Mixing a tricyclic with bupropion

[paranoid android]

I have been having a fuck of a hard time sleeping lately even though i am on 6mg's of clonazepam a day, 150mg's of morphine or if i run out of my script early 18 to 54mg's of IV hydromorphone and 300-400mg's of quetiapine all taken at night. My sleep is completely fucked up and not really restful at all. My doctor thought that a tricyclic might help and i have been on amitriptyline before with good results. I found it to be the best sleep aid i have ever taken and it's the only anti-depressant i have taken besides bupropion that worked and didn't drive me manic.

I have been on 100mg's of amitriptyline and 300mg's of bupropion before but not while i have been on quetiapine. I take lamotrigine, quetiapine and bupropion to control my bipolar disorder but even when i am not manic sleep is difficult. Zopiclone only works for a maximum of 3 days before i have to take a break for atleast another 3 days. My doctor is wary of adding a hypnotic benzo like temazepam or nitrazepam to the mix as i am already on clonazepam and combine that with the morphine and quetiapine and it's no wonder he is wary of adding another benzo.

I am thinking of either trying amitriptyline or doxepin. I have heard that doxepin is so sedating that it makes amitriptyline look like a amphetamine by comparison and that is saying alot . I don't want to have to go off the bupropion as it does help my bipolar depression alot and it also helps my seasonal affective disorder that nails me every winter. I know amitriptyline is basically a SNRI with heavy anti-cholinergic side effects and doxepin is basically a norepinephrine reuptake inhibitor with strong anti-histaminic and anti-cholinergic side effects. Bupropion is a norepinephrine and dopamine reuptake inhibitor. Bupropion is also a potent cyp2d6 inhibitor which is the liver enzyme that is needed to metabolize amitriptyline but the bupropion didn't seem to have a negative effect on how the amitriptyline worked the last time i was on this combo.

I would like to get peoples opinions on how good or bad of a idea it would be to add a tricyclic to this mix. My mood has been good lately so i really don't want to fuck it up by adding another drug to the mix but the insomnia is killing me. Would adding 2 drugs that are norepinephrine reuptake inhibitors increase the risk of mania? I'm just sorta at a loss here as on one hand i don't want to set off rapid cycling or anything but as the same time i need some fucking sleep

Any help or advise would be much appreciated.

 

[ebola?]

1. This forum isn't really here to tell you what drugs to take.
2. At this point, the mixture of psychoactive drugs you're taking is so complex that no one can really tell you what the results will be before you try something out. Basically, anything blocking reuptake of (or releasing) any monoamine will risk inducing mania and subsequent cycling. Concurrent administration of an anti-psychotic might 'balance things out', but we can't know for sure a priori.

ebola

 

[sekio]

I don't think adding more drugs to that cocktail is the solution...

Try a milder sleeping aid like doxylamine or diphenhydramine before you go to a tricyclic, I think. TCA's are very dirty drugs that have many interactions.

 

[TCMVegas]

Many MD's have a shitty policy of trying to fix side effects with more drugs. And most "advanced" posters think MDs are often, if not usually, poor at neuropharmacology.

Frankly, if you're on (extremely high) doses of opiates like that, it "ruins your sleep architecture", as Epsilon Alpha put it. Bupropion alone causes insomnia, at doses half of what you take.

You're on:
An NDRI,
A sodium channel blocker
A dopamine antagonist (at the same time as an NDRI...)
High dose opiates

I personally consider it stupid to add a TCA to the mix unless you've tried the huge number of simpler combos first. It would be wise to drop the opiates first. Should enhance sleep quality. If insomnia persists, or of you can't quit opiates first, drop the bupropion to 150mg or get off it.

If you took every psych drug that exists, you'd have side effects... which shouldn't be treated with more drugs.

 

[Morphling]

Amitriptyline produces some pretty funky side effects. I'd be pretty wary about adding that to your little cocktail. I've taken it concurrently with Pristiq, but at a low dose. Therapeutic benefits do begin at 20mgs, I believe.

 

[atara]

Let me get this right.

You are on: quetiapine, clonazepam, hydromorphone, lamotrigine, and bupropion? 8(

I have no idea. Progenitorivox beats diet and exercise. There's basically no way a tricyclic is going to help you sleep, and antihistamines won't either, because quetiapine is such a potent antihistamine and antiserotonin that the tricyclic won't have any receptors left to bind to. It might make sense to drop both [not quetiapine] lamotrigine and bupropion in favor of a tricyclic, but it also might make sense to invade Russia from the east, what do we know, nobody's ever tried it. Lamotrigine alone has such weird pharmacology that nobody ever knows what's going to interact with it.

