Questions about meds?

[pokerfan]

Hi all. I am a 40 year old male from the US. I posted a bit on AZ before they shut it down. I was very happy when i saw that Ian had found a new home at No More Panic. He is has a wealth of information and is always willing to share it. So most of my questions are for him but anyone else is welcome to chime in.
A not so quick summary of how i got to this point and hopefully it jogs Ian's mind about who i am. I started taking 50mg of Zoloft when i was 19 for anxiety. I would get better stop taking have a relapse and get back on it. This went on for the next 5 years until i graduated college got a job working in a cubical for a financial company. At this point i had a break down quit my job and went up to 100mg of Zoloft. After a rough couple months i recovered and started teaching tennis. Over the next 5 years life was pretty good. I got married, had a couple of kids bought a house. Man i was living the dream (mostly). During this time i would have a few setbacks here and there but nothing to seriously. Anxiety would show its face from time to time but for the most part i was able to get through it.
Five years later (2008) i had a very rough summer. There was nothing in particular that would cause my anxiety to come on. It just seemed to have a mind of its own. At this point i went up to 150mg for about 1.5 months then up to 200 after that. After a couple months i seemed to stabilize and went on with my life. Over the next few years i would once again have little periods (mostly a couple weeks) where i didn't feel right but nothing i wasn't able to manage. I then went about 4 years with nothing. I was even able to go to the Philippines with my family which i would have never been able to do before. In the fall of 2015 i dropped my dose down to 150mg. i did this mostly because my main side effect was being tired. It didn't help much with the sleepiness but it didn't affect my anxiety state either. That is until march of last year.
Last March i had i pretty big relapse so my pdoc decided to put me back on 200mgs. After about 5 weeks of hell i started to come out of it and it was time to get going with life again. At the beginning of June it all came crashing down on me again. i was very frustrated and scared not wanting to deal with this again after such a short period of relief. In the past i had never had an episode so quickly again. So we tried buspar which didn't seem to do anything (although i don't think i gave it a fair enough chance), enlyte which didn't do anything as well. So after another 6 weeks of struggle we decided to try a new med.
Enter Celexa. I started on 20 mg. The funny thing is at around this time i was starting to feel better. I never made it to feeling 100% but i definitely had a good month in a half. Around this time though the anxiety started to come back so we slowly increased my dose to 40mg. Over the next 6 to 8 weeks i was still not improving so we decided to try something else.
Next on the list was cymbalta. I started at 60mg. I would have some decent times but mostly rough ones. We then moved it to 90 and eventually 120 by the middle of December. I slowly started to improve where January i felt ok and February i was pretty close to 100%. Until i about a week ago the anxiety started creeping back in to the point where the last couple days i felt pretty miserable.
Sorry for the long post but now it is on to the questions.

1. Ian do you remember my post from AZ last year?

2. What next? I'm pretty discourage at the moment. Should i just stick it out on the cymbalta for a bit long to see if i can come out of it? Im not suposse to see the doc again till the end of the month. Ive tried 2 ssri and now an snri and im having trouble finding something that clicks with me. I know TCAs are an option but im a bit concerned with these. I know they have more side effects. Plus i believe there is some interactions with food and alcohol. (I could be wrong here)

3. I recently had a physical and blood work. I came back with low white blood cell count. My pdoc thinks it is probably from the cymbalta but she doesn't know for sure so i am in the process of making an appointment with a hematologist. Have you heard of ADs causing a decrease in white blood cells.

4. In the blood work it also showed that i have the double recessive gene in the mthfr 677C>T. So about 2 weeks ago i started taking enltye again. Do you think this is a waste of time or something that could help me. I seem to have gotten worse since i started on it. Although that is probably just a coincident.

Thanks for the replies in advance. I am sure i will have some more questions soon.

[panic_down_under]

1. Ian do you remember my post from AZ last year?

Sure do, though I'd forgotten some of the details - just another sign of the advancing years :weep: - so thanks for the recap.


Should i just stick it out on the cymbalta for a bit long to see if i can come out of it? Im not suposse to see the doc again till the end of the month.

After nearly 3 months at 120mg it might be time to pulls the plug. I definitely would if there isn't a significant improvement by the end of the month.


