![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by Bob on February 28, 2016, at 23:37:00
I was doing some reading on Parnate today and was surprised to learn that the drug has a half-life of a mere 2.5 hours. Is it recommended to dose this drug multiples times per day to compensate for this short half-life?Bob
Posted by SLS on February 29, 2016, at 7:20:14
In reply to Parnate, posted by Bob on February 28, 2016, at 23:37:00
>
> I was doing some reading on Parnate today and was surprised to learn that the drug has a half-life of a mere 2.5 hours. Is it recommended to dose this drug multiples times per day to compensate for this short half-life?
>
> BobIt is recommended to take Parnate in divided doses. You can divide them by taking one dose in the morning and one in the early afternoon.
Parnate gets in quickly and binds to MAO permanently. Any excess is metabolized quickly, but the number of inactivated MAO enzymes remains the same. The necessity to dose on a regular basis is to offset the synthesis of new MAO.
Several people on Psycho-Babble take all of their Parnate dosage once in the morning. If orthostatic hypotension becomes a problem, I would consider taking Parnate 3 times a day, with your final dose to be taken at 3:00 PM if insomnia is a problem. Blood pressure usually ebbs at 4:00 PM. I used to have a cup of coffee at this time to reduce hypotension. However, the longer I took Parnate, the less hypotension was a problem.
What is your current treatment regime, if you don't mind my asking?
- Scott
Posted by Bob on February 29, 2016, at 15:10:29
In reply to Re: Parnate » Bob, posted by SLS on February 29, 2016, at 7:20:14
> >
> > I was doing some reading on Parnate today and was surprised to learn that the drug has a half-life of a mere 2.5 hours. Is it recommended to dose this drug multiples times per day to compensate for this short half-life?
> >
> > Bob
>
> It is recommended to take Parnate in divided doses. You can divide them by taking one dose in the morning and one in the early afternoon.
>> Parnate gets in quickly and binds to MAO permanently. Any excess is metabolized quickly, but the number of inactivated MAO enzymes remains the same. The necessity to dose on a regular basis is to offset the synthesis of new MAO.
>
> Several people on Psycho-Babble take all of their Parnate dosage once in the morning. If orthostatic hypotension becomes a problem, I would consider taking Parnate 3 times a day, with your final dose to be taken at 3:00 PM if insomnia is a problem. Blood pressure usually ebbs at 4:00 PM. I used to have a cup of coffee at this time to reduce hypotension. However, the longer I took Parnate, the less hypotension was a problem.
>
> What is your current treatment regime, if you don't mind my asking?
>
>
> - Scott
>
Hey Scott... thanks for the detailed answer. You are always quite informative with your posts.My current regimen is getting slowly more complex. I currently take the following:
Nortriptyline 200mg (75mg 2x per day and 50mg at bedtime)
Brintellix 10mg (5mg 2x per day)
Aripiprazole 4mg (2mg 2x per day)
Lithium 112.5mg at bedtime
Lithothyronine T3 25mcg in the morning
Pramipexole .375mg (.125mg 3x per day)
I assumed that Parnate might have to be taken multiple times per day to stabilize blood levels. Seems like the levels would get pretty low with a once per day dosing and a 2-hr half-life. I've found for some reason that for me it seems even for meds with a relatively long half-life it helps to dose more than once per day. This is especially true when starting a new medicine.I'm not getting a super-robust response from what I'm now taking and everything I take eventually fades in effectiveness. I recently added small amounts of pramipexole which is actually helping somewhat. MAOIs are the only class of drug I haven't tried to date and there is suggestions that they are more suited to atypical depression (which I seem to have) and are less prone to losing effectiveness over time. Then again I've seen people on this very forum who claim to have lost effect with MAOIs.