Lamotrigine is generally accepted to be a member of the sodium channel blocking class of antiepileptic drugs, but it could have additional actions since it has a broader spectrum of action than other sodium channel antiepileptic drugs such as phenytoin and carbamazepine and is effective in the treatment of the depressed phase of bipolar disorder [...] Calabrese found that lamotrigine was effective in individuals with bipolar depression, with a number needed to treat (NNT) of 11

One in eleven people with bipolar depression will experience improvement with lamotrigine. Do you like those odds? GlaxoSmithKline likes those odds, if it doesn't work you'll take more, won't you?

a retrospective study of 109 patients' medical records found that 6.7% of patients experienced an 'alerting effect' resulting in intolerable insomnia, for which the treatment had to be discontinued

Worth considering. The thing is it's really hard to go to a doctor and ask to have a medication reduced, especially if it treats bipolar disorder, "I heard about side effect X" and you sound like you're in a mental ward refusing to eat, but it can't hurt to ask, the two things that could be keeping you up are lamotrigine and bupropion, that and the huge tolerance you've no doubt developed to benzodiazepines and atypical antipsychotics, but it's too late to turn back now. Lamo, what a great name, doesn't treat rapid cycling anyway, that's all seroquel's doing:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2580079/

My suggestion would be to drop lamo and lower your dosage of bupe. If you need energy during the day coffee may be a good idea, and if you are depressed then amitryptiline becomes a possibility. Tapering clonazepam will probably improve your life once this is all settled, let me express that differently, I don't know anyone who is on benzos long-term and happy about it. Obviously only a good idea if everything is mostly stable, which means not right now.

Low-dose buspirone may help bipolar depression in conjunction with a mood stabilizer see http://www.karger.com/Article/Abstract/235985 but should not be used without one see http://psycnet.apa.org/psycinfo/1990-12984-001

Weed is either good or bad depending on who you voted for in 2012, what state you live in, and, of course, the phase of the moon, the price of tea in China, and the weather in London:

http://journals.lww.com/jonmd/Abstr...nnabis_Use_Affect_Treatment_Outcome_in.7.aspx
http://www.tandfonline.com/doi/abs/10.1080/02791072.1998.10399687#.UgKBL37dkmM
http://jop.sagepub.com/content/19/3/293.short

edit: removed some accidentally terrible advice, wrote quetiapine where i should have written lamotrigine, stupid.

 

[truckeeman]

You have quite a mix going on. I have met with only one or two Dr's in my long life that could even understand the chemical reactions at work. That being said, I can tell you that Doxepin is a powerful and effective sleep med that works when others will not. It does have next day drowsiness, but generally a 5 minute sit in the sun will take care of it. I am treatment experienced as well, although you may take the cake. I have taken high doses of Dexedrine for ADHD since I was 5 y/o and in later life, have taken many AIDS meds that are not too much fun, one of which is a CYP450 inhibitor. At times Doxepin is the only thing that works for me. Years ago a 10mg dose knocked me out..recently it took up to 150mg to put me out. My Dr. tells me 300mg is safe as a daily dose. I titrated to get myself down to 50mg per day for fear of CYP450 issues.

I don't knowingly have the psychiatric issues you describe although nothing would surprise me at this point, so I can't really talk to your question about 2 norepinephrine reuptake inhibitors and how that would affect you. What I do know id that without good sleep, nothing else matters and that benzos are evil drugs that should be outlawed..they do much more harm than good. Another drug you should look into is Trazadone. I know many that use it for years without any apparent side neg. effects.

 

[truckeeman]

atara. LMFAO all night long. thx.

 

[paranoid android]

Well dropping the opiates or lamotrigine is not a option at this point. I have trigeminal neuralgia and have tried just about everything else for it but only opiates bring the pain down to a level where i can function. The lamotrigine has helped my bipolar disorder more then any other drug i have tried though i have been thinking about trying lithium so that maybe i can get off the goddamn quetiapine before i come down with type 2 diabetes or some shit. I am on alot of meds but much to everyones surprise i am not dopey at all unless i overdo it on the opiates or smoke way too much indica. I have met doctors who couldnt believe that i was on that many different meds at those doses simply because i don't look impaired. But i have always seemed to build a fast tolerance to everything so maybe that explains it.

