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what's the problem with switching from one SNRI to another?


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After at least 10 good years on venlafaxine XR, it is definitely not working for me anymore.  

 

My psychopharmacologist seems to think that Brintellix is the next option for me, after trials on six different add-on medications.  Even with that, he expresses some doubt that Brintellix will work for me.  I asked why he's not looking at another SNRI (like Cymbalta) for me, but he said it doesn't make sense to go to a drug in the same class as venlafaxine.  

 

I'm so confused.  I mean, my history as well as some genetic testing shows that SSRIs won't be particularly helpful for me.  Brintellix is basically just a jazzed up SSRI, right?  Even though venlafaxine and Cymbalta are in the same class, my body could react differently to them, just like some people respond to some SSRIs and not to others.  
 

Any thoughts on how I can make my case to my doctor?

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How old are you?

When meds quit working, it's usually due to a change in the nature of your MI and not immunity or anything like that.  Those genetic tests are totally worthless.  All they can tell is how likely you are to have a handful of side effects and maybe help with dosing.  

What dose venlafaxine have you been on?  At doses around 300mgs a day it starts to have a much stronger effect on norepenephrine.  Cymbalta has a much stronger effect on norepenephrine than even the highest dose of Effexor, so if high dose Effexor was much more effective than it was at a lower dose, there is a chance that Cymbalta could be helpful.  We've had people around here on 450mgs Effexor a day, so you might be able to increase in some more.  It's an absolutely miserable drug to come off of, even if you're cross-tapering onto something else. so it might be prudent to totally max out the dose before going off it.  

The thing about Cymbalta is that it might eat your liver with some fava beans and a nice chianti.  

One of the most active threads on this site right now is one where people are comparing their experiences with Brintellix.  You might want to take a look at that.  

Most of the tricyclic ADs are also SNRIs.  Desipramine is almost a pure NRI.  They have a lot more potential side effects than newer ADs but are as cheap as shit and can really kick depression and anxiety in the ass.  

I'm personally rolling my own SNRI by taking Wellbutrin in conjunction with Luvox and some other stuff.  

 

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On 12/16/2015 at 7:39 PM, Velvet Elvis said:

How old are you?

When meds quit working, it's usually due to a change in the nature of your MI and not immunity or anything like that.  Those genetic tests are totally worthless.  All they can tell is how likely you are to have a handful of side effects and maybe help with dosing.  

What dose venlafaxine have you been on?  At doses around 300mgs a day it starts to have a much stronger effect on norepenephrine.  Cymbalta has a much stronger effect on norepenephrine than even the highest dose of Effexor, so if high dose Effexor was much more effective than it was at a lower dose, there is a chance that Cymbalta could be helpful.  We've had people around here on 450mgs Effexor a day, so you might be able to increase in some more.  It's an absolutely miserable drug to come off of, even if you're cross-tapering onto something else. so it might be prudent to totally max out the dose before going off it.  

The thing about Cymbalta is that it might eat your liver with some fava beans and a nice chianti.  

One of the most active threads on this site right now is one where people are comparing their experiences with Brintellix.  You might want to take a look at that.  

Most of the tricyclic ADs are also SNRIs.  Desipramine is almost a pure NRI.  They have a lot more potential side effects than newer ADs but are as cheap as shit and can really kick depression and anxiety in the ass.  

I'm personally rolling my own SNRI by taking Wellbutrin in conjunction with Luvox and some other stuff.  

 

Thanks for the feedback!  

So, I was experiencing some significantly lowered effectiveness of venlafaxine ER (I was taking 375 mg) prior to April 2014.  It was at that point that, due to my desire to become pregnant, the psychiatric nurse practitioner I was seeing decided to pull the Effexor rug out from under me and get me on Zoloft.  She decreased me from 375 mg to 225 mg without starting me on Zoloft first. She didn't even warn me about the withdrawal syndrome, even when I asked.  Her plan was to get me completely off Effexor in 6 weeks.  Needless to say, I thought I was dying.  I managed to get down to 75 mg Effexor and 150 mg Zoloft before I said "enough" and she titrated me back up to 375 mg and off Zoloft.

I was never the same after that.  Effexor had become way less effective at that point.  She increased me to 450 mg, but about five weeks in, I was hit with some crazy side effects, insane dizziness, etc. that just wouldn't go away.  I then (finally) got in to see a different psychiatrist - a psychopharmacologist at another practice - who put me back on the 375 mg.  

