Emsam doesn't seem to be working...

[mikl_pls]

I'm currently on the Emsam 9 mg/24 hr patch plus Adderall XR 40 mg to potentiate it, and it doesn't seem to be doing its job at all. I am completely anhedonic, find no pleasure in doing anything I used to do, and my friends and family have even noted that I am quieter and don't talk much at all anymore. What's strange is that I also seem to randomly snap at people for no apparent reason from time to time (which I don't even see coming, and it happens very seldom, but enough to be troublesome). I must confess that I've resorted to wearing two 6 mg patches to get 12 mg for a few days at a time, and I seemed to feel a little bit better, but not very much—if that's the case, if I did step up to the 12 mg patch, I wonder just how much benefit I would actually get out of it?

Should I stick with Emsam and go up to the 12 mg patch before switching to something else, or ditch the Emsam and switch to something else? If I switch to something else, I was thinking about Parnate. I don't want to take Nardil because of the associated weight gain, sedation, hepatotoxicity, and vitamin B6 deficiency. Marplan I believe also causes hepatotoxicity and vitamin B6, but I can't seem to find anything that says for sure whether it causes sedation or weight gain, so I'm on the fence about that one. I have idiopathic hypersomnia and am prediabetic, so sedation and weight gain are both nono's for me. Parnate I've heard is quite stimulating and can even cause weight loss. Even though it's conventionally contraindicated, my pdoc would likely add a stimulant to the Parnate after I get settled with the dosage to help with my IH and ADHD and to potentiate the antidepressant effects of the Parnate.

Can anyone share their Emsam and/or Parnate experiences please? It would be much appreciated. Thanks!

[jt07]

If it were me, I'd take the Emsam up to 12 mg so that I could say that I gave it a fair chance. After that, I'd look at the Parnate.

As to Marplan, I actually took Marplan as a teenager. I did not find that it caused weight gain, but maybe that is relative to the other med (Elavil) which did cause weight gain and that I took as a teen. It's been a while so my memory is not all that clear. It certainly was not a major weight gainer. I did not find Marplan particularly helpful for me. Too bad they didn't give me Parnate.

[mikl_pls]

Thanks for your feedback, @jt07. At least I feel a little more comfortable about Marplan as an alternative in case she won't prescribe Parnate. The only thing about it is that it's a tier 4 brand-name only med... ridiculous.

I'm just worried if I take the Emsam up to 12 mg and still get a subtherapeutic response, then that will be another month wasted, you know what I mean? Where as I could have spent that month instead washing out the Emsam and starting up the Parnate. But I will still consider it and of course discuss this with my pdoc.

I'm worried she won't want to prescribe me Parnate because I've asked her numerous times to prescribe it to me and she either refused, or the last time I asked her she wanted me to do a 5-week washout for some dumb reason. I guess she was trying to be overly cautious because Parnate is indeed the most dangerous of the MAOIs.

Edited December 19, 2016 by mikrw33

[Butterflykisses]

Sorry the Emsam isn't working. IMO I think you should talk to your pdoc about the possibility of getting on something else (maybe the med you mentioned) because if your not getting much of any relief with the med then its probably not the one for you. I've noticed with mostly ALL of my medication if it was going to work after a few days. 

 

The AD that works really well for me is Prozac. I used to have SEVERE ocd. OCD that was so severe it looked psychotic (even though I do as well have psychosis) Prozac took it ALL away. I found the only remaining anxiety I had left was a side effect of high blood pressure which the Propranolol helps with. 

 

Lithium ER took away all my suicidal thoughts and mania and also gave me motivation to keep up with self care, apartment cleaning, etc. And seroquel IR took away my depression and psychosis. 

I say all that to get to this: I knew what meds were going to stay and work within the first few days.

 

If I were you I would highly consider making a pdoc appointment to discuss an alternative medication

[mikl_pls]

1 hour ago, Butterflykisses said:

If I were you I would highly consider making a pdoc appointment to discuss an alternative medication

 

I think I'll do that this coming Wednesday, the first day they're in their office (assuming they aren't closed for Christmas...) If they're closed for Christmas, then I'll probably go to my GP and beg for mercy for him to work with me and my meds and see if he will prescribe me either Emsam 12 mg or Parnate. He knows me well and knows that I know my meds well, so I think he would trust me to ask him for specific meds like that.

[Lark]

For anyone being plagued by serious and debilitating Nardil side-effects I can say that for me switching from Nardil to the EMSAM patch got rid of 7 of 8 Nardil side-effects and, as well, I was able to move down to a very low dose of EMSAM.

