Can you take two SNRI together?

[lebonvin]

Specifically venlafaxine and duloxetine, 150mg and 20 mg. A search will tell you you'll get serotonin syndrome which a guy here said is so rate that most doctors ain't never dealt with a case.

The pharmie I use is run by these real nice Indians. I find if I ask two docs about a medication they'll say two different things.

I figure that a pharmie get to see a lotta prescriptions from docs all over the area and so form their own judgment what is in common use. So this pharmie told me that mirtazspine is often added to venlafaxine but I can't take it because it gave me the mother of all side effects. She then said that Cymbalta can be added to Effexor in a low dose. Was kinda surprised but not doubting her experience.

Has anybody here ever taken both at the same time? I know that panic down under says that Effexor isn't really an SNRI.

[panic_down_under]

Specifically venlafaxine and duloxetine, 150mg and 20 mg. A search will tell you you'll get serotonin syndrome which a guy here said is so rate that most doctors ain't never dealt with a case.

That's because not many doctors would attempt what you're suggesting. Might you get away with it, possibly, although I wouldn't risk it for the reason I highlight below, but my question is why would you do this anyway? At that dose the amount of noradrenaline/norepinephrine reuptake inhibition from duloxetine is not going to add much. It would be better, and possibly cheaper, to add a small dose of one of the noradrenergic/norepinephrinergic TCAs nortriptyline, or desipramine. Or simply switch to duloxetine, or levomilnacipran, or a TCA such as clomipramine, or imipramine. Another option would be to 'roll your own' SNRI by combining sertraline with nortriptyline, a favourite combination of old time psychiatrists who understand antidepressants don't begin and end with SSRIs and SNRIs.


I know that panic down under says that Effexor isn't really an SNRI.

It was an opinion formed when I tried venlafaxine back in the early 1990s. I can't tolerate SSRIs, they make me manic. So did venlafaxine, but not duloxetine. Plus, guys actually qualified to make that call have long claimed the same, for example: Venlafaxine: an enduring SNRI myth (https://psychotropical.com/venlafaxine-an-enduring-snri-myth/) - btw, note the warning about serotonin toxicity. And it's borne out by the pharmacology (https://en.wikipedia.org/wiki/Pharmacology_of_antidepressants#Receptor_affinity) . The NE transporter (NET) binding potential of venlafaxine is 2,700 Ki, for duloxetine it is 5.9 Ki (lower is better). That is a huge difference. The SSRIs paroxetine (NET=56.7 Ki), fluoxetine (NET=660 Ki) and sertraline (NET=667 Ki) are more potent SNRIs than venlafaxine, albeit still only very weak ones.

[lebonvin]

Hi panic

I don't got the medical knowledge to question your advice.

I'm a bit confused so a few more questions for yer

If Venlafaxine works for a few years then poops out, would your next AD be SSRI or SNRI if you can't get TCA?

If for any reason you had to come off venlafaxine and given the difficulty of doing it, would it be easier to switch to a different AD then come offs that instead like using valium to come off another benzo?

You says you was taking duloxetine but then somewhere else you said you take TCA. What happened tomakev you change AD?

If I could roll my own as you put it, how much sertraline dose and how much of the other stuff would you need?

Thanks

Charlie

[panic_down_under]

If Venlafaxine works for a few years then poops out, would your next AD be SSRI or SNRI if you can't get TCA?

If I remember right, SSRIs have not worked for you in the past which leaves SNRIs as your best option in the absence of TCAs, or MAOIs. They are certainly better, imho, than going down the antipsychotic route straight away which is likely what your doctor will suggest.


If for any reason you had to come off venlafaxine and given the difficulty of doing it, would it be easier to switch to a different AD then come offs that instead like using valium to come off another benzo?

Yes. Trying to quit venlafaxine directly is unwise. The usual tactic is to switch to fluoxetine (Prozac) and weaning off it. Given its very long half-life and the even longer one for its active metabolite, fluoxetine is essentially self-tapering, though I'd still taper the dose too.


You says you was taking duloxetine but then somewhere else you said you take TCA. What happened tomakev you change AD?

Duloxetine didn't send me manic, the problem was it didn't work therapeutically either. Seems the only ADs I respond well too are TCAs and MAOIs.


If I could roll my own as you put it, how much sertraline dose and how much of the other stuff would you need?

Firstly, can you get nortriptyline given it's a TCA?

This is one of those how long is a piece of string question which can only be answered with 'it depends.' There are two ways of approaching it, either make sertraline the primary AD and supplement it with nortriptyline, or do the reverse. Given the potential roadblocks to getting a script for nortriptyline it would probably be better to make it the secondary med as the dose will be lower. Either way ramp the main AD up to a highish dose and if it doesn't adequately treat the anxiety (or depression) begin slowly ramping up the other in small incremental steps. It will help having a knowledgeable doctor to monitor and guide the process.

[lebonvin]

Thanks for that panic

Charlie