I have mulled over the idea of taking Parnate (or even Nardil for that matter) but I fear having to taper off of my current nortriptyline and brintellix. My doctor will absolutely not allow the nortriptyline (and obviously the brintellix) to coexist with Parnate. I have had some pretty bad experiences with withdrawal in the past and I don't want to spend weeks getting through the transition on the edge of suicide - especially if I find that the MAOIs are not tolerable or effective for me. That would suck, particularly since the MAOI would be bookended with two potentially hellish transitions. I'm also not currently prepared to find a new doctor.
I think I saw recently where you said if you don't achieve remission with your current regime you may try an SNRI? Is the Parnate + nortriptyline not helping enough?
Bob
Posted by SLS on February 29, 2016, at 16:58:39
In reply to Re: Parnate » SLS, posted by Bob on February 29, 2016, at 15:10:29
> My current regimen is getting slowly more complex. I currently take the following:
> Nortriptyline 200mg (75mg 2x per day and 50mg at bedtime)For most people, this is too much. If you haven't already checked your blood level, you can do that and get a good idea if a dosage adjustment is necessary. The reason I mention this is because nortriptyline has a very real therapeutic window. More is not better. If the dosage of nortriptyline is too high, it stops working.
Have you ever tried desipramine? I am doing better on desipramine than I had been doing on nortriptyline. I find that it gives me more mental energy. I get more things done. I take 300 mg/day. I am optimistic that I will respond more robustly to desipramine than to nortriptyline. Stay tuned...
> Brintellix 10mg (5mg 2x per day)
I have no personal experience with this drug, and have not seen enough anecdotes to have an opinion. I have had experience with Viibryd, and have a doctor who has used it quite a bit. I would recommend talking to your doctor about it. Compared to Britellix, Viibryd is a more potent serotonin reuptake inhibitor. Viibryd is also a 5-HT1a partial agonist (like aripiprazole and buspirone), while Brintellix is a full agonist. I don't know for sure what the significance of this is, but my guess is that a partial agonist would act more like a stabilizer of serotonin activity.
> Aripiprazole 4mg (2mg 2x per day)
I would explore higher dosages. For me, the sweet-spot is 10 mg/day. I lose the antdepressant effect at 5 mg/day. However, my depression is of an unusual type of bipolar disorder.
> Lithium 112.5mg at bedtime
Why not 300 mg/day (150 mg x 2)?
> Lithothyronine T3 25mcg in the morning
Does it help depression? What about thyroxine T4?
> Pramipexole .375mg (.125mg 3x per day)
I'm not a big fan of full agonists of dopamine receptors. They usually don't help that much or for that long. I have seen two exceptions, though.
> I assumed that Parnate might have to be taken multiple times per day to stabilize blood levels.I don't think there are any blood levels to stabilize. Parnate is more of a hit-and-run drug. Still, I make it a habit of dosing three times a day. I would be just as comfortable dosing twice a day.
> Seems like the levels would get pretty low with a once per day dosing and a 2-hr half-life. I've found for some reason that for me it seems even for meds with a relatively long half-life it helps to dose more than once per day. This is especially true when starting a new medicine.
The first time I tried Parnate, I needed to take it 3 or 4 times a day to help reduce postural hypotension.
> I'm not getting a super-robust response from what I'm now taking and everything I take eventually fades in effectiveness. I recently added small amounts of pramipexole which is actually helping somewhat. MAOIs are the only class of drug I haven't tried to date and there is suggestions that they are more suited to atypical depression (which I seem to have) and are less prone to losing effectiveness over time. Then again I've seen people on this very forum who claim to have lost effect with MAOIs.
It is my impression that Nardil is more likely to poop-out than Parnate. It happens, though, that someone will respond well to Nardil for many years and be completely unresponsive to Parnate.
> I think I saw recently where you said if you don't achieve remission with your current regime you may try an SNRI?
I have never combined Effexor or Cymbalta with a therapeutic dosage of nortriptyline or desipramine.
> Is the Parnate + nortriptyline not helping enough?
I have switched from nortriptyline to desipramine because I felt that I was stuck with an unacceptable improvement. Things get a little complicated because I only recently discontinued prazosin, which apparently was "polluting" my response to desipramine. Perhaps the prazosin was limiting my response to nortriptyline as well. If I get stuck again, I would opt for doing a very quick switch back to nortriptyline as an experiment.
