Nortriptyline augmentation options.

[Schlep]

Hi. What are some good nortriptyline augmentation options? I tried Lyrica back in 2012 and it was pretty productive. I'm wondering if there's anything new out there.

[looking for answers]

what are you trying to augment? or what symptoms are you having

[looking for answers]

im not sure why i got a confused reaction. why does the nort. need augmented? depression?

[CrazyRedhead]

@Schlep do you need augmentation due to your depression, or something else to help with anxiety?......

[Schlep]

Just something to boost the effects of it, if it's the case that Nortriptyline is starting to lose its edge. At one point when it seemed like it was (though other factors were ultimately to blame) my old Pdoc had me try out risperdal for this purpose (which ended up increasing my anxiety), followed by Lyrica, which gave my mood a slight boost. This was followed up by Buspar, which really didn't do anything. I ended up cutting back pn all this because I was on a 1.5 mg dose of clonazepam as well and felt overwhelmed. I started feeling a lot better once I cut back, but now sadly all of my tribulations have returned. 

Edited October 21, 2018 by Schlep

[looking for answers]

12 minutes ago, Schlep said:

Just something to boost the effects of it, if it's the case that Nortriptyline is starting to lose its edge. At one point when it seemed like it was (though other factors were ultimately to blame) my old Pdoc had me try out risperdal for this purpose (which ended up increasing my anxiety), followed by Lyrica, which gave my mood a slight boost. This was followed up by Buspar, which really didn't do anything. I ended up cutting back pn all this because I was on a 1.5 mg dose of clonazepam as well and felt overwhelmed. I started feeling a lot better once I cut back, but now sadly all of my tribulations have returned. 

im a big fan of lithium............

[CrazyRedhead]

1 hour ago, looking for answers said:

im a big fan of lithium............

Agree with trying Lithium....Abilify and Rexulti have also been used to augment antidepressants..

[Schlep]

Lithium already devastated me, probably because it was prescribed in an irresponsible manner. And doesn't Abilify carry a risk of tremors? Rexulti I've never heard of, is it new? I've also had Effexor and Trintellex suggested, as well as gabapentin. I was already aware of gabapentin at the time I was taking Lyrica; there must have been a reason I didn't go along with it.

[looking for answers]

39 minutes ago, Schlep said:

Lithium already devastated me, probably because it was prescribed in an irresponsible manner. And doesn't Abilify carry a risk of tremors? Rexulti I've never heard of, is it new? I've also had Effexor and Trintellex suggested, as well as gabapentin. I was already aware of gabapentin at the time I was taking Lyrica; there must have been a reason I didn't go along with it.

every medication carries a risk of something, doesnt mean its gonna happen,, id talk to ur doc, but everyone reacts differently

what happened with lithium

all very different suggestions

Edited October 21, 2018 by looking for answers

[Schlep]

34 minutes ago, looking for answers said:

every medication carries a risk of something, doesnt mean its gonna happen,, id talk to ur doc, but everyone reacts differently

what happened with lithium

all very different suggestions

An interim pdoc I was seeing suggested I replace Nortriptyline with Lithium apparently based on some theory that patients who suffer both anxiety and depression are undiagnosed bi-polar. I really had no reason to switch, but didn't see any harm in trying. He started me on the first dose of Lithium (don't remember the dosage, but four pills I think.) After the first week I began to have reservations so I called him and began to taper down. During the taper I suffered a panic attack, and then another once off the medication, then anxiety that evening. Thinking this might have been withdrawal I went back on about half the dosage and thought I's taper more slowly. Expereienced generalized anxiety the next three days, followed by a feeling of blacking out and then a massive panic attack that landed me on the floor. (This was ironically during the Michael Jackson tribute a few weeks following his death from over-medication.)

I called an ambulance I was brought to the emergency room, where they gave me some Ativan and was feeling better that night. I had a sceduled meetig with the pdoc the following day and given a prescription for 1.5 mg clonazepam, and that was about it. It was months before I was able to see another pdoc.

I never really recovered from that day. 

