HARK! A challenge! Want find other TRD meds, but have allergies

[thebakerbunny]

Hi, all. I feel like a newb oldie: been on here a while, still feel dumb as shit with all the o chem breakdowns and acronyms.

Anyway- I've been maxed out on effexor xr for years now. I've taken it pretty consistently for...12 years? with a few breaks to try something new. There aren't many details I can remember well (always had a bad memory, now it's basically a vestigial feature), but here's what I've garnered: 

*SSRIs and i seem to not mix. Not just some side effects, but all the side effects, and no or negative improvement.

*wellbutrin did nothing for me. Not good, not bad- just nothing. 

*Effexor was good- great, even- before I tapped out. I've just been staying with it till I can figure something out.

*currently, I take 225 mg Effexor (and several doctors have told me now that they flat out won't go above that), 150 lamictal, and klonopin and Ambien as needed. (And as I've been mightily depressed lately...I've been "as needing" them a lot more.)

 

I've been wanting to change for a while now, and I've been studying up to see what might be some better options, but haven't had a tdoc or pdoc in the meantime. I'm meeting new ones shortly and I want to take some suggestions to them. Problem is that I'm allergic to a few things, with varying degrees of severity and type of allergic reactions. Any suggestions of SNRIs, TCAs, or MAOIs that aren't: 

*sulfa-meds (full body hives. Like...full body- between my toes, in my buttcrack...😬)

*compazine (difficult breathing, light anaphylaxis.)

*darvocet, Vicodin (full-blown anaphylaxis.)

 

I have been given morphine with no reaction (so, what- does this mean that synethics cause issues, but cleaner natural versions don't?), and take imitrex regularly. I'm not smart enough to understand all of the individual components, and too ADD to have the patience to learn which causes what.

I feel like it's got be something pretty potent, since I've been middling- to severely-depressed pretty constantly (easily 8 out those 12 years), but I also don't need anything that's going to make me lethargic. Apathetic, fine- just please, no serious drowsiness.  

I defer to you guys and gals and pals for what your thoughts are on what might be most effective, but also won't send me to the ER.

 

Edited May 8, 2020 by thebakerbunny

[Blahblah]

Hey @thebakerbunny I'm in a bit of the same situation. I'm also on Lamictal, and was on Effexor for over a year, which works well for severe depression & anxiety, but at higher doses the apathy was worsening (plus Effexor is one of the worst meds to titrate off of). I tapered off of it successfully (using low-dose Prozac) and have been  waiting things out to figure what to switch to. Wellbutrin has no effect and SSRIs make me numb and apathetic. (BTW stimulants help somewhat if you are trying to treat apathy or fatigue)

I've been experimenting with some stricter dietary changes (no alcohol or sugar) and a daily regimen of supplements to see if it helps.

What symptoms are you mainly dealing with now?  TCA's often have higher rate of side effects, I've only tried Pamelor years ago. I have mainly considered trying an MAOI next, however, pdocs are really not into prescribing those...and @mikl_pls and @browri are pretty awesome at helpful suggestions.

[browri]

3 hours ago, thebakerbunny said:

Hi, all. I feel like a newb oldie: been on here a while, still feel dumb as shit with all the o chem breakdowns and acronyms.

Hahah don't worry and don't feel dumb. We talk like we know what we're talking about, but we're not doctors. And even if we were, we don't truly understand enough of how the brain works.

3 hours ago, thebakerbunny said:

Anyway- I've been maxed out on effexor xr for years now. I've taken it pretty consistently for...12 years? with a few breaks to try something new. There aren't many details I can remember well (always had a bad memory, now it's basically a vestigial feature), but here's what I've garnered: 

*SSRIs and i seem to not mix. Not just some side effects, but all the side effects, and no or negative improvement.

Which SSRIs have you tried and can you remember if there were any side effects that were specific to one med or worse on one than on the others?

3 hours ago, thebakerbunny said:

*wellbutrin did nothing for me. Not good, not bad- just nothing. 

This is notably interesting...

3 hours ago, thebakerbunny said:

*Effexor was good- great, even- before I tapped out. I've just been staying with it till I can figure something out.

*currently, I take 225 mg Effexor (and several doctors have told me now that they flat out won't go above that), 150 lamictal, and klonopin and Ambien as needed. (And as I've been mightily depressed lately...I've been "as needing" them a lot more.)

....considering that SNRIs seem to help a lot, I would expect that Wellbutrin would have a similar positive effect. The fact that it didn't work indicates that you do need some sort of serotonergic intervention, but perhaps inhibition of serotonin reuptake isn't the path to take in this case.

