7 replies to this topic

[Mr Kebab]

Hi all...long time reader...first time poster. I have a heap of questions so will ration them out so I don't drive people crazy

My first one is regarding SJW. I have been fascinated with this for a while (particularly BDNF effects compared to SSRIs). I have mild anxiety & mild Fibro and have taken stuff like Lexapro (5mg) Sertraline (25mg) Amitryptiline (20mg), Mirtazapine (15mg) (not all the same time btw). I also take Tramadol 2-3 times a week (50mg) when I have fibro pain.

As my anxiety is mild I would have thought I am a good candidate for SJW i/o SSRI. I am currently taking 5mg lexapro and keen to try SJW but scared off by all the drug interactions. It would be particularly troublesome if it prevented me from obtaining relief from Tramadol.

So my question is -

a) how dramatic is the reduction in effectiveness of drugs affected by SJW? (seems both Mirtazapine & Tramadol are impacted based on enzyme used)
b) SJW appears to have a long half life so curious if I took SJW before bed, would it impact Tramadol metabolism if I took it the next day?
c) how have people found SJW compared to SSRI?

thanks for any replies

[nupi]

Do NOT mix SJW with either other anti depressants or opioids - big risk of Serotonin syndrome:

https://en.wikipedia...ic_interactions
Also, Tramadol is (among other things) a Serotonin releaser so should not be mixed with antidepressants (especially not SSRI, SNRI or MAOI, not sure about TCAs). Frankly if you doctor lets you mix Escitalopram and Tramadol he should have his license revoked (it even says not to mix them in the patient leaflet)- if you did not tell him you are mixing them, faults on you, obviously.

I tried SJW for a while almost a decade ago during a MDD episode. Did absolutely nothing for me.