Mirtazapine (remeron) And Duloxetine (cymbalta)

[Kas_Can_Fly]

I had been taking 30mg Mirtazapine since late December with some pretty poor results. About two-three weeks ago, I was put on 60mg Duloxetine, but still had the Mirtazapine at full dose - wow! It was like the Duloxetine fixed the Mirtazapine and they made a party in my head. I was amazing. I was healthier, more active, sleeping better, more happy, less stressed, more positive - It wasn't forced or unnatural, it was beautiful. My family noticed it, hell even the neighbour noticed it when I passed by and most importantly (for me at least!) - I noticed it.

A few days ago I dropped to 15mg immediately my nightmares returned (as they did if I ever missed a dose accidentally before). Four days later, I feel terrible. I'm having nightmares again, I'm waking up again. I'm tired - exhausted in that depressed way as well. I feel miserable and it gets worse each day I don't take the higher dose of Mirtazapine. I phoned my social worker - who's since spoken to the Psychiatrist and because of the NICE guidelines I'm not allowed to go on the only thing that has ever helped me and I've tried so many things.

It's sucks so bad. I've pretty much said I will probably end up ordering in the Mirtazapine from Canada or seeing a private Psychiatrist because I actually really need it. It's not even like benzodiazepines which are addictive. It's probably just my state of mind today but all I want to do is cry out "It's not fair!". Has anyone encountered the NHS stopping them from having the only thing that helps just because of guidelines?

 

[digger]

Is this a very new guideline? I was on both at those doses. I'm off mirtazapine now and down to 30mg duloxetine, but the combination was good for me when I needed it.

 

[Kas_Can_Fly]

I don't know if it's a guideline actually or if it's because their book of crossovers says it can cause serotonin syndrome (saw the GP's one the other day) and as the Psych Dr. advised me - it's more common in the USA but not here as we're not so "Pro-drugs". I've read many people have had success with this combination and honestly, it was amazing. I feel like a junkie who wants their drugs back. But really I just want my life back! I might find out if I can seek a second opinion on the NHS. Some things I have no idea about though! I hate asking people for things, but I am going to be adamant about this I think.

Thank you so much for saying you were on this combo in the UK. It helps and restores a little hope! Apparently I'm getting an appointment ASAP with him and I will prepare information to take with me.

No one's said why and that's something I MUST ask.

 

[mytai]

@Kas_Can_Fly, so glad you found a combination that makes you feel healthier. As long as you didn't feel over stimulated and like you couldn't control your actions I would fight tooth and nail to get back on the combination if I were in your position.

Maybe you could get your family to write a note about how much of an improvement they noticed in you when you were on the combo. I know my psych doctor will rarely listen to what I say a drug is making me feel but he will listen and respond to others observations. Not saying all psych docs are like that, but in some cases they are and they value outside observation more than what we say about ourselves. Just a thought.

I hope this appointment goes well for you and that you are able to get back on the right combination again.

 

[Kas_Can_Fly]

I am going to @mytai because it was such a difference. I felt a little fidgety but it was like it was positve energy rather than nervous energy. Instead of repeatedly visualising me chopping my fingers off or stabbing my temple with an ice pick I was visualising playing card games (preferable :D).

The problem imminently is that if I go back up to the higher dose now is that don't have many days - less than a week of the dose. I'm tempted to ring up the crisis team as I'm quite really nervous and worried right now and see if their psychiatrist will prescribe me the mirtazapine for another week or so until I see the other psychiatrist. I've taken some lorazepam just to see me through to tonight when I'll take the normal higher dose.

I don't like having to fight for something like this, but I'm going to so strongly I think he might be bowled over!

 

[digger]

I have a friend, also in the UK who was on this combination, prescribed I think by a neurologist in her case, but still same combination and doses - possibly even on the 45 dose mirtazapine at one point.

It was a good combination for me, but I would advise a little bit of caution that both drugs are notoriously hard to come off, especially duloxetine.