Ive tried 2 ssri and now an snri and im having trouble finding something that clicks with me. I know TCAs are an option but im a bit concerned with these. I know they have more side effects.

Well so far you've been playing with popguns. It might be time to bring out the TCA cannons. Either imipramine (Tofranil), or clomipramine (Anafranil) would be good initial choices. The latter is the more potent of the two - and arguably the most potent non MAOI antidepressant currently on the market, but it can be a more sedating than imipramine.

The TCAs can produce more ongoing side-effects, mostly nuisance ones such as dry-mouth and constipation which are manageable. I was on 350mg of imipramine for several years and and the side-effects weren't too bad, but YMMV.


Plus i believe there is some interactions with food and alcohol.

Only the MAOI class antidepressants have food restrictions, but thanks to modern food processing techniques this is now much less of an issue then when I tried one nearly 30 years ago. Plus, adding a moderate dose of one of the norepinephrine/noradrenaline reuptake inhibitors such as the TCA nortriptyline (Pamelor) blocks the tyramine pressor response (http://www.wikiwand.com/en/Tyramine) making it possible to eat nearly everything.

Alcohol should be limited with all antidepressants. The TCAs are no worse than the others.


Have you heard of ADs causing a decrease in white blood cells.

Yes. It isn't a listed duloxetine side-effect, but there are isolated case reports of it occurring with nearly every antidepressant (and many other medications). Adding some lithium will usually correct the problem and may be beneficial for anxiety too.

UPDATE: Low white blood cell count - leukopenia - wasn't listed in the duloxetine monograph I looked at, but it is listed in the Patient Information data - p11, PDF (https://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/EnforcementActivitiesbyFDA/WarningLettersandNoticeofViolationLetterstoPharmac euticalCompanies/ucm054172.pdf), as is increased WBC count.


4. In the blood work it also showed that i have the double recessive gene in the mthfr 677C>T. So about 2 weeks ago i started taking enltye again. Do you think this is a waste of time or something that could help me.

I keep reading about how great enltye type supplements are, but the handful of AZ posters that tried it were disappointed so I'm not convinced by the hoopla. However, there's probably no harm in taking it...except maybe to your wallet, and who knows, the microbes living in your sewer may get a kick out of it. :D

[pokerfan]

Thanks for the quick response.

You mentioned that Anafranil is the most potent AD. What does this mean exactly. I guess my question is what makes it more potent? Couldnt you just take more of another AD to increase the potency or do they not work this way?

Also my doctor was talking to me back in December before i had a bit of a remission about the next possible choice of ADs. When i was on zoloft i had a bit of an issue with delayed ejaculation. That has pretty much gone away with the cymbalta. her thought was this might mean that i am lacking a bit on the serotonin part of the snri. Since my family has had some success with Prozac she thought we might try dropping the cymbalta to 60 and adding Prozac. What do u think of this idea. Or would it be best to just go for the TCA?

[panic_down_under]

You mentioned that Anafranil is the most potent AD. What does this mean exactly. I guess my question is what makes it more potent?

How strongly it binds to receptor, or transporter molecules. Anafranil binds to the serotonin transporters as well as all but most potent SSRI, paroxetine (Paxil), but is also a very potent inhibitor of norepinephrine/noradrenaline reupatke through its main metabolite.


When i was on zoloft i had a bit of an issue with delayed ejaculation. That has pretty much gone away with the cymbalta. her thought was this might mean that i am lacking a bit on the serotonin part of the snri.

Hmmm. Just about every antidepressant attracts the same complaint so I wouldn't read to much into this.


Since my family has had some success with Prozac she thought we might try dropping the cymbalta to 60 and adding Prozac. What do u think of this idea. Or would it be best to just go for the TCA?

I'm not a fan of poly prescribing. Why take two meds when one should be capable of doing the job? It is sometimes necessary, but it should be among the last options. Secondly, you've now had two SSRIs and one serotonin biased SNRI poop-out so adding another SSRI is likely to be a long shot, imho.

In fact, on reflection, I think a norepinephrine reuptake inhibitor such as the TCAs nortriptyline (Pamelor) and desipramine (Norpramin) and the SNRIs milnacipran (Savella) and levomilnacipran (Fetzima) should also be on the list of alternatives with Anafranil and Tofranil). Anafranil would still be my top pick, followed by either nortriptyline or desipramine.