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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 7 of 7. This is the beginning of the thread.
Posted by tonyz on April 20, 2010, at 15:35:48
My pdoc wants me to do the following, but checking the drug interactions checker on drugs.com, I'm not very comfortable. Opinions please.... here's the cocktail:
Nortriptyline was 125mg reduce to 75mg
fluvoxamine start at 100mg
lithium continue at 600mg
remeron (had taken 15-30 past few days) stop
restoril 30mg
clonazepam 1mgI'm concerned with the potential interactions between lithium and fluvoxamine and fluvoxamine and nortriptyline.
Posted by linkadge on April 20, 2010, at 16:38:33
In reply to How dangerous is this combination, posted by tonyz on April 20, 2010, at 15:35:48
The fluvoxamine and nortriptyline should be ok in terms of CNS interaction. There is the potential that one will affect the blood level of the other, but I'd have to check the specifics.
I think the issue is the lithium and fluvoxamine. The lithium can increase the serotonergic effects of the fluvoxamine. I would start at 50mg of fluvoxamine if you can break the tablets. You may even want to start at 25mg if you can quarter the tablets.
You might also consider lowering the lithium to 300mg before starting a low dose of fluvoxamine.
Fluvoxamine can be a potent antidepressant, and I would think that it (in combination with nortriptline) could be very effective for depression.
Fluvoxamine (on its own) can help sleep, but I'm not sure how it would interact with lithium or remeron.
I've been on all these meds (not in combination however). I think with tweaking some of these meds you should get some relief.
I've been on a remeron + fluvoxamine combination and that was pretty damn good. Nortriptyline + fluvxamine is probably also a very good combination. Adding a wee bit of lithium to these might bo ok, but be careful for serotonin syndrome like effects. If you can stop (or reduce) the remeron before starting the fluvoxamine, this might help reduce interaction possibilities.
For some reason, lithium + SSRI never seems to agree with me. I do well on SSRI's and lithium alone, but the combination does some strange things.
Theoretically, all of remeron, nortriptyline, lithium and fluvoxamine can increase serotonin activity. So, together could be a problem.
Linkadge
Posted by tonyz on April 20, 2010, at 17:22:45
In reply to Re: How dangerous is this combination, posted by linkadge on April 20, 2010, at 16:38:33
Linkadge - really appreciate your response. Gives me some encouragement that maybe something will start working here. I am worried about the combination of meds and the chance of the Nortriptyline blood levels rising - I'll see if I can find some info on this.
Anyway before reading your post, I had decided to reduce the starting dose of the fluvoxamine to 50mg. Ditched the remeron and ditching the LI for today.
Posted by bulldog2 on April 20, 2010, at 17:53:46
In reply to How dangerous is this combination, posted by tonyz on April 20, 2010, at 15:35:48
> My pdoc wants me to do the following, but checking the drug interactions checker on drugs.com, I'm not very comfortable. Opinions please.... here's the cocktail:
>
> Nortriptyline was 125mg reduce to 75mg
> fluvoxamine start at 100mg
> lithium continue at 600mg
> remeron (had taken 15-30 past few days) stop
> restoril 30mg
> clonazepam 1mg
>
> I'm concerned with the potential interactions between lithium and fluvoxamine and fluvoxamine and nortriptyline.Luvox is not the right ssri for this combo. It has to many drug interactions and who knows how high the levels of the other drugs might go to. I would express your concerns to your p-doc.
Posted by bleauberry on April 21, 2010, at 17:51:17
In reply to How dangerous is this combination, posted by tonyz on April 20, 2010, at 15:35:48
Well, the interactions concern is a valid one. You could do more research on that with google, since your doctor doesn't look to me like he is displaying signs of expertise in that matter.
What worries me more than that however is the rapid and huge changes in meds. Cutting Nortriptyline in half in one move? Dropping remeron without a long taper? Yikes. For most people, moves that create some severe discomfort and destabilization. I would take it a lot slower and in much smaller steps, personally.
Posted by linkadge on April 21, 2010, at 17:55:07
In reply to Re: How dangerous is this combination, posted by bleauberry on April 21, 2010, at 17:51:17
I think that blueberry has a point. You want to make sure you don't go too fast for your system to adjust.
I would recomend tapering off the lithium a little slower if you do. Going from 600mg to 0 could be a little too fast. You might notice some rebound instability or sensitivity to light/sound.
I wouldn't worry too much about interactions between the nortriptyline and fluvoxamine. On paper, there shouldn't be an interaction, and a blood test can tell you if you have too much nortriptyline in your system.
Linkadge
Posted by tonyz on April 21, 2010, at 19:20:12
In reply to Re: How dangerous is this combination, posted by linkadge on April 21, 2010, at 17:55:07
Thanks again for the quick responses to my posting, and although my doctor assured me it was safe he suggested reducing the Nortriptyline to 50mg and agreed with 50mg starting dose of fluvoxamine, but wanted the Lithium back to 600. The remeron I had only been on a few days so I think stopping it should not be a problem.
I think the issue with fluvoxamine may be more of an issue with other tcas, but not absolutely sure,
Took the Li and fluvoxamine this morning, no problems that I noticed. I'm a bit worried about the interaction with fluvoxamine and lithium, but since nothing has happened, I'm probably ok.
Hopefully, sleep will be better tonight.
Thanks again guys.
This is the end of the thread.
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