I have already tried diphenhydramine, doxylamine and hydroxyzine for insomnia. They only seem to work for a week at most if i take them every night. They do help to edge me off to sleep if i haven't taken any anti-histamines in awile. For some reason even though quetiapine is a potent H1 antagonist it doesn't seem to block the effects of anti-histamines. Then again every one of those drugs besides hydroxyzine is also a strong anti-cholinergic and quetiapine is not a very potent anti-cholinergic at all so maybe that's why they still work.

You guys are right there is no way to predict what will interact with what and any medication that increases the levels of serotonin, norepinephrine or dopamine can trigger mania. It's just that some do it worse then others.

Thanks for all the advice guys . Mods feel free to close this if you wish.

 

[Hammilton]

If I'm not mistaken, currently one, if not the, most fatal combinations happens to be opioids combined with TCA's and/or SSRI's. Unless your doc is aware that you're taking that much hydromorphone at a time, IV no less, I would be real careful about adding more potential interactions.

 

[paranoid android]

If I'm not mistaken, currently one, if not the, most fatal combinations happens to be opioids combined with TCA's and/or SSRI's. Unless your doc is aware that you're taking that much hydromorphone at a time, IV no less, I would be real careful about adding more potential interactions.

Really? I could see it happening with a tricyclic because of the added respiratory depression through the strong anti-cholinergic effects but i never knew a SSRI could do it. Though i do know they interact with certain opioids such as tramadol and Demerol.

My doctor of course doesn't know that i slam that much dilaudid. I only take the dilaudid if i run out of my regular pain meds or if i just wanna get high and yes i already know i should keep my opiate use at prescribed levels.

 

[sekio]

SSRIs can potentiate opioids in a variety of situational-specific ways (enzyme induction and inhibition, protein binding competition) - and it is much better to be safe than dead.

 

[atara]

Oh, um, also, there's always melatonin. Melatonin, however, has complex interactions with bipolar disorder, despite being otherwise mild, so ask the doctor. Surprised nobody mentioned it. Agomelatine (melatonin agonist) is likewise sedating, though I've never heard of it used as anything but an antidepressant:

In depressed patients, treatment with the drug increased slow wave sleep without modification of REM (Rapid Eye Movement) sleep amount or REM latency. Agomelatine also induced an advance of the time of sleep onset and of minimum heart rate. From the first week of treatment, onset of sleep and the quality of sleep were significantly improved without daytime clumsiness as assessed by patients.

Trigeminal neuralgia is a fucking hell of a disease, I wish you luck, also lithium is not really that bad the only thing is you'll have to get used to drinking shittons of water. I looked it up and found this:

Serious complications of an MVD may include death

and laughed a little, because that is, in fact, a serious complication.

i am not dopey at all unless i [...] smoke way too much indica.

If that isn't normal I am doing something horribly wrong.

 

[paranoid android]

SSRIs can potentiate opioids in a variety of situational-specific ways (enzyme induction and inhibition, protein binding competition) - and it is much better to be safe than dead.

Well SSRI's are out for me anyway. The closest thing i have ever taken to a SSRI was the SNRI venlafaxine. This was years before i was diagnosed as having bipolar disorder and this medication made me completely insane. At the dose i was on which i think was 150mg's of the XR version it was likely only acting as a serotonin reuptake inhibitor and maybe acting abit on norepinephrine. I was only on that med for 6 weeks at the most i think but it scared me off all psych meds besides benzos for years. This was about 10 years ago so my memory is a tad fuzzy but i could never forget the awful side effects i got while on the med and the absolutely brutal withdrawal symptoms i had coming off this supposedly non addictive medication . I would happily go through the worst opiate withdrawals I've had rather then to go through a day of that ever again. Although amitriptyline is also a serotonin norepinephrine reuptake inhibitor granted with strong anti-cholinergic side effects it never gave me any withdrawal symptoms despite being on it for years and being on 150mg's a day which is the highest outpatient dose.

I know that many tricyclics, SSRI's, SNRI's as well as bupropion act as cyp2d6 inhibitors. This would pose a problem with say codeine or dihydrocodeine but i don't think either morphine or hydromorphone need that enzyme to be metabolized at all. Besides there is no way my doctor would consider giving me a SSRI as he is rather cautious about giving me any psych meds that may destabilize my moods and besides i would never take one. The only reason he brought up trying a tricyclic is to see if it would help my sleep patterns and also to help my insomnia and actually give me some restorative sleep. The only anti-depressant i have been on besides bupropion that worked and didn't drive me batshit was amitriptyline so that is why he mentioned it.