 

[Kas_Can_Fly]

I'm quite happy to deal with withdrawal when I get to it, at the moment, I want the combination to stay on for the foreseeable future, but that's not to say that I'm not aware of the risks or prepared for them. I'm fearful of drugs and it's taken me years to accept that I need them but now I have I want something that works!

 

[cherryblossom]

I'm always interested in questions about medicines and drugs (just the ex-medic in me, that has always been fascinated with drugs and how they work /what they do).

Within the BNF (British National Formulary), both of these drugs fall into the category of 'other antidepressants', being that neither fall into the class of older drugs MAOI's (Monoamine-oxidase inhibitors) & tricyclics, or the more common SSRI's (Selective Serotonin Re-uptake Inhibitors).

The BNF is the guidelines that all prescribing doctors or nurses in the UK will use.

So, according to the BNF

Duloxetine inhibits the re-uptake of both serotonin and noradrenaline and is licensed to treat major depressive disorder.

Mirtazapine, a presynaptic alpha2-adrenoreceptor antagonist, increases central noradrenergic and serotonergic neurotransmission.

So it would appear that they both work in very different ways. Which is a good thing. It would be more worrying to be prescribed 2 different medications that essentially both did exactly the same thing.

However, both of these drugs (in different ways) are going to increase the amount or increase the effects of both noradrenaline and serotonin. And whilst serotonin syndrome might be rare in the UK, it is still a very real possibility. And it can be fatal, so it does need to be considered very carefully, when prescribing high dosages of drugs that can potentially lead to it.

And while I'm not trying to scare you, the onset of serotonin syndrome can be very rapid, and as I said fatal, so please do be careful, if you are considering increasing your dosage against your doctor's advice.

Talk to your prescribing doctors, be as informed as you can. (learn all you can about serotonin syndrome symptoms in case it happens to you). Serotonin syndrome is real, and can be fatal, so please be careful.

Your prescribing doctors are right to be cautious, and of course you can check out the nice guidelines for yourself to see where both you and they stand with regards to recommended / current practice.

I'd also agree with @digger1 , in that these drugs will likely cause you withdrawal effects, which means coming off them could take you up to a year.

 

[macbeth]

I've found that duloxetine at 60mg takes a little while to kick in but it stabilized me when nothing else worked. I have it in combination with Seroquel 200mg. It took me and my Psychiatrist about 12 months to find the right combination. You may just have to give it a little more time. You said that you've only been taking your new meds for 2-3 weeks. I was told to give 6-8 weeks to feel the full effect. Hang in there and I hope you can feel better soon. :hug:

 

[Kas_Can_Fly]

Thank you very much @cherryblossom. Both for the warning and for the medication specifics. Just a disclaimer: I don't want to increase my dose above what I was originally on and have been on for two weeks already. I want just that but they're taking it away from me. I knew that was the plan but it worked and already since decreasing, it's not working. I feel desperate and helpless. I also know it might be not good for others, but it was good for me.[DOUBLEPOST=1398437403,1398437188][/DOUBLEPOST]I've gone away and printed out loads of Psychiatry journals, reports, case files and other information all of which speak highly of the combination (also referred to as Limerick Rocket Fuel) and suggest that in cases of treatment resistant depression it is one of the most effective forms of treatment. I would agree personally. I'm going to go through them with a highlighter and take them with me to my next appointment. :bookworm:

 

[cherryblossom]

I do always wonder whether someone is clinically depressed (i.e. has an imbalance of brain chemicals), or is simply 'depressed' because of all the PTSD symptoms.

Despite trying a whole host of different anti-depressants, they actually didn't make much difference to me. PTSD symptoms are what made me depressed, as opposed to a chemical imbalanced in my brain which anti-depressants try to address.

I also don't think you are helpless. Arm yourself with the facts, and have a good knowledge, then speak to your prescribing doctors, to come up with a workable plan for you,

 

[Kas_Can_Fly]

I do always wonder whether someone is clinically depressed (i.e. has an imbalance of brain chemicals), or is simply 'depressed' because of all the PTSD symptoms.

I have also always wondered about this, but the change that I saw was so huge, I suppose I must be!