I try not to leave any stone unturned.
- Scott
Posted by Bob on March 1, 2016, at 0:42:58
In reply to Re: Parnate » Bob, posted by SLS on February 29, 2016, at 16:58:39
> > My current regimen is getting slowly more complex. I currently take the following:
>
> > Nortriptyline 200mg (75mg 2x per day and 50mg at bedtime)
>
> For most people, this is too much. If you haven't already checked your blood level, you can do that and get a good idea if a dosage adjustment is necessary. The reason I mention this is because nortriptyline has a very real therapeutic window. More is not better. If the dosage of nortriptyline is too high, it stops working.
>Yes, I've had my blood levels taken many times. The recent few times have been between 130 and 147 mcg/L. I'm not sure where the level would be the best for me but these values are within the accepted therapeutic range of 50-150 mcg/L.
> Have you ever tried desipramine? I am doing better on desipramine than I had been doing on nortriptyline. I find that it gives me more mental energy. I get more things done. I take 300 mg/day. I am optimistic that I will respond more robustly to desipramine than to nortriptyline. Stay tuned...
>I have not tried desipramine and would not rule it out. My doctor seems to think it is a harsher med in his experience. Still, I'd consider it in place of nortriptyline.
> > Brintellix 10mg (5mg 2x per day)
>
> I have no personal experience with this drug, and have not seen enough anecdotes to have an opinion. I have had experience with Viibryd, and have a doctor who has used it quite a bit. I would recommend talking to your doctor about it. Compared to Britellix, Viibryd is a more potent serotonin reuptake inhibitor. Viibryd is also a 5-HT1a partial agonist (like aripiprazole and buspirone), while Brintellix is a full agonist. I don't know for sure what the significance of this is, but my guess is that a partial agonist would act more like a stabilizer of serotonin activity.
>Yes, it's difficult to say exactly what the advantages of partial over full agonists may be. I wasn't really aware Viibryd was a potent partial agonist. Seems worth considering for sure. When you say you have experience with it does that mean you've taken it yourself or is it second-hand experience?
> > Aripiprazole 4mg (2mg 2x per day)
>
> I would explore higher dosages. For me, the sweet-spot is 10 mg/day. I lose the antdepressant effect at 5 mg/day. However, my depression is of an unusual type of bipolar disorder.
>God knows my depression is of an unusual type. How did you arrive at 10mg being your sweet spot? Did you ever take it at higher levels?
> > Lithium 112.5mg at bedtime
>
> Why not 300 mg/day (150 mg x 2)?I'm taking the Eskalith CR 450mg pill. I could divide that in half for 225mg however it seems to slow me down at higher doses. I just take a quarter so that I have "trace" amounts of lithium present. Probably not doing much buy I'm taking it nonetheless.
>
> > Lithothyronine T3 25mcg in the morning
>
> Does it help depression? What about thyroxine T4?Like anything else I've taken I got a real nice boost as an adjunct to my ADs and then that eventually faded somewhat -- still the T3 seems to help a little. My doctor and the literature seem to concentrate on T3 more than T4.
>
> > Pramipexole .375mg (.125mg 3x per day)
>
> I'm not a big fan of full agonists of dopamine receptors. They usually don't help that much or for that long. I have seen two exceptions, though.I realize that pramipexole might not be the best approach but I'm running out of options and suffer with significant anhedonia even on all these meds. There aren't a lot of drugs out there addressing this for me. Pramipexole tends to be a little edgy and may poop out completely on me but for now I'm sticking with it.
>
> > I assumed that Parnate might have to be taken multiple times per day to stabilize blood levels.
>
> I don't think there are any blood levels to stabilize. Parnate is more of a hit-and-run drug. Still, I make it a habit of dosing three times a day. I would be just as comfortable dosing twice a day.