I am not going to even pretend i know anything about protein binding so i will just take your word on that.

Oh, um, also, there's always melatonin. Melatonin, however, has complex interactions with bipolar disorder, despite being otherwise mild, so ask the doctor. Surprised nobody mentioned it. Agomelatine (melatonin agonist) is likewise sedating, though I've never heard of it used as anything but an antidepressant:

I am abit wary of melatonin as a few people i know with major depression said it plunged them into a fit of depression for awile after waking up and i have known more then a few people who said it made their dreams very vivid. Agomelatine is not available in Canada and in fact none of the melatonin agonist's seem to be on the market here yet. so that one is out for me. Also i do know people who have been on melatonin agonist's and i have not heard much good about them atleast in treating depression anyway. I tend to get the depression part of bipolar abit more then mania so that worries me and i also already get awful vivid nightmares where i actually feel depressed while having the nightmare. These nightmares often leave me feeling horribly depressed after i wake up and it can take a long time to shake that feeling. The only thing that seems to stop the nightmares is smoking Cannabis right before i go to sleep. Hash and indica strains of weed like kush or sour diesel seem to work the best at keeping the boogeyman at bay. It also helps my sleep quality and my insomnia but do to lack of funds and the very iffy supply here lately where i live (i am not paying good money for shit weed fuck that plus there's no point) i can't smoke it as often as i would like or need to. I did get some purple kush the other day and i managed to get the best sleep i have had in weeks but now i can't afford anymore for about a week or so.

Trigeminal neuralgia is a fucking hell of a disease, I wish you luck, also lithium is not really that bad the only thing is you'll have to get used to drinking shittons of water.

Tell me about it . I thank fuck that i now have it under control because there was a point where i wouldn't shave unless i was doped to the gills on opiates and i refused to go outside if it was windy or cold. Actually at my worst i basically just became a total shut in as i was in constant fear of another attack of face pain which usually triggered off a bout of vomiting as the pain would be so intense that i would just keep dry heaving long after everything was already up. But ever since i had my morphine dose increased from 120mg's a day to 150mg's about a year and a half ago I've been the most pain free for the longest amount of time since i got this stupid fucking disease . To say the very least i really wish i had paid for a root canal instead of getting that tooth pulled . Since the meds still work for me and as i think that the surgeries used for TN should be a absolute last resort especially since just about everyone i know who has had any of the surgeries has had only very minimal relief that didn't last. Not to mention that they all scare the living shit out of me so i am not even considering them at this point. I may consider them down the road if i reach the point where the 100UG fentanyl patches don't even work anymore but thankfully my tolerance to the analgesic effects seems to have leveled off. If i have to go on such a high dose of morphine where the side effects become a problem i would consider switching to methadone as i have heard it's great for neuropathic pain. Too bad you need a special license to script it and there are only maybe 2 doctors anywhere near my area that have a license to do so.

I have heard good things about lithium and it seems to work for alot of people i know far better then many of the other drugs commonly used such as lamotrigine and divalproex. I have been on carbamazepine which i tried for trigeminal neuralgia which not only didn't work on either my trigeminal neuralgia or my mood swings but after a few weeks of being on it i got sick as i have ever been in my life as well. Epival which is what they call divalproex here in Canada did absolutely fuck all in terms of either good or bad side effects though i think it may have made the depression side abit worse but i can't quite remember. After that failed my psych suggested i try either lithium or lamotrigine. Since i live a hour's drive outside of the city and i would have to get a run to the hospital there to get blood tests (the last time i checked the so called clinic down here no longer did blood work) it would be a hassle to say the least. I would like to try it in combination with lamotrigine so that i could probably drop the quetiapine and bupropion atleast.

If that isn't normal I am doing something horribly wrong.

Well yeah pretty much . I prefer indica strains because it helps with my nerve pain as well as the insomnia more then sativa strains do. Plus the relaxing i am sinking into the couch feeling i get after a few bowls of purple kush is mighty handy when your stressed the fuck out all the time because of your living situation . Opiates don't really relax me much these days unless i chuck back a load of morphine with a benzo. Sadly the rush from IV dilaudid and morphine doesn't last nearly long enough to keep me relaxed for more then 30 minutes at best.