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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by lisamb on September 20, 2001, at 4:46:41
I did a search but couldn't find anything that exactly answered my questions here. I'm currently on 75mg of zoloft, 30 mg of ritalin and 15mg of ambien per day. My therapist said some months ago after my ADD diagnosis that she didn't think zoloft was right for me - but I seemed to stabilise and so we left things as-is. I've been in a downward slump over the past few weeks, though, and now we're revisiting the issue. She wants me to switch across to Ethipramine (local generic name for Imipramine) - she believes it's more suited to the ADD/depression dx and will help more effectively with the mood swings..??
I could really use some input on the process of switching across from an SSRI to a tricyclic-- how easy is it.. Zoloft was the first AD I was put on and so I don't have any experiences with any others. I'm anxious about coping with the tapering off period, and dealing with new side effects.. I'm on the thin side already, but I'm obsessing about the possibility of putting on weight with the Ethipramine. I DON'T want this to happen. My therapist knows it's a "thing" for me and deliberately left it out when she was listing the potential side effects for me.
Sorry not very clear... hoping for any input/advice/experience.
Thanks so much
Lisa
Posted by SalArmy4me on September 20, 2001, at 10:45:08
In reply to Experiences w/ switching from SSRI to tricyclic?, posted by lisamb on September 20, 2001, at 4:46:41
Desipramine has less side-effects and has been studied more for ADD than imipramine.
Wilens, Timothy E. MD et al. Six-Week, Double-Blind, Placebo-Controlled Study of Desipramine for Adult Attention Deficit Hyperactivity Disorder. American Journal of Psychiatry. 153(9):1147-1153, September 1996:
"...The magnitude of the reduction in ADHD symptoms with desipramine is similar to that reported in adults with ADHD who received robust doses of methylphenidate. Like methylphenidate, desipramine treatment resulted in significant reductions in the broad categories of inattention, impulsivity, and hyperactivity. The current findings with desipramine, together with previously reported findings with psychostimulants, support the notion that pharmacological agents effective in reducing ADHD symptoms appear to operate through their catecholaminergic properties..."
Posted by pellmell on September 20, 2001, at 11:33:40
In reply to Experiences w/ switching from SSRI to tricyclic?, posted by lisamb on September 20, 2001, at 4:46:41
Lisa,
I've never taken a tricyclic before, but I do have a tip for coming off of Zoloft.
As you taper down, you'll probably experience some withdrawal side-effects. Mine were pretty mild (and actually kinda trippy-cool): staccatto vision and hearing, moments of dizziness. I only felt them when I was moving (getting up out of a chair, walking down the street) and they came on strongest when I was tired. Anyway, you almost certainly will have to deal with some degree of withdrawal.
When it became especially hard for me to deal with, though, I found that taking a very small amount of Zoloft cleared up the symptoms within a few minutes to an hour. I'd recommend cutting a few 25mg pills in half and carrying them with you at all times. If you don't have any pills this small, ask your doc for some samples or try to split a 50mg pill into quarters with a sharp knife. Even after the end of your tapering-off period, I'd keep some of these pill-chips with you. I remember feeling that dizziness again a few days after taking my "last" pill, even though I'd felt completely fine for the two days before.
Good luck, and tell us how it goes.
-pm
Posted by Jane D on September 20, 2001, at 13:16:54
In reply to Experiences w/ switching from SSRI to tricyclic?, posted by lisamb on September 20, 2001, at 4:46:41
Lisa -
I'm not sure you will have to deal with any withdrawal from Zoloft. I didn't. This is a problem with the short half life SSRI's such as Paxil and Effexor. Also most, if not all, tricylics act on serotonin. Switching from one SSRI to another prevents withdrawal so I would think that switching to a tricylic might have the same affect. - Jane
Posted by Cam W. on September 20, 2001, at 17:38:23
In reply to Re: Experiences w/ switching from SSRI to tricyclic? » lisamb, posted by Jane D on September 20, 2001, at 13:16:54
Jane - I have seen withdrawl symptoms with Zoloft™ (sertraline) and Luvox™ (fluvoxamine), as well. It seems that it happens to people who metabolize these drugs more quickly. These people possibly have multiple copies of the cytochrome-P450-2D6 gene. I believe that this occurs in about 10% of people of European descent (I could be wrong). This would explain why some people have extreme difficulty withdrawing from Effexor, as well.
- Cam
Posted by Jane D on September 20, 2001, at 20:19:02
In reply to Re: Experiences w/ switching from SSRI to tricyclic? » Jane D, posted by Cam W. on September 20, 2001, at 17:38:23
Cam - Just curious here. What happens when switching to a tricyclic if you go directly from one to the other?
Regarding quick metabolizers having more withdrawal symptom could the 2D6 inhibition by Prozac be why it seems to work so well in preventing withdrawal? Or would the timing of that be all wrong?
Jane - who didn't even know what the CYP450 system was before she started reading your posts.
