Fluoxetine + Nortriptyline Combination

[bigalxyz]

Hello forum,

I've had long term problems with treatment-resistant depression and also - in the last 3 or 4 years - have suffered from vertigo, migraines and stomach cramps.

I have been taking 40mg fluoxetine daily which doesn't do much at all - makes me slightly less irritable, give me some very strange & vivid dreams, but not much else.

Doctor has just given me some nortriptyline to take alongside the fluoxetine as a combination therapy. Initial dose 25mg and then increase to 50mg after 10 days.

I started with the 25mg of nortriptyline 4 days ago and it has hit me quite hard. I felt very drowsy at first although this has eased a little now. Sleeping a lot too - possibly not a bad thing because my sleep quality isn't great. Feel "stoned" but not necessarily in a good way. On the other hand, no vertigo, no migraines, no stomach cramps and my mood is ok (albeit in a daze).

I read something about fluoxetine interacting with TCAs like nortriptyline - something to do with liver enzymes that I don't understand - the upshot of it all was that one should be careful with TCA dosages because fluoxetine makes the TCA hang around in the system longer, as if it were a bigger dose than it actually is.

Doctor has talked about gradually getting the nortriptyline dosage up to 75mg - 100mg in due course. But I don't know on reflection how familiar he is with this drug (especially in combination with fluoxetine) - he is following the guidance of a psychiatrist who assessed me, but I don't think the psychiatrist gave any advice on suitable dosages. Also the doctor said it's ok to drink alcohol in moderation when taking nortriptyline , which contradicts what I've read elsewhere (I don't plan to drink btw).

I'm a bit concerned...should I be, do you think?

(I would ask the doctor myself but it can take 3 weeks to get an appointment with him!)

Thanks,

A.

 

 

 

 

Edited May 5, 2018 by bigalxyz
can't spell nortriptyline!

[CrazyRedhead]

2 hours ago, bigalxyz said:

    I'm a bit concerned...should I be, do you think?

Personally, I think I would be somewhat concerned about this combination, if my doc prescribed it for me.

Here's a rundown from drugs.com about the potential interactions:....... https://www.drugs.com/drug-interactions/nortriptyline-with-prozac-1734-0-1115-648.html?professional=1

That being said, even if you can't get an appt with him for 3 weeks, you should be able to call his office with your concerns, and leave a message for him to call you back.........That's what I would do.

Edited May 5, 2018 by CrazyRedhead

[bigalxyz]

8 hours ago, CrazyRedhead said:

I think I would be somewhat concerned about this combination

I think you're right. I've checked and the official guidance here in the UK also gives a warning about the interaction between fluoxetine and nortriptyline. The same warning occurs for paroxetine, but not for citalopram or sertraline. Come to think of it...I don't remember whether the psychiatrist recommended "fluoxetine + nortriptyline" or "a suitable SSRI + nortriptyline" so maybe a swap to a different SSRI would be appropriate.

I think I'm going to halve the dosages and phone the surgery on Monday with an urgent request to speak to the doc on the phone.

Thank you,
A

 

Edited May 5, 2018 by bigalxyz

[CrazyRedhead]

39 minutes ago, bigalxyz said:

  Thank you,

You're very welcome......

[bigalxyz]

Dropped down to 20mg fluoxetine and 12.5mg nortiptyline today. Feel a lot more alert & generally quite good now. Felt a bit restless/shaky but then I realised that my breakfast had been two strong double espressos and no food...

Spoke to a pharmacist today and she said that the combo isn't expressly banned otherwise the IT system that the doc uses would have flashed up all kinds of red flags when he did the prescription - but said yes do speak to the doctor again if you're concerned.

Doctor's surgery closed until Tuesday so will do same meds tonight/tomorrow and try to speak to doc after that.

Edited May 6, 2018 by bigalxyz

[HydroCat]

Nortriptyline is closest to a SNRI than to anything else, but has more affinity to N transporter than to the S one. Fluoxetine is an SSRI.

Changing the ratio between them can create sort of a custom-made balanced SNRI.

Because both of them have serotonin reuptake inhibition they can potentially cause serotonin syndrome. That's what the internet would say