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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 4 of 4. This is the beginning of the thread.
Posted by scleme1 on September 14, 2015, at 11:13:01
I'll try to be brief. I was on 40mg Paxil from 2000 to 2011. Switched to Zoloft 200mg in 2011 due to some weight gain and breakthrough anxiety. For the past couple years, I've been struggling with night-time inner nervousness/anxiety that I now attribute to the Zoloft. I think it's a mild case of akathisia, but not 100% sure. Could just be that the Zoloft is messing with my dopamine and my brain doesn't like that.. I've tried Mirapex, Inderal, Ambien, etc. to alleviate the waves of adrenaline I deal with on an almost nightly basis, but the only way I've been able to get through it is 1mg clonazepam each night. Knocks me right out, but I don't want to take clonazepam daily because of dependence.
So...with some reluctance (because the Zoloft works so well for my OCD and anxiety)...my doc is switching me to 200mg Luvox CR. 100mg in the morning, 100mg in the evening. I don't want to get back on the med merry-go-round, but I also know that I don't want to dread bedtime each night because of the nervousness. Doc offered to increase the dose of Mirapex before switching (from .125 to .25), but I hate the idea of treating a side effect with another med.
Also of note: I use an ecigarette, and the nicotine changes the bioavailability of the Luvox., which is something else to consider.
Anyone have any insight on Luvox CR? Anyone made the switch from Sertraline to Luvox CR? Any help/input would be much appreciated.
Posted by SLS on September 14, 2015, at 17:06:01
In reply to Switching from Sertaline to Luvox CR. Thoughts??, posted by scleme1 on September 14, 2015, at 11:13:01
Generally speaking, there is no better SSRI for OCD than fluvoxamine. I'm sure you know that already. I don't know if this is relevant to clinical observations, but fluvoxamine is unique among SSRIs in its potency as a sigma-1 receptor agonist. I am a little surprised that Zoloft worked well for you with respect to OCD and anxiety. I guess that just reinforces the notion that one cannot be so categorical as to where to place drugs clinically or physiologically.
I have read a few articles suggesting that fluvoxamine works for anxiety disorders, but it is not approved for this use by the U.S. FDA.
http://www.ncbi.nlm.nih.gov/pubmed/18568110
You may need to consider polypharmacy. Phidippus is pretty good with OCD. He has some personal experience with several different treatment strategies. I believe he has reported success with the use of vortioxetine (Brintellix) at a dosage of 40 mg/day.
Have you tried one of the atypical antipsychotics? 5-HT2a receptor antagonism might be helpful. Nortriptyline also does this. I don't know of anyone who has combined nortriptyline with a SSRI for OCD, but it might be worth doing a quick literature search.
http://www.ncbi.nlm.nih.gov/pubmed/9786103
Perhaps combining potent SRI with NRI would work in a manner similar to clomipramine, but without the anticholinergic side effects. Also, it may be that, because of its 5-HT2a receptor antagonism, nortriptyline confers some anxiolytic effects without needing the dopamine receptor antagonism of an antipsychotic.
As usual, I'm just thinking out loud.
At this juncture, you can either continue with sertraline and make dosage adjustments and/or add other agents, or switch from sertraline to a different treatment strategy.
It appears that fluvoxamine can produce either initial somnolence or insomnia. I don't know how persistent these side effects are. I hope they are only startup effects. I have never tried fluvoxamine.
One step at a time, I guess.
Good luck.
- Scott
Posted by Scleme1 on September 14, 2015, at 20:22:22
In reply to Re: Switching from Sertaline to Luvox CR. Thoughts?? » scleme1, posted by SLS on September 14, 2015, at 17:06:01
Scott - thanks for the response. I appreciate your input. I do hope that Phiddipus chimes in, as I would love to hear how he is doing on the Brintellix. I'll try to answer a few of your ?'s below.
>
> I am a little surprised that Zoloft worked well for you with respect to OCD and anxiety.Quite honestly, I'm not even sure the meds are doing much for me anymore. I've only ever been on the 2 SSRI's - Paxil and Zoloft. I've been on them so long, I don't remember what it was like to be without them. It seems like they both have worked relatively well, but I feel like Paxil did work a little better for me. On the Zoloft, I feel like I get agitated a little easier, and of course - I'm having this terrible insomnia/agitation/akathisia side effect. I don't remember ever having anything like that while on the Paxil.
>
> You may need to consider polypharmacy. Phidippus is pretty good with OCD. He has some personal experience with several different treatment strategies. I believe he has reported success with the use of vortioxetine (Brintellix) at a dosage of 40 mg/day.It's funny you mention Brintellix. I have a friend that is a nurse practitioner, and she recently suggested Brintellix to me. She's been seeing great results using it for anxiety at her office.
>
> Have you tried one of the atypical antipsychotics? 5-HT2a receptor antagonism might be helpful. Nortriptyline also does this. I don't know of anyone who has combined nortriptyline with a SSRI for OCD, but it might be worth doing a quick literature search.I haven't tried any atypical's yet. I'm a little worried about full blown akathisia with the atypical's, since that is the very thing I'm trying to avoid and the reason I'm abandoning the Zoloft.
>
> At this juncture, you can either continue with sertraline and make dosage adjustments and/or add other agents, or switch from sertraline to a different treatment strategy.I think I'm going to give Luvox CR a try for a few weeks. My doctor is also willing to let me try clomipramine, so that's another option. She has had great success combining low dose clomipramine with several of the other SSRI's.
>
> It appears that fluvoxamine can produce either initial somnolence or insomnia. I don't know how persistent these side effects are. I hope they are only startup effects. I have never tried fluvoxamine.I've read reports of both - somnolence and insomnia, but like you suggested...it looks like those side effects subside pretty quickly.
>
> One step at a time, I guess.One step at a time indeed. Thankfully, there are hundreds of options out there for me to try. It's just a little scary taking the first few steps away from something you've known for so long.
Posted by SLS on September 14, 2015, at 23:00:10
In reply to Re: Switching from Sertaline to Luvox CR. Thoughts?? » SLS, posted by Scleme1 on September 14, 2015, at 20:22:22
> Scott - thanks for the response. I appreciate your input. I do hope that Phiddipus chimes in, as I would love to hear how he is doing on the Brintellix. I'll try to answer a few of your ?'s below.
> > I am a little surprised that Zoloft worked well for you with respect to OCD and anxiety.
> Quite honestly, I'm not even sure the meds are doing much for me anymore. I've only ever been on the 2 SSRI's - Paxil and Zoloft. I've been on them so long, I don't remember what it was like to be without them. It seems like they both have worked relatively well, but I feel like Paxil did work a little better for me. On the Zoloft, I feel like I get agitated a little easier, and of course - I'm having this terrible insomnia/agitation/akathisia side effect. I don't remember ever having anything like that while on the Paxil.Zoloft = sigma-1 antagonist = pro-akathisia
Luvox = sigma-1 agonist = anti-akathisiaI think the chances of your having akathisia with Luvox are pretty small. We'll see, I guess.
> I think I'm going to give Luvox CR a try for a few weeks.
You really need to think in terms of months with OCD - not weeks. With SSRIs, there is a tendency to need higher dosages than those that are used for depression. It also takes more time to see a response emerge.
> My doctor is also willing to let me try clomipramine, so that's another option. She has had great success combining low dose clomipramine with several of the other SSRI's.
That's very interesting.
- Scott
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