Since November 2014, I have tried augmentation with Abilify, then Wellbutrin, then Deplin, then Buspar, then Remeron, and now Rexulti.  Some slight improvement only with Remeron and Rexulti, but combo side effects were way too much to handle, and with only limited success in making my depression and anxiety a little less bad.  I'm still on the Rexulti, but I'll have to go off it if I go on something else, says my doctor.

 

I should also note that I am in weekly CBT therapy, practicing daily mindfulness, exercising, etc.  I'm not hypo- or hyperthyroid, all my bloodwork checks out as normal, and no hormone issues.

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7 hours ago, apsdecatur said:

Thanks for the feedback!  

So, I was experiencing some significantly lowered effectiveness of venlafaxine ER (I was taking 375 mg) prior to April 2014.  It was at that point that, due to my desire to become pregnant, the psychiatric nurse practitioner I was seeing decided to pull the Effexor rug out from under me and get me on Zoloft.  She decreased me from 375 mg to 225 mg without starting me on Zoloft first. She didn't even warn me about the withdrawal syndrome, even when I asked.  Her plan was to get me completely off Effexor in 6 weeks.  Needless to say, I thought I was dying.  I managed to get down to 75 mg Effexor and 150 mg Zoloft before I said "enough" and she titrated me back up to 375 mg and off Zoloft.

I was never the same after that.  Effexor had become way less effective at that point.  She increased me to 450 mg, but about five weeks in, I was hit with some crazy side effects, insane dizziness, etc. that just wouldn't go away.  I then (finally) got in to see a different psychiatrist - a psychopharmacologist at another practice - who put me back on the 375 mg.  

Since November 2014, I have tried augmentation with Abilify, then Wellbutrin, then Deplin, then Buspar, then Remeron, and now Rexulti.  Some slight improvement only with Remeron and Rexulti, but combo side effects were way too much to handle, and with only limited success in making my depression and anxiety a little less bad.  I'm still on the Rexulti, but I'll have to go off it if I go on something else, says my doctor.

 

I should also note that I am in weekly CBT therapy, practicing daily mindfulness, exercising, etc.  I'm not hypo- or hyperthyroid, all my bloodwork checks out as normal, and no hormone issues.

If the 'fex was only helpful at higher doses, that would seem to indicate that serotonin imbalance isn't your only problem.  

What's your official diagnosis?

Which is worse, the depression or the anxiety?

 

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According to what I've read here and on other forums, the best way to come off Effexor is to moderately reduce the dose, start taking an SSRI with a long half-life such as prozac, stick with that for a while, then finish tapering off the 'fex, then taper off the prozac.  I've heard of nortryptiline being used for this as well.

I got off Cymbalta by cross-tapering onto celexa.   

 

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  • 6 months later...

I had come off all meds, effexor had been switched to celexa, but since I felt pretty god with a low does of celexa, I discontinued it and went completely to the bad place, wanting to commit suicide but too scared. A wonderful doctor started me right away on 10 mg Brintellix and 10 mg latuda  and lorazapam for sleep. Worked ok for a week or two then back to not-quite-so-bad, but bad. So he upped the brintellix to 20 mg. and halved to latuda. God, I am so miserable. This heaviness. The fear. I really want to go back to what HAD worked, effexor or celexa! WHAT should I do? Should I experiment myself? Get permission from the doctor. What if he says no? 

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Experimenting (in the sense of taking leftover meds or getting them from someone or anything like that) is not a good idea.  It's not a long term solution in that even if it proves helpful, you're going to eventually have to admit it to your pdoc and ask for more.  It's not necessarily the exact same thing as self-medicating with benzos or opiates where it will keep most psychiatrists from being willing to prescribe it in the future, but it's still not good.  Also, there can be significant safety issues (whether to combine with what you are actually prescribed) and essentially makes your pdoc appointments useless (no way to tell if a side effect is due to a med he/she doesn't know about as an example).

i don't mean that as a lecture and I'm sorry if it comes off that way.  It can just really get you into a bad place in the blink of an eye.

your other idea--asking your psychiatrist--is much safer and sustainable.  You can even phrase it as a "this medication worked really well for me before and I thought it might makes sense to try it again.  Is there a reason why we aren't?"  If you get a no, you get to give it consideration--does the reason make sense even if it's not what you would have thought of or preferred?  Is he willing to try it if you stick the current regimen put a little longer and it's really not helping?  Do you want to try to get  a second opinion on this issue alone? (I think thats usually not done and it's reserved for bigger picture questions like whether you're even working to treat the right illness, but others here might think differently.)

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