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Cymbalta + Strattera ?


Guest Sleepyhead

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Guest Sleepyhead

I've been taking Cymbalta 60mg daily for 6 months. It has helped my chronic depression greatly - increased my motivation etc. My p-doc previously thought I may be ADD, so we had tried Adderall then Concerta with limited success (I wasn't taking an AD at that time).

Although I was feeling MUCH better on the Cymbalta, I still wasn't getting much done. I went to see a psychiatrist, who diagnosed me as Adult ADD. Since I felt like the NE reuptake inhibition of Cymbalta was what helped me more than the serotogenic affect (I have been on Prozac and Zoloft before, which just made me feel emotionally blunted and still very tired), I asked about Strattera.

So now I have added Strattera to the Cymbalta. I know Strattera is a NRI and Cymbalta a SSNRI, but should they be prescribed together? I have checked all the info, googled etc. but I can't find any info about the efficacy of this combo.

I started on 25mg Strattera for week 1, then 40mg week 2, 60mg week 3 and I am now supposed to be on 80mg. Since I went up to 80mg, I have crashed! I feel as tired and zombified as I did before I started the Cymbalta. I just want to sleep all the time. Am I overloaded on NRIs? Are they competing with each other?

I still can't seem to get anything organized, and now I am sleepy most of the time. I was taking the Strattera and Cymbalta together in the morning, but I have been trying the AD in the afternoon for the past few days. Today, I just took 40mg Strattera and haven't yet had my Cymbalta , but I am still really sleepy.

To recap from my ramblings; Does anyone have advice or comments on this combo:

60mg Cymbalta

80mg Strattera

300mg Neurontin (gabapentin) at night for Periodic Limb Movement Disorder.

Thanks!

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In my opinion (and like all but one or two of us 'round here, I'm not a doctor), you titrated too fast and/or 80 mg is just too high and combined with the norepinephrine reuptake inhibition you're getting with the Cymbalta you're on overload. A much better explanation can be found here (go to the "Strattera's Dosage and How to Take Strattera" section - about halfway down).

And if you want a really technical explanation, here's the co-administration warning from AIDSmeds.com (a really good medication interaction program that covers all meds, despite the URL):

MONITOR: Coadministration with drugs that are inhibitors of CYP450 2D6 may increase the plasma concentrations of atomoxetine, which is primarily metabolized by the isoenzyme. In patients who are extensive metabolizers of CYP450 2D6 (approximately 93% of Caucasians and more than 98% of Asians and individuals of African descent), potent inhibitors of the isoenzyme such as fluoxetine and paroxetine have been shown to increase atomoxetine systemic exposure (AUC) by 6- to 8-fold and peak plasma concentration (Cmax) by 3- to 4-fold. These higher concentrations are similar to those observed in CYP450 2D6 poor metabolizers given the drug alone. In vitro studies suggest that coadministration of CYP450 2D6 inhibitors to poor metabolizers will not further increase atomoxetine plasma concentrations. MANAGEMENT: Pharmacologic response to atomoxetine should be monitored more closely whenever a CYP450 2D6 inhibitor is added to or withdrawn from therapy, as dosage adjustment of atomoxetine may be necessary in extensive metabolizers. During coadministration, patients should be advised to contact their physician if they experience excessive adverse effects of atomoxetine such as dizziness, dry mouth, anorexia, sleep disturbances, and palpitations.
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Eli Lilly would recommend adding some Zyprexa to that.

It looks bad on paper, but when you bring it down to the neurotransmitters each is playing with, it doesn't seem that bad, because Cymbalta's banging the two of them anyways, it really has no right to complain about what Strattera's doing.

But that seems like a really fast titration even if you weren't on any other meds, being on something that's a) in the same vague ballpark and b) gets you dealing with CYP450 interactions, you'd generally want to go up as slowly as possible, since there's no guarantee you'd need the supposed "full therapeutic dose" of the Strattera just to juice up the Cymbalta a little. Hell, there's certainly no guarantee you'd need said full dose anyways, even if you were taking absolutely nothing else.

Did you feel any better on any dose of the Strattera than with the Cymbalta alone?

You may find things work well even trying something such as a lower than "normal" dose of both the Strattera and the Cymbalta, if you can find a decent balance between the serotonin and norepinephrine, but I don't know how easy for you it'd be to change the strength you're getting of the Cymbalta. There's even a chance that with the Strattera you may not need the Cymbalta, or could change to a small dose of a serotonin-only antidepressant + normal dose of Strattera.

The Neurontin, at least, isn't too likely to be interfering with the other meds.

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MONITOR: Coadministration with drugs that are inhibitors of CYP450 2D6 may increase the plasma concentrations of atomoxetine ...

Translation: You'll have a lot more circulating atomoxetine in your system if you're on Paxil or Prozac than you would normally on the same dose; you'd better really like the effects and side-effects of both atomoxetine and duloxetine (Cymbalta not only needs the 2D6 isoenzyme for its metabolism, but although makes the enzyme less effective in the process - kind of like a really needy S.O. ); and if you're on Wellbutrin just don't even think it unless you are very desperate and prepared to start low and go slow on the Straterra.

Now go back and read the CrazyMeds link Sunshine provided, follow the NRI link, and read all the way through.

The MAO theory makes some sense, considering that noradrenaline is the end product of a long synthesis chain that starts with phenylalanine or tyrosine, and produces heavy-hitting molecules like l-dopa, dopamine, and noradrenaline. The brain's neurons are probably very good at nuking the one it uses for a fast-acting fight-or-flight signaller. The "give it two weeks and start from a minimal dose" is also similar to the careful dosing required around MAOIs...

Given how you feel now, you and your doctor certainly need to reconsider how much Straterra to add to a working Cymbalta regimen and how fast you should be doing it. Maybe amino acid supplementation will help; maybe it won't. If you're feeling this zonked because of NA depletion, it's almost a given that switching to a stimulant now will make you feel as bad or worse (you can't release what you ain't got)

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