Posted by stjames on September 20, 2001, at 21:24:39
In reply to Experiences w/ switching from SSRI to tricyclic?, posted by lisamb on September 20, 2001, at 4:46:41
I don't see a reason to taper down, there are no contraindications, such as with the MAOI's. The TCA will help with any effects you have with stoping the SSRI.
I've gone right from SSRI to TCA, and vice versa.
Do keep in mind how long the SSRI remains active vs. how fast you raise the TCA dose, and while there is still SSRI active don't rasie the TCA dose too quickly.James
Posted by Cam W. on September 20, 2001, at 21:37:14
In reply to Re: Experiences w/ switching from SSRI to tricyclic? » Cam W., posted by Jane D on September 20, 2001, at 20:19:02
Jane - There should be no problem switching directly from an SSRI with a short half-life to a "serotonergic" TCA. That is, there should be no problem switching from Zoloft™ (sertraline) to Ethipramine™ (imipramine - Tofranil™).
There may have been some problem (mostly theoretical) in switching from Prozac™ (fluoxetine) to Ethipramine, as Prozac inhibits (stops the product of metabolizing enzymes) the cytochrome-P450-2D6 enzyme system AND has a very long half-life. Prozac would have slowed the CYP-2D6-enzyme from being produced, and since Ethipramine (Tofranil) is mainly metabolized by the 2D6-enzyme, Ethipramine would not be metabolized as readily as it would have, if the Prozac weren't present. The Prozac has a long elimination half-life (4 to 6 days at steady-state), so it lasts a long time in the body; thus may be able to artificially increase Ethipramine levels.
Having said that, even this interaction probably would not be significant, in the real world. The CYP-2D6-enzyme system is usually in a state of overabundance in the liver and, even after a short term inihibition by Prozac, there should be enough of the enzyme around to metabolize the Ethipramine.
Unless of course, you were a "poor metabolizer" (ie. had lower than normal levels of the CYP-2D6 enzyme; like 5% of the caucasian population).
Also, if you took Prozac and Ethipramine together, you would be at increased risk of serotonin syndrome, as well as increased risk of Ethipramine side effects (eg tachycardia, dry mouth, etc.). You may have to take a lower than normal dose of Ethipramine to avoid the TCA side effects.
Basically, this is another reason to be treated by a doctor. Instead of doing blood tests for Ethipramine, the doctor would watch for signs of TCA toxicity and serotonin syndrome (and hopefully also tell you what to watch for). Actually, most docs wouldn't put a patient on a TCA and Prozac, unless absolutely necessary, because it is a pain-in-the-ass to monitor.
To answer your first question: no it should be no problem switching from Zoloft to Ethipramine. Zoloft doesn't inhibit CYP-2D6 to any great extent and has a relatively short half-life (approx. 60h.).
Now, don't even ask me about going from an SSRI to a "noradrenergic" TCA (theoretically it is a problem with SSRIs; and may be with regular Effexor™ - venlafaxine).
Hopefully, I answered your second question, as well. The reason quick metabolizers would use Prozac to wean from Effexor (or Zoloft or Paxil or Luvox) is because of it's very long half-life. When you inhibit an enzyme system, there is less enzyme around to metabolize the drug. Quick metabolizers would have an overabundance of enzyme around.
I really hope that you can make something out of this mess. I really did try to be clear. - Cam
Posted by SLS on September 21, 2001, at 1:15:31
In reply to Experiences w/ switching from SSRI to tricyclic?, posted by lisamb on September 20, 2001, at 4:46:41
> I did a search but couldn't find anything that exactly answered my questions here. I'm currently on 75mg of zoloft, 30 mg of ritalin and 15mg of ambien per day. My therapist said some months ago after my ADD diagnosis that she didn't think zoloft was right for me - but I seemed to stabilise and so we left things as-is. I've been in a downward slump over the past few weeks, though, and now we're revisiting the issue. She wants me to switch across to Ethipramine (local generic name for Imipramine) - she believes it's more suited to the ADD/depression dx and will help more effectively with the mood swings..??
>
> I could really use some input on the process of switching across from an SSRI to a tricyclic-- how easy is it.. Zoloft was the first AD I was put on and so I don't have any experiences with any others. I'm anxious about coping with the tapering off period, and dealing with new side effects.. I'm on the thin side already, but I'm obsessing about the possibility of putting on weight with the Ethipramine. I DON'T want this to happen. My therapist knows it's a "thing" for me and deliberately left it out when she was listing the potential side effects for me.
>
> Sorry not very clear... hoping for any input/advice/experience.
>
> Thanks so much
> LisaHi Lisa.
If you are ADD, and need to address the behavioral (as opposed to the attentional) aspects of your illness, a tricyclic is often effective; imipramine being the one most often chosen. If your doctor thinks that desipramine would work as well, it is not as liable to produce weight-gain. However, I'm not convinced that it is as good as imipramine for ADD.
If you are trying to address depression, it might make sense to first try increasing the Zoloft if you had previously been happy with it.