[notloki]

Emsam does not really hit MAO-A hard until 12 mg, there is a little activity at 9 mg

[mikl_pls]

I've actually been switched over to Parnate. I'm currently on 20 mg/day, and doing actually pretty well on it, but I anticipate at my next appointment that my pdoc will titrate me higher, to 40-60 mg I hope, because so far, this has been profoundly amazing! The Adderall (which I'm currently on a low dose of and titrating up) helps it that much more, as well as the Mirapex. Colors are brighter, I can feel the colors as this tingling sensation in my chest, and I have an overwhelming sensation of being glad to be alive, which I have not had since I can't remember. It's really unusual, and I'm thinking about asking my pdoc for some lithium to ensure that my mood stays like this.

[300.3]

Mikr 

I'm not sure if I can reply here.. but I'm very happy for you and what your experiencing . It seems like your having an inner sense of well being. Contentment ..it seems like an amazing breakthrough.. I can tell you if any one deserves this it's you!!!.

 

Edited January 20, 2017 by 300.3

[Lark]

I can only report on my experience. I switched to EMSAM patch and almost all Nardil side-effects were gone very quickly. Keep in mind 95% of the serotonin in our bodies is in the bowels.

I have to assume that for me, at least, that is where the side-effects were being generated. That is, of course, where the diet problems and dietary restrictions abide.

I was never on more than a 6mg patch per day and relatively quickly have gone down to less than 1mg per day fro several years now.

[mikl_pls]

15 hours ago, 300.3 said:

Mikr 

I'm not sure if I can reply here.. but I'm very happy for you and what your experiencing . It seems like your having an inner sense of well being. Contentment ..it seems like an amazing breakthrough.. I can tell you if any one deserves this it's you!!!.

 

 

Thank you @300.3! I couldn't be happier to have my inner sense of wellbeing and contentment back! It really is an amazing breakthrough that I did not expect!

[cloudmonger]

25 minutes ago, mikrw33 said:

Thank you @300.3! I couldn't be happier to have my inner sense of wellbeing and contentment back! It really is an amazing breakthrough that I did not expect!

Congrats!!! What great news - hope it continues for you. I have never tried an MAOI (kind of scared to be honest) but when I read all the amazing reviews...It may be worth thinking about.

Question though: Do you really have to strictly avoid ALL of the foods/meds that are listed? Can you still have the hypertension effect if you are someone with low blood pressure? It seems like there are a ton of interactions (I'm not sure what the worst offenders are - like tyramines, wine, cheese, coffee, chocolate?) also seems contraindicated with antihistamines, stimulants, herbs, cold/flu medicine etc)?

Edited January 20, 2017 by cloudmonger

[mikl_pls]

8 hours ago, cloudmonger said:

Congrats!!! What great news - hope it continues for you. I have never tried an MAOI (kind of scared to be honest) but when I read all the amazing reviews...It may be worth thinking about.

Question though: Do you really have to strictly avoid ALL of the foods/meds that are listed? Can you still have the hypertension effect if you are someone with low blood pressure? It seems like there are a ton of interactions (I'm not sure what the worst offenders are - like tyramines, wine, cheese, coffee, chocolate?) also seems contraindicated with antihistamines, stimulants, herbs, cold/flu medicine etc)?

3

Thanks!

It's not as strict as things are commonly represented... MAOIs actually will lower your blood pressure, and will cause orthostatic hypotension, commonly as the dose goes higher. I think Nardil (phenelzine) is the worst for that symptom though. Or maybe it's Parnate (tranylcypromine)? I can't remember... it's one of those... But you definitely can have a hypertensive reaction regardless of your basal blood pressure. I've yet to have a hypertensive reaction (thankfully!), surprisingly so since I'm taking it with Adderall, but it just goes to show you that you don't have to avoid ALL the drugs they commonly say to avoid.

There are quite a lot of interactions with many drugs and herbal/natural supplements—like, you can't take 5-HTP, L-tryptophan, or L-tyrosine (although I think some psychiatrists used to combine MAOIs with these in the olden days); I think they've proven that you can take the common decongestants with MAOIs, but don't quote me on that; you can definitely take stimulants with care, like you need to start at a low dose and titrate up just to be safe and to safely assess at what dose you can tolerate the stimulant with the MAOI; and you can also take specific tricyclic antidepressants with them, specifically the secondary amines (desipramine (Norpramin), nortriptyline (Pamelor), and protriptyline (Vivactil)) because of their potent noradrenaline reuptake inhibition, which actually inhibits the tyramine response ("cheese reaction" which causes the hypertensive effects), for example 100 mg of desipramine can completely abolish the tyramine reaction, what amount of tyramine I don't know (it's just something I read somewhere) and lack of serotonin reuptake inhibition and therefore lack of risk of serotonin syndrome, and some of the tertiary amines (amitriptyline (Elavil), trimipramine (Surmontil)), the only one that is contraindicated is clomipramine (Anafranil) because it's so serotonergic and would cause serotonin syndrome.