>
> > Seems like the levels would get pretty low with a once per day dosing and a 2-hr half-life. I've found for some reason that for me it seems even for meds with a relatively long half-life it helps to dose more than once per day. This is especially true when starting a new medicine.
>
> The first time I tried Parnate, I needed to take it 3 or 4 times a day to help reduce postural hypotension.
>
> > I'm not getting a super-robust response from what I'm now taking and everything I take eventually fades in effectiveness. I recently added small amounts of pramipexole which is actually helping somewhat. MAOIs are the only class of drug I haven't tried to date and there is suggestions that they are more suited to atypical depression (which I seem to have) and are less prone to losing effectiveness over time. Then again I've seen people on this very forum who claim to have lost effect with MAOIs.
>
> It is my impression that Nardil is more likely to poop-out than Parnate. It happens, though, that someone will respond well to Nardil for many years and be completely unresponsive to Parnate.
>
> > I think I saw recently where you said if you don't achieve remission with your current regime you may try an SNRI?
>
> I have never combined Effexor or Cymbalta with a therapeutic dosage of nortriptyline or desipramine.
>
> > Is the Parnate + nortriptyline not helping enough?
>
> I have switched from nortriptyline to desipramine because I felt that I was stuck with an unacceptable improvement. Things get a little complicated because I only recently discontinued prazosin, which apparently was "polluting" my response to desipramine. Perhaps the prazosin was limiting my response to nortriptyline as well. If I get stuck again, I would opt for doing a very quick switch back to nortriptyline as an experiment.
>
> I try not to leave any stone unturned.I too would like to leave no stone unturned but it is quite difficult to transition on and off medicines.
>
>
> - Scott
>
Posted by SLS on March 1, 2016, at 8:23:19
In reply to Re: Parnate, posted by Bob on March 1, 2016, at 0:42:58
> > > My current regimen is getting slowly more complex. I currently take the following:
> > >
> > > Nortriptyline 200mg (75mg 2x per day and 50mg at bedtime)
> > For most people, this is too much. If you haven't already checked your blood level, you can do that and get a good idea if a dosage adjustment is necessary. The reason I mention this is because nortriptyline has a very real therapeutic window. More is not better. If the dosage of nortriptyline is too high, it stops working.
> Yes, I've had my blood levels taken many times. The recent few times have been between 130 and 147 mcg/L.Those are ideal numbers. You are likely a rapid metabolizer of CYP450 2D6. Be careful when adding Prozac, Paxil, or Wellbutrin. These drugs will cause the blood level of nortriptyline to rise sharply.
> > Have you ever tried desipramine? I am doing better on desipramine than I had been doing on nortriptyline. I find that it gives me more mental energy. I get more things done. I take 300 mg/day. I am optimistic that I will respond more robustly to desipramine than to nortriptyline. Stay tuned...
> I have not tried desipramine and would not rule it out. My doctor seems to think it is a harsher med in his experience.
It is - at first. Perhaps being harsher on the brain is a good thing in your case. Back in the old days, it was recognized that someone who responds to desipramine might not respond to nortriptyline, and vice versa.
> > > Brintellix 10mg (5mg 2x per day)
> > I have no personal experience with this drug, and have not seen enough anecdotes to have an opinion. I have had experience with Viibryd, and have a doctor who has used it quite a bit. I would recommend talking to your doctor about it. Compared to Britellix, Viibryd is a more potent serotonin reuptake inhibitor. Viibryd is also a 5-HT1a partial agonist (like aripiprazole and buspirone), while Brintellix is a full agonist. I don't know for sure what the significance of this is, but my guess is that a partial agonist would act more like a stabilizer of serotonin activity.
> Yes, it's difficult to say exactly what the advantages of partial over full agonists may be. I wasn't really aware Viibryd was a potent partial agonist. Seems worth considering for sure. When you say you have experience with it does that mean you've taken it yourselfYes. I found it to be remarkably clean with respect to side effects. I responded to it in the third week. Unfortunately by the fifth week, I lost it. I find it meaningful when a drug can budge my brain at all.