I find it laughable that doctors would bother trying Effexor if they aren't willing to go to 300mg. You CAN go to 450mg, but that's heroic. You should AT LEAST be willing to go to 300mg though if the patient is tolerating 225mg. There's a lot of evidence that in some people, the more potent pro-dopaminergic effects of Effexor aren't seen until the top of the dose range.

At what point did you add Lamictal, and would you say it was an improvement in your treatment? I mention this because Lamictal is a glutamate reducing agent although I prefer to say it modulates because it can promote glutamate signaling in some ways. Glutamate is an excitatory neurotransmitter in the brain, and it's believed that Lamictal's effect on glutamate can have positive impacts on depressive states and mood swings. This is why they use it in bipolar disorder, but they do find that there's a subset of those with MDD that experience depression with anxious distress who respond well to medications that calm glutamate signaling (or we just give them benzos to increase GABA signaling, which is just an indirect way of doing the same thing).

If you have major depressive disorder, there is the option of reducing the Lamictal to 100mg to see if there is some improvement in mood. Alternatively, you could increase it because there is often additional benefit seen all the way to 200mg.

3 hours ago, thebakerbunny said:

I've been wanting to change for a while now, and I've been studying up to see what might be some better options, but haven't had a tdoc or pdoc in the meantime. I'm meeting new ones shortly and I want to take some suggestions to them. Problem is that I'm allergic to a few things, with varying degrees of severity and type of allergic reactions. Any suggestions of SNRIs, TCAs, or MAOIs that aren't: 

*sulfa-meds (full body hives. Like...full body- between my toes, in my buttcrack...😬)

*compazine (difficult breathing, light anaphylaxis.)

*darvocet, Vicodin (full-blown anaphylaxis.)

I have been given morphine with no reaction (so, what- does this mean that synethics cause issues, but cleaner natural versions don't?), and take imitrex regularly. I'm not smart enough to understand all of the individual components, and too ADD to have the patience to learn which causes what.

I feel like it's got be something pretty potent, since I've been middling- to severely-depressed pretty constantly (easily 8 out those 12 years), but I also don't need anything that's going to make me lethargic. Apathetic, fine- just please, no serious drowsiness.  

I defer to you guys and gals and pals for what your thoughts are on what might be most effective, but also won't send me to the ER.

So I can think of a couple possibilities here.

1. If you're seeing a new pdoc shortly....someone who is an experienced psychiatrist, then you should really start by optimizing doses of existing medications as far as you can tolerate them. If the issue with Effexor is that it seems to have pooped out but there aren't any side effects, then it should be increased to 300mg. Additionally, if you feel that Lamictal has helped you, it should also probably be pushed to 200mg before deciding to change medications to something else.
2. Effexor is a very effective antidepressant in a lot of cases that don't respond to other first-line agents. Considering that it has historically been the one thing that has worked for you, perhaps you augment it with something else besides Lamictal. My recommendation in this case would be Remeron because the Effexor+Remeron combo is referred to as "California Rocket Fuel" as it gained popularity among psychiatrists in California and elsewhere along the west coast. Remeron on its own is generally regarded as a sedating medication until you get to the higher doses, but combined with Effexor it can supposedly be quite stimulating for many and can breathe new life into Effexor if the patient stops responding to it. This can also have a calming effect on anxiety. So it's possible that you may be able to rely on Klonopin less. And Remeron would be taken at bedtime. It's sedating enough at low to moderate doses that you may not need Ambien anymore either.
3. By contrast, if you felt that you noticed a considerable improvement when adding Lamictal, I would say consider swapping Effexor for Trintellix. I'm currently taking it and find it to be continuously effective and it hasn't caused the activating/agitating side effects that SSRIs and SNRIs cause me except maybe at the highest dose. Additionally, if you didn't respond well to SSRIs due to side effects, it's possible that you may experience some of those problems on Trintellix at the highest dose (20mg). However, I personally rarely ever go to that dose. I find it to be too activating and unnecessary. 15mg is usually enough even in the deep of Winter and despite being really close to 20mg seems to be more tolerable. 5mg and 10mg are a cake walk when you adjust to them.
4. I personally find Rexulti very calming and helps with sleep. It's an atypical antipsychotic approved as an add-on to an antidepressant for MDD like Abilify and Seroquel. It's been far better for me than either of them though. You could possibly swap Lamictal for Rexulti, and over time you may find that your anxiety gets better as well as sleep, thus necessitating less Klonopin and Ambien like in #2.

I'd be curious to know other medications you've tried and what your experience was like with them.

[Iceberg]

I agree with @browri about adding remeron, that might be a good move for TRD. What other snris have you tried? Pristiq, cymbalta, Fetzima ?