If you have not responded well to the other SSRIs, it might make sense to simply add a tricylic to your Zoloft. You can always try to discontinue the Zoloft once you feel the depression has been controlled. However, an SSRI and a tricyclic can sometimes work when neither alone produces an adequate response. The one tricyclic you would probably want to stay away from is clomipramine (Anafranil). Clomipramine, like Zoloft, is a serotonin reuptake inhibitor. Some people react to such combinations with something called the serotonin syndrome. I'll defer to someone else to itemize the symptoms if necessary.
Just to throw out a few more ideas...
If depression is the only feature of your illnesses needing treatment, it probably makes sense to first increase the Zoloft.
If your doctor feels strongly that a tricyclic by itself will treat everything, then switch.
If your depression has previously failed to respond to other SSRIs, and you are still receiving some benefit from Zoloft, you might be better off continuing it and not risk becoming completely non-responsive to it in the future. You can try increasing the dosage of Zoloft first and then add your tricylic once you determine if the increased dosage of Zoloft is of any benefit. I doubt you would need more than two weeks to see if it helps.
If you haven't already tried Effexor, you should keep it in mind as it has shown efficacy in both depression and ADD (behavioral symptoms).
Good luck.
- Scott
Posted by pellmell on September 21, 2001, at 11:18:18
In reply to Re: Experiences w/ switching from SSRI to tricyclic? » Jane D, posted by Cam W. on September 20, 2001, at 17:38:23
Thanks, Cam...this could explain why I even go through withdrawal coming off of Prozac. The symptoms I experience are pretty minor, but definitely there.
Could this also explain why I needed 200mg of Zoloft (+Li) to feel any effect? And why Effexor doesn't seem to be doing much even at 225mg?
Oh, and I've come up with another (maybe farfetched) theory: this could also explain my sensitivity to Wellbutrin. Perhaps my body creates a lot of an active activating bupropion metabolite very quickly, leading to a quick case of the jitters. 150mg Wellbutrin SR/day seems to be plenty for me.
Do you know off hand if Celexa is metabolized through this same pathway? If you don't, I'll look it up on rxlist.com sometime. I'm asking 'cause I'm considering asking my pdoc if I can give it a try if things don't work out on my current Effexor/Wellbutrin mix.
Thanks for putting up with my recent ramblings,
-pm
> Jane - I have seen withdrawl symptoms with Zoloft™ (sertraline) and Luvox™ (fluvoxamine), as well. It seems that it happens to people who metabolize these drugs more quickly. These people possibly have multiple copies of the cytochrome-P450-2D6 gene. I believe that this occurs in about 10% of people of European descent (I could be wrong). This would explain why some people have extreme difficulty withdrawing from Effexor, as well.
>
> - Cam
Posted by Jane D on September 24, 2001, at 12:13:03
In reply to Re: Experiences w/ switching from SSRI to tricyclic? » Jane D, posted by Cam W. on September 20, 2001, at 21:37:14
> There may have been some problem (mostly theoretical) in switching from Prozac (fluoxetine) to Ethipramine, as Prozac > Having said that, even this interaction probably would not be significant, in the real world. The CYP-2D6-enzyme system is usually in a state of overabundance in the liver and, even after a short term inihibition by Prozac, there should be enough of the enzyme around to metabolize the Ethipramine.
>
> Unless of course, you were a "poor metabolizer" (ie. had lower than normal levels of the CYP-2D6 enzyme; like 5% of the caucasian population).I had been wondering about the real life significance of these interactions. Does this mean, for example, that unless you were already a poor metabolizer you would not need to worry about your Prozac disabling your Codeine? And is the inhibition dose dependant?
> Hopefully, I answered your second question, as well. The reason quick metabolizers would use Prozac to wean from Effexor (or Zoloft or Paxil or Luvox) is because of it's very long half-life. When you inhibit an enzyme system, there is less enzyme around to metabolize the drug. Quick metabolizers would have an overabundance of enzyme around.So. Let's see if I understand this. The withdrawal symptoms are caused by the rapid reduction of serotonin levels. The serotonin levels fall more rapidly in quick metabolizers causing worse symptoms. Replacing a drug like Effexor with Prozac could work in 2 ways. Directly by its SSRI properties - fully replacing the SSRI properties of the Effexor at first, and then, because of its long half life, allowing the serotonin levels to fall slowly. Or, theoretically, by inhibiting the 2D6 enzyme and thereby slowing down the metabolism of the Effexor so that its own SSRI properties are withdrawn more slowly. And, if this were true, then taking Effexor with, or switching, to a drug that induced 2D6 would make the withdrawal that much worse. Except that in actual practice this would not happen because the inhibition /induction of the enzyme is not significant when compared to the total amount of the enzyme present?
>
> I really hope that you can make something out of this mess. I really did try to be clear. - CamYou were clear. Of course I had to read it a couple of times :-) I also tried to be clear. Oh well!
Jane
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