Yes, tyramine is a big offender, and it is present in certain cheeses. Wine consumption is to be limited. You can still drink coffee, it's perfectly safe, I don't even know why the drug sheets say to avoid it with MAOIs... Chocolate is perfectly safe (thank god!!)

Antihistamines, I'm not sure about... The current antihistamine I take, desloratadine (Clarinex), doesn't affect me negatively at all. I haven't researched the use of antihistamines concomitantly with MAOIs... Stimulants are safe with care as I said. Herbs you have to watch out for. Cold/flu medicines are supposedly safe, but supposedly you have to watch out for some of the decongestants, but I've read they're perfectly safe with MAOIs, but again, don't quote me on that.

Overall, MAOIs are very safe, very tolerable medicines. If you are on the fence about taking an MAOI or unsure or fearful of their effects, Emsam (selegiline transdermal system) is a safe, "intro" MAOI. It's fairly innocuous, supposedly you don't even have to follow the diet at all, but for prudence they recommend the diet for the 9 mg and 12 mg dose (6 mg dose doesn't have to follow the diet). Marplan (isocarboxazid) is one of the older ones, yet for some reason in the US it's brand-name only. It's not really as well-researched as the other ones, but I've read good things about it. Weight nuetral and doesn't cause fatigue. Nardil (phenelzine) is another oldy, causes quite significant weight gain usually, and I've read causes quite a lot of fatigue, but has great antidepressant, anxiolytic, and anti-panic effects. Parnate (tranylcypromine) is supposedly the worst offender of the hypertensive effects, but is stimulating (it was brought about to be an analog for amphetamine, and has norepinephrine and dopamine releasing properties 1/10th the potency of amphetamine) which is good for atypical depression and depressives who are understimulated or lethargic. So far, the only ones I've taken are Emsam and Parnate, and Emsam I actually went all the way up to 15 mg by wearing a 6 mg patch with a 9 mg patch, and it was only then when it became slightly effective. Parnate is by far the most effective antidepressant I've ever taken.

[300.3]

Any updates? I hope things just keep getting better for you Mik.

[mikl_pls]

1 hour ago, 300.3 said:

Any updates? I hope things just keep getting better for you Mik.

Thanks!

Well, it seems things have "settled down" with Parnate. I'm not quite as euphoric as I was before, but I'm definitely in a much, much better mood than I was on Emsam. I feel more "me" and am engaging in more activities in my life. I see my pdoc next week and I hope she'll raise my Parnate, Adderall, and Mirapex. The only problem I'm noticing about Parnate is that it's very stimulating at night, and even with Thorazine 100 mg, trazodone 200 mg, and Restoril 60-90 mg, I have trouble sleeping more than 1-4 hours at a time, but trazodone doesn't really work for sedation for me anyway. I think I'm going to ask my pdoc for some doxepin, something like phenobarbital or meprobamate, and switch from Thorazine to Loxitane because the Thorazine is causing quite a lot of weight gain.

[300.3]

Do you need frequent blood work with an maoi?

[mikl_pls]

4 hours ago, 300.3 said:

Do you need frequent blood work with an maoi?

No, not that I know of. Only when you are treatment resistant will they do bloodwork, which they will test for MAO platelet inhibition, which is really only testing for MAO-B inhibition (there's really no good way to test for MAO-A inhibition, which modulates the antidepressant effect, though some benefit from selective MAO-B inhibition, like from low doses of selegiline (Deprenyl). They will test to make sure you are getting ≥ 80% MAO inhibition I think, and in some cases of treatment-resistance will push the dose up high enough, in many cases beyond the maximum dose, to obtain as much as 90% inhibition.

The max dose of phenelzine (Nardil) is 90 mg, tranylcypromine (Parnate) is 60 mg, Marplan (isocarboxazid) is 60 mg, selegiline (Deprenyl) is 40-60 mg, and Emsam ( selegiline transdermal system) is 12 mg, but I've read of phenelzine being used in doses of up to 135 mg/day, tranylcypromine 80 mg (200 mg in the old days...), Marplan 170 mg, and Emsam 24 mg. These can even be potentiated with stimulants (normal and high doses) like Adderall, Dexedrine, Desoxyn, etc.