Catwoman

Increasing Zoloft / sertraline to 200 mg

34 posts in this topic

6 hours ago, browri said:

@Catwoman I actually have an idea that you might be interested in. And @mikl_pls check my work on this one because I know I can count on you ;)

Clomipramine and fluvoxamine may both be the answer here if you're finding that anxiety and OCD-like symptoms are difficult to treat along with your depression:

https://www.ncbi.nlm.nih.gov/pubmed/8666564

Clomipramine (as a molecule hereby referred to as CMI) is extensively metabolized by CYP1A2 to desmethylclomipramine (DCMI). While CMI is a strong serotonin reuptake inhibiter, DCMI is mostly a norepinephrine reuptake inhibitor. CMI has a shorter half-life ranging from 19 to 37 hours while DCMI ranges from 54 to 77. This means clomipramine as a whole at steady state has a higher affinity for the norepinephrine transporter.

Luvox happens to be a strong CYP1A2 inhibitor (as well as an SSRI of course) and by taking it with clomipramine, you can increase the levels of CMI in your system and this fluvoxamine/clomipramine combination would be a much stronger serotonin reuptake inhibitor combined with the potency of fluvoxamine's sigma receptor properties.

In fact, Stephen Stahl goes into this combination in some detail in his Essential Psychpharmacology PDR.

Thoughts?

Great article! The only thing I foresee is increased levels of clomipramine from coadministration with fluvoxamine, so low doses of clomipramine would need to be used, and probably even routine blood work to monitor the levels of clomipramine to make sure they're within therapeutic range and not in toxic range.

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Posted (edited)

17 hours ago, mikl_pls said:

Apparently, they've used up to 400 mg sertraline before in treatment-refractory patients.
https://www.ncbi.nlm.nih.gov/pubmed/16426083

Yes, I found that article earlier. I've been on 250 mg for about two weeks, but it seemed to make my intrusive thought(s) more frequent....Not sure if 400 mg does the trick when 20 mg of ecitalopram and 200 mg of fluvoxamine did...
I think I could handle 400 mg (though I should not take it before bed, because it irritates my stomach and esophagus) but I don't think my doctor would approve.

I wonder about the role of those sigma recepters, since sertraline is an antagonist and fluvoxamine and fluoxetine are angonists at that site.

Edited by Catwoman

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7 hours ago, mikl_pls said:

Great article! The only thing I foresee is increased levels of clomipramine from coadministration with fluvoxamine, so low doses of clomipramine would need to be used, and probably even routine blood work to monitor the levels of clomipramine to make sure they're within therapeutic range and not in toxic range.

I found a Dutch article on that combo:

http://www.dejongepsychiater.nl/onderzoek/842-fluvoxamine-clomipramine-ocd-depressie

Maybe Google Translate will work. The writers of the article aren't quite sure if there's enough clinical evidence of the addition of clomipramine to fluvoxamine.
But they do think it can be useful for refractory OCD....

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3 hours ago, Catwoman said:

I found a Dutch article on that combo:

http://www.dejongepsychiater.nl/onderzoek/842-fluvoxamine-clomipramine-ocd-depressie

Maybe Google Translate will work. The writers of the article aren't quite sure if there's enough clinical evidence of the addition of clomipramine to fluvoxamine.
But they do think it can be useful for refractory OCD....

Makes me wonder what the difference between combining clomipramine and fluvoxamine and just administering supratherapeutic doses of fluvoxamine is (> 300 mg/day).

As for the interaction between CYP1A2, luckily most of the population are rapid CYP1A2 metabolizers.

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17 hours ago, Savannah said:

There are many books by Stahl including several that say "Essential Psychopharmacology ".

 

which o you recommend?

The one I have is the 5th Edition of his Prescriber's Guide, but the 6th Edition just came out. I've gotta get it.

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Posted (edited)

19 hours ago, mikl_pls said:

Have you tried any antiglutamatergic drugs?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4425334/

http://www.medscape.org/viewarticle/778119_8

Lamotrigine, topiramate, zonisamide, memantine, amantadine, pregabalin, riluzole, N-acetylcysteine, stimulants, lithium, etc.

Yes and no....
I asked for memantine when I saw the pdoc in January but he said it was too experimental and too expensive. He said I should ttry the usual treatments and since I've already been on SSRI's he said I should try clomipramine or even adding quetiapine  to sertraline (which I don't want to take because it mostly blocks histamine). I did try NAC at high dosages (I wasn't on sertraline at that moment) and for a few weeks it seemed to help with the intrusive thought, but when I started the new bottle I didn't feel anything from it anymore. I'm not sure yet if the glumamatergic route is for me...

Edited by Catwoman

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Looking at your signature and the conversation we've had thus far, I still think an antipsychotic would do you good. intrusive thoughts aren't really helped well with SSRIs and they can even make it worse if it isn't under control. Luvox and loxapine would be a good combo as would clomipramine and loxapine. Saphris did a really good job of quieting my thoughts taking just 2.5mg at night and not twice daily like the dosing suggests. Olanzapine also did a good job at quieting my thoughts but the metabolic side effects aren't worth the trial in my mind.

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I had an appointment with my psychologist today (been seeing her for a year now) I also did my mindfulness meditation course with her. I have one session left, but she's willing to refer me to a psychiatrist.  She actually thought it would be much more helpful for me to have a pdoc to discuss medication once in a while instead of going through more therapy.


The thing is: I'm not looking forward to be put on a waitinglist, then sit in a doc's waiting room for hours, explain the full story and then he/she will offer Seroquel or Risperdal. That's not what I want. I want go over the various options and I rather do this on the phone or by e-mail (which is more time efficient).  Some doctors may not like patients who read about pharmacology and some may think I'm a know-all, but I just want to talk more indepth and come up with a treatment that is not 'general'. 

Oh well, I'm going back to my general doctor and maybe I'll them him this. I'm leaning towards Prozac and I think he's willing to let me go on it.

What worries me the most about trying another SSRI is that I'm afraid my brain is now adapted to medication like this and not sensitive to the method of action. 
I'm actually really scared that nothing else will work because I've been on Lexapro so long and this med altered something permanently.....:(:(

 

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