EMSAM 6mg + 20mg fluoxetine == serotonin toxicity?

[cr33py]

Posting for a friend who is on EMSAM 6mg and accidentally took 20mg fluoxetine along with her vitamins. Shes pretty depressed / anxious already and is trying to avoid going to ER due to anxiety with leaving the house, etc. Seems pretty intense so I believe her. Not sure how you take prozac with your vitamins. Dont think it was a suicide attempt or anything, not at that dose. She hasnt demonstrated any borderline-like attention seeking stuff before either.
Only advice I could give her (besides go to the ER) is watch heart rate, blood pressure, reflexes, clonus, fever, all those classical ST symptoms.
Two things I think will probably work in her favor though, the dosage is low even considering the extra bioavailability you get with the dermal patch. also shes pretty overweight (like 250lb) so the amount of MAO inhibition she has is probably not that high.
Shes on a low dose of topiramate 50mg for weight control but if she did have seizure activity thats not going to do much.
18 hours after she took the fluoxetine, no symptoms of ST yet. How long does it take to show symtoms of ST if its going to be an issue?

 

[cr33py]

well if anyone is curious she had zero symptoms aside from anxiety.
I think her weight and dosage had a big effect on the outcome. if she was on 12mg emsam and took that, would probably have been a different story.

 

[plumbus-nine]

Yeah, as long as one remains in the dosage range of selegiline (EMSAM, deprenyl etc) which is selective for MAO-B, there's little danger for serotonin toxicity. Still, EMSAM was specially designed to reach MAO-A levels without interfering too much with tyrosine metabolism in the gut, and 20mg fluoxetine don't fully inhibit SERT but a good part of it.. so I'd call it luck, thankfully it was such. Serotonin toxicity can be serious.

I've probably bramaged some drain when as adolescent I took a recreational dosage of DXM (like 350mg+) and downed the first, newly prescribed 20mg paroxetine on top. Got some anxiety, restlessness etc. but in retrospective what most worries me is that it was the last time ever I got full-color CEVs from any substance, besides LSD, strangely. These CEVs were pretty unlikely anything before, like one of these patterns from oriental carpets, but frozen. Completely frozen, no movement at all, despite opening and closing the eyes etc. Oh, and it scared me, even then. Granted, DXM can have a demonic aura but that one was weird. Oh, also the LSD took like 4 hours for any visuals to set in, and one DXM trip afterwards had again some color, just hints of, but at least.

LSD repairing serotonergic damage??

But @cr33py, may I ask how the EMSAM affects her, if possible compared to oral/sublingual selegiline or other antidepressants? I'm thinking about giving it another try but 5mg oral were just increased aggression.. :/

 

[cr33py]

Not sure. She seems less irritable on it than she was on SSRIs. But without the numbing of the SSRI she seems to respond to things that trigger intense sadness. That can be a good thing in therapy, sometimes.
She would probably do better on 12mg or on a stronger MAOI but has tried those and the sedation was very difficult and if I remember her doctor was against prescribing any stimulating medication for that, even modafinil.
I looked that up and there is a contraindiction with that, something about dopaminergic toxicity. despite this being a popular combo for many years in the past.

as far as the irritability on SSRIs my theory is this is anxiety from excess stimulation. Try taking some benzos for a day or two and you may notice this 'resets' your apathy on the medication as well.

 

[sekio]

it need 24h for st to be seen, its better to take anti oxidative stress med like vit c to avoid brain damage,

Serotonin syndrome occurs pretty rapidly after the wrong cocktail of drugs is ingested. And vitamin C is not going to prevent damage at all.

If you don't see SS when the C_max of the drugs hits (i.e. the point where the drug has the highest concentration, usually about 20 min-2 hours after ingestion) then it will not usually occur later, as the drug concentrations drop slowly.

I've probably bramaged some drain when as adolescent I took a recreational dosage of DXM (like 350mg+) and downed the first, newly prescribed 20mg paroxetine on top.

DXM is already a SNRI, 20mg of paroxetine won't tip the scales I don't think
that said don't take DXM and antidepressants

 

[plumbus-nine]

DXM is already a SNRI, 20mg of paroxetine won't tip the scales I don't think

Yeah, I didn't suspect anything for longer either but remains the point that afterwards I only ever got black/white shadowy CEVs and no more full color. They always say SS comes when introducing a new serotonergic to another and that one strong SSRI can be enough under certain circumstances which is weird too.

I somewhat abused the combination of venlafaxine 150mg + DXM 60-150 mg/d after this incident for its reliable hypomania inducing effects and didn't get anything bad even from going higher but then again hypomania should maybe be a warning sign of that it wasn't low serotonin which caused your symptoms.

 

[plumbus-nine]

As an anecdotal experience I found emoxypine to abolish the rebound from -phenidates, which seems to confirm that it's a powerful antioxidant maybe taking the free radicals from dopamine oxidation - would this one help to protect against serotonin syndrome related damage too?

 

[sekio]

As an anecdotal experience I found emoxypine to abolish the rebound from -phenidates, which seems to confirm that it's a powerful antioxidant

those two things do not correlate... for instance BHT is an antioxidant but I don't think it will do dick for comedowns