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MuddlingThru

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I've been on Fetzima & Wellbutrin combo for a few years. I had to stop Fetzima when I had cervical spinal surgery two years ago, but went back on it after I had tapered off of the heavy duty post-op meds. Lately though I feel foggy and just blah. Lots of personal stuff going on but that's always the case. Left my job recently so that doesn't help. I'm in therapy and eating (which is a big deal for me) and am doing PT for my back and neck, trying to taper off some of my neuropathic pain meds & muscle relaxants. Adjuvants generally haven't worked.

I had GeneSight done a few years ago and it confirmed what I'd experienced: SSRIs and I do not mix. My list of attempted meds (in sig) is long. Essentially, my genetic profile showed Fetzima and Pristiq. I'm wondering aside from what I'm doing on the pain stuff, what meds my shrink can try? I'm thinking the only thing left is some of the milder TCAs - as long as they don't cause weight gain or lethargy because I can't handle that. Thoughts? What do you do when what you've got is essentially the end of the second-tier road?

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3 hours ago, MuddlingThru said:

Thoughts? What do you do when what you've got is essentially the end of the second-tier road?

TCAs can cause weight gain in some people, but not everyone, so might be at least worth a try.  I've tried a few TCAs....I remember that amitriptyline did cause some weight gain for me, but doxepin, clomipramine and nortriptyline did not....That said, I do remember that I took a very low dose of doxepin.

Keep in mind that those were just my experiences, and you could react differently.

Also, how about Effexor, or Cymbalta, which are SNRIs? 

There is also ketamine, but you have to go to a ketamine clinic to get an infusion, and it is expensive.

Edited by CrazyRedhead

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1 hour ago, MuddlingThru said:

I've been on Fetzima & Wellbutrin combo for a few years. I had to stop Fetzima when I had cervical spinal surgery two years ago, but went back on it after I had tapered off of the heavy duty post-op meds. Lately though I feel foggy and just blah. Lots of personal stuff going on but that's always the case. Left my job recently so that doesn't help. I'm in therapy and eating (which is a big deal for me) and am doing PT for my back and neck, trying to taper off some of my neuropathic pain meds & muscle relaxants. Adjuvants generally haven't worked.

I had GeneSight done a few years ago and it confirmed what I'd experienced: SSRIs and I do not mix. My list of attempted meds (in sig) is long. Essentially, my genetic profile showed Fetzima and Pristiq. I'm wondering aside from what I'm doing on the pain stuff, what meds my shrink can try? I'm thinking the only thing left is some of the milder TCAs - as long as they don't cause weight gain or lethargy because I can't handle that. Thoughts? What do you do when what you've got is essentially the end of the second-tier road?

Do you think tweaking your doses of either Fetzima or Vyvanse would help? If you're not super anxious or depressed and  just need a brightening/ cognitive boost, seems like more of a stimulant effect would be of help.

Other similar SNRI's like Effexor or Cymbalta (helps with pain) maybe? Only TCA I took was Nortyptyline (which is supposedly less likely to cause fatigue/weight gain, help with pain -I think, can't remember the effect) What about an MAOI? Emsam maybe (never tried that one) @mikl_pls or @browri might have some better ideas.

Edited by Blahblah

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You said that SSRIs don't work well for you, but SNRIs do. Fetzima has particularly more Noradrenaline effect than Serotonin effect.

In this case trying Cymbalta makes sense. It is a relatively balanced S/N.

If you want to go down the TCA path, then ones with more N than S may be the way to go (Doxepin, Amitriptylin or Nortriptyline for example).

Back on SNRIs, maybe Milnacipran (Savella), the “parent” drug of Fetzima will work but it is not FDA approved so it is not available in every country.

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@MuddlingThru do you have a copy of the results of your GeneSight test? Usually what you truly need to pay attention to is the list of drugs that are in the "red" list. The yellow list means they could be bad matches but the science isn't totally certain, and the greens mean you don't have any pharmacogenomic interactions but that doesn't necessarily mean they won't work for you, just that they should be "tolerable"

Without the test results I could make a few suggestions.....or rather....I would simply +1 what has previously been said. If you do have pain issues, you will find that the SNRI class will be helpful with your pain. There's a reason for this. When you are in a fight or flight situation, your body releases adrenaline, which does increase your body's pain tolerance / reduces its sensitivity to pain. SNRIs work by increasing the adrenergic baseline in the nervous system thus increasing your pain tolerance baseline as well.

With this in mind I would second the use of Cymbalta (duloxetine) or Pristiq (desvenlafaxine) in lieu of Fetzima (levomilnacipran). Going back to the question about the GeneSight results, I would be curious to know why the test said Pristiq was fine but Effexor XR was not. This could be a CYP2D6 genetic interaction that would be critical to knowing which drugs would be preferable to your system. That being said, you did indicate that you and SSRIs don't mix. Fetzima is a norepinephrine-heavy SNRI and that may be the only reason you are tolerating it if you can't handle SSRIs or more serotonin-heavy SNRIs. Cymbalta will be 1:1 in its affinity for the serotonin and norepinephrine transporters, Pristiq will be more serotonin-heavy. However, Effexor has been shown to have more positive impact on pain than Pristiq despite the fact that Pristiq is simply Effexor's chief metabolite. Effexor has a wider array of interactions in the body than Pristiq which could have a positive impact for you where Pristiq did not.

If you do decide to go the TCA route, I would probably direct you towards nortriptyline first being that it's more norepinephrine-heavy. Another option would be desipramine. Either of these TCAs can be combined synergistically with a low dose of good ole fluoxetine (Prozac) to augment them. At that rate though, I would say to ditch the bupropion (Wellbutrin).

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