[looking for answers]

13 minutes ago, Schlep said:

An interim pdoc I was seeing suggested I replace Nortriptyline with Lithium apparently based on some theory that patients who suffer both anxiety and depression are undiagnosed bi-polar. I really had no reason to switch, but didn't see any harm in trying. He started me on the first dose of Lithium (don't remember the dosage, but four pills I think.) After the first week I began to have reservations so I called him and began to taper down. During the taper I suffered a panic attack, and then another once off the medication, then anxiety that evening. Thinking this might have been withdrawal I went back on about half the dosage and thought I's taper more slowly. Expereienced generalized anxiety the next three days, followed by a feeling of blacking out and then a massive panic attack that landed me on the floor. (This was ironically during the Michael Jackson tribute a few weeks following his death from over-medication.)

I called an ambulance I was brought to the emergency room, where they gave me some Ativan and was feeling better that night. I had a sceduled meetig with the pdoc the following day and given a prescription for 1.5 mg clonazepam, and that was about it. It was months before I was able to see another pdoc.

I never really recovered from that day. 

doesnt sound fun, sorry to hear that............doesnt sound like an option for oyu. I do like trintellix

[argh]

3 hours ago, Schlep said:

Lithium already devastated me, probably because it was prescribed in an irresponsible manner. And doesn't Abilify carry a risk of tremors? Rexulti I've never heard of, is it new? I've also had Effexor and Trintellex suggested, as well as gabapentin. I was already aware of gabapentin at the time I was taking Lyrica; there must have been a reason I didn't go along with it.

why did you end up stopping the lyrica?

[CrazyRedhead]

13 hours ago, Schlep said:

And doesn't Abilify carry a risk of tremors? Rexulti I've never heard of, is it new? I've also had Effexor and Trintellex suggested, as well as gabapentin. 

There are potential side effects with every medication, but like @looking for answers said, that doesn't necessarily mean you'll get them.

For instance, I take Abilify and I've never gotten tremors or restlessness....I take 15mg which would probably be considered a moderate dose....You would probably be started on a much lower dose for augmentation purposes.....I think the lowest dose is 2.5 mg.

Yes, Rexulti is new, it's been out for only a few years.......It's a chemical cousin to Abilify, but it's supposedly less likely to cause the restlessness that some people get on Abilify..

Effexor, Trintellix, and gabapentin are possibilities, too......

Edited October 22, 2018 by CrazyRedhead

[DammitJanet]

Rexulti is also supposed to be helpful for depression. 

[Schlep]

16 hours ago, argh said:

why did you end up stopping the lyrica?

You get a trophy for your name alone, argh. I was on 1.5 mg of clonazepam at the time and was having drowsiness issues on them. On one occasion I was travelling somewhere on a subway a long way from my house and out of nowhere became overwhelmed with a spell of sleepiness. I had to immediately turn around and the ride home wasn't fun at all. Then a few months later I just started feeling weird ( I had also started Buspar) and decided I'd be better off phasing out everything.

6 hours ago, CrazyRedhead said:

There are potential side effects with every medication, but like @looking for answers said, that doesn't necessarily mean you'll get them.

For instance, I take Abilify and I've never gotten tremors or restlessness....I take 15mg which would probably be considered a moderate dose....You would probably be started on a much lower dose for augmentation purposes.....I think the lowest dose is 2.5 mg.

Yes, Rexulti is new, it's been out for only a few years.......It's a chemical cousin to Abilify, but it's supposedly less likely to cause the restlessness that some people get on Abilify..

Effexor, Trintellix, and gabapentin are possibilities, too......

I think I have an increased sensitivity to meds and am convinced that if there is a negative side effect, I'll probably get it. Looking back, my present depression arose concomitant with the Actavis clonazepam, so I just may need to resolve one situation, and in so doing resolve the other. 

[argh]

27 minutes ago, Schlep said:

You get a trophy for your name alone, argh. I was on 1.5 mg of clonazepam at the time and was having drowsiness issues on them. On one occasion I was travelling somewhere on a subway a long way from my house and out of nowhere became overwhelmed with a spell of sleepiness. I had to immediately turn around and the ride home wasn't fun at all. Then a few months later I just started feeling weird ( I had also started Buspar) and decided I'd be better off phasing out everything.