> > > Aripiprazole 4mg (2mg 2x per day)
> > I would explore higher dosages. For me, the sweet-spot is 10 mg/day. I lose the antdepressant effect at 5 mg/day. However, my depression is of an unusual type of bipolar disorder.
> God knows my depression is of an unusual type. How did you arrive at 10mg being your sweet spot? Did you ever take it at higher levels?I started Abilify at 20 mg/day. It helped. It still does. However, I found that at 20 mg/day, I had a mild-to-moderate amount of blunting of cognition and affect, along with some brain fog. Eventually, I reduced the dosage as an experiment and found that these side effects disappeared. 10 mg/day worked. 5 mg/day did not.
> > > Lithium 112.5mg at bedtime
> >
> > Why not 300 mg/day (150 mg x 2)?
>
> I'm taking the Eskalith CR 450mg pill. I could divide that in half for 225mg however it seems to slow me down at higher doses. I just take a quarter so that I have "trace" amounts of lithium present. Probably not doing much buy I'm taking it nonetheless.The folks at Harvard / Massachusetts General found that low dosage lithium was represented by a dosage range of 300-600 mg/day, with the average effective dosage being 450 mg/day. For me, 450 mg/day is too much. I experience apathy, flat affect, passivity, and an overall worsening of depression. I've experimented with lower dosages and found that I felt better at 300 mg/day.
> > > Lithothyronine T3 25mcg in the morning
> > Does it help depression? What about thyroxine T4?
> Like anything else I've taken I got a real nice boost as an adjunct to my ADs and then that eventually faded somewhat -- still the T3 seems to help a little. My doctor and the literature seem to concentrate on T3 more than T4.T3 has been the thyroid hormone most studied, primarily because it was chosen first to be investigated. I think the choice was mostly arbitrary. Personally, my depression is severely exacerbated by T3 (Cytomel). T4 was a completely different drug for me. It helped - just not enough. You might want to get your TSH checked and make sure that it is below 2.0 mIU/L.
> > > Pramipexole .375mg (.125mg 3x per day)> > I'm not a big fan of full agonists of dopamine receptors. They usually don't help that much or for that long. I have seen two exceptions, though.
> I realize that pramipexole might not be the best approach but I'm running out of options and suffer with significant anhedonia even on all these meds.Anhedonia has been problematic for me, too. I found SNRIs to be better than SSRIs to treat this. I also found Nardil to be better for anhedonia than Parnate. I stay with Parnate because, when added to TCA, it is more forgiving with respect to the side effects of hypotension, hyperhidrosis, and urinary retention.
> > I try not to leave any stone unturned.
> I too would like to leave no stone unturned but it is quite difficult to transition on and off medicines.The logical move might be to switch from nortriptyline to desipramine now and leave everything else in place. I would suggest titrating to a target of 200 mg/day. More severe cases indicate increasing the dosage to 300 mg/day. You don't need a washout period. I don't necessarily suggest this, but I have switched by skipping a day of nortriptyline and starting desipramine the next morning at 50 mg/day.
- Scott
Posted by babbler20 on March 1, 2016, at 19:36:38
In reply to Parnate, posted by Bob on February 28, 2016, at 23:37:00
Welp, that would explain why getting off of it was like getting off heroin and I ended up in the hospital and having extreme back pain for like 3 months.
Posted by Bob on March 1, 2016, at 22:57:46
In reply to Re: Parnate, posted by babbler20 on March 1, 2016, at 19:36:38
> Welp, that would explain why getting off of it was like getting off heroin and I ended up in the hospital and having extreme back pain for like 3 months.
Are you talking about getting off Parnate?
Posted by SLS on March 2, 2016, at 8:01:59
In reply to Re: Parnate » babbler20, posted by Bob on March 1, 2016, at 22:57:46
> > Welp, that would explain why getting off of it was like getting off heroin and I ended up in the hospital and having extreme back pain for like 3 months.
>
>
> Are you talking about getting off Parnate?I am similarly confused.
- Scott
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.