any of the major tricyclics. Overall, it seems that tricyclics are considerably more likely to cause cardiac arrhythmias than other ADs, including all SSRIs. QT prolongation is dose-dependent, so anyone at risk should avoid high doses and overly complex med combinations.
Amitriptyline in particular tends to cause QT prolongation, which is part of the reason that it is very toxic in overdose.
Posted by ed_uk2010 on December 3, 2013, at 13:06:28
In reply to Re: Safest tricyclics?, posted by Lamdage22 on December 3, 2013, at 9:01:13
>Antipsychotics are said to prolong qt as well, thats why.
Most do yes, Seroquel and Zyprexa are not terribly bad in this respect but the effect may be increased by the combination. Perhaps you could initiate an AD once you've tapered off Zyprexa and started Lamictal.
Posted by Lamdage22 on December 4, 2013, at 3:37:28
In reply to Re: Safest tricyclics?, posted by ed_uk2010 on December 3, 2013, at 13:06:28
Thanks, i will keep that in mind.
Its good to know that other SSRIs are still an option.
Posted by ed_uk2010 on December 4, 2013, at 8:59:11
In reply to Re: Safest tricyclics?, posted by Lamdage22 on December 4, 2013, at 3:37:28
> Thanks, i will keep that in mind.
>
> Its good to know that other SSRIs are still an option.
>Zoloft, Celexa and Lexapro have the fewest drug interactions amongst the SSRIs, which is useful if you're on multiple meds. Given your previous reaction to Zoloft, a low starting dose of any SSRI would be essential eg. Lexapro 5mg in the morning, or Celexa 10mg in the morning. You could even take less for the first few days if you prefer, just to make sure you're OK with it, and then increase up to a more normal dose over a period of a few weeks. No more than 40mg of Celexa or 20mg of Lexapro should be taken per day. Some people do take higher doses off-label, but it's not safe when you're on other drugs which may prolong the QT interval.
After an initial low starting dose, 'standard' therapeutic doses are 20mg Celexa or 10mg Lexapro, but individual adjustment may be needed. To be honest, it might be best not to exceed these doses while taking Seroquel, unless it's unavoidable. I do not think it would be a good idea to take either Celexa or Lexapro while still on two antipsychotics, since the effect on the QT interval may be additive. Once you've tapered off Zyprexa you have more options. It is possible (thought not entirely clear) than Lexapro may be slightly more effective than Celexa. It is unfortunately a lot more expensive, and not everyone prefers it. Overall, they are very similar meds.
Zoloft has no effect on the QT interval, but it sounds like you tolerated it badly so I guess it's a no-go.
Prozac and Paxil have very little, if any, cardiac effects, but they do have a lot of drug interactions which can make med combinations awkward. I do not believe that either of these drugs interact greatly with Seroquel, however. On the other hand, they do tend to cause slightly more side effects than Celexa or Lexapro.
Have you considered mirtazapine (Remeron)? It may be a useful AD. It does not appear to prolong the QT interval and it may improve depression and insomnia when coming off Zyprexa. You could consider starting Remeron after (very slowly) reducing your dose of Zyprexa.
Any idea what your doc thinks about all this? Stopping Zyprexa is a major event because there is a risk of relapse and withdrawal anxiety/insomnia.
Posted by Lamdage22 on December 5, 2013, at 2:10:03
In reply to Safest trycyclics?, posted by Lamdage22 on November 24, 2013, at 10:10:19
Im thinking about aurorix though after cymbalta.
Posted by Lamdage22 on December 5, 2013, at 4:25:22
In reply to Safest trycyclics?, posted by Lamdage22 on November 24, 2013, at 10:10:19
I read that paxil induces suicidality. I want it to do the opposite :(
Posted by phidippus on December 5, 2013, at 17:07:39
In reply to Safest trycyclics?, posted by Lamdage22 on November 24, 2013, at 10:10:19
Most TCAs are fine on the heart, but if large doses are applied, they can cause QT problems which can lead to death.
Posted by Lamdage22 on December 7, 2013, at 5:58:33
In reply to Re: Safest trycyclics? » Lamdage22, posted by phidippus on December 5, 2013, at 17:07:39
Since Sertraline worked instantly and remarkably, does that mean there is a good chance that another Ssri works as well?
Sertraline gave me horrible akathisia.
So far i had Effexor and it worked minimally. Currently im on Cymbalta and it doesnt work yet.
Posted by ed_uk2010 on December 8, 2013, at 2:03:15
In reply to Re: Safest trycyclics?, posted by Lamdage22 on December 5, 2013, at 2:10:03
> Im thinking about aurorix though after cymbalta.
Aurorix is a novel one. You'll need to wait until Cymbalta is fully out of your system before starting it, or else severe side effects will occur. Since Cymbalta is a short-acting drug, it is normally fully out of your body within 4 days after your very last dose. Your doctor may advise leaving a gap of one week for increased safety. Remember, the dose of Cymbalta often needs to be reduced gradually to prevent withdrawal symptoms.
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