I think I have an increased sensitivity to meds and am convinced that if there is a negative side effect, I'll probably get it. Looking back, my present depression arose concomitant with the Actavis clonazepam, so I just may need to resolve one situation, and in so doing resolve the other. 

Benzos with sleepiness could definitely be a thing. However, if you need the benzo for anxiety, how about adding a low dose of Wellbutrin? Nortriptyline does hit NET pretty hard though..not sure if an NDRI on top of that would be a bit much.

Stimulating at any rate. If you do happen to be bipolar, it statistically has the lowest chance of hypo/manic switching.

Perhaps ask your doc about that?

[mikl_pls]

I know you have most definitely taken an SSRI/SNRI, but have you taken an SSRI with nortriptyline?

Nortriptyline is a secondary amine tricyclic antidepressant, this class of which mostly act upon norepinephrine reuptake inhibition. Adding an SSRI, particularly sertraline (Zoloft) (since it supposedly has the least CYP2D6 inhibition and subsequently the least drug-drug interaction with nortriptyline) will obviously increase serotonin levels, but will create a sort of "customized SNRI," wherein the ratio of SRI to NRI is customizable by the dose of each agent. This is commonly done by many pdocs. However, if you have tried SSRIs and they are simply just not for you, I definitely understand. If I remember correctly, lower doses of nortriptyline will work better for anxiety and higher doses for depression, because lower doses are generally more sedating for most people (due to the affinity for the H₁ receptor and likely the 5-HT_2A receptor) and  higher doses are more stimulating (due to the affinity for the NET).

I also second the addition of what others here have said with the possible addition of an atypical antipsychotic such as Abilify, but be careful with Abilify because while it may boost the efficacy for depression, by its stimulating nature, especially in low doses, it just might exacerbate your anxiety; however, on the other hand, a handful of people are paradoxical responders insofar as they are sedated by Abilify, so YMMV. Abilify works extremely well for my depression and mood swings though (I'm bipolar type 2). It really keeps me out of  the LOW-lows and keeps me from going over the edge (most of the time). There are other AAP options, though, for anxiety... Geodon (a good weight-neutral option), Risperdal (be careful for hyperprolactinemia), Invega (also be careful for hyperprolactinemia), Seroquel (may be too sedating in some people, and causes weight gain), and Zyprexa (also may be too sedating for some people, causes immense weight gain, and is diabetogenic , which are all things to watch out for with this one...). There are the ones that insurance companies may be reluctant to pay for too, like Rexulti, Latuda, and Saphris (Saphris was really good for my anxiety until my insurance put it on step therapy...).

Some anticonvulsant mood stabilizers can be really good for anxiety, as you've already experienced with Lyrica. Personally, I really like my combo of Topamax and Trileptal. The Topamax will give you some cognitive issues at first, but if you can get past that, they will subside eventually. Also, for some, Topamax causes a lot of weight loss, so that's a thing... Trileptal can cause low sodium levels, so you might have to pay attention to that because that can cause seizures, ironically. But my anxiety was quelled so much by this combo I was able to get off the Valium I was taking at the time when I first was switched to this combo.

[Iceberg]

@mikl_pls As to that top suggestion-I kno someone who is currently is in the nortryptaline with cymbalta and when I asked my pdoc about that he said it was different but not too crazy 

[mikl_pls]

13 minutes ago, Iceberg said:

@mikl_pls As to that top suggestion-I kno someone who is currently is in the nortryptaline with cymbalta and when I asked my pdoc about that he said it was different but not too crazy 

I was at one point on desipramine with Cymbalta because my pdoc replaced fluoxetine with it and it worked pretty great, so long as the Cymbalta was maxed out at 120 mg. (She later lowered the Cymbalta to 80 mg and I crashed... :/ )

My current sertraline + desipramine combo is working quite swimmingly.

[Iceberg]

@mikl_pls If you don't mind, What are the doses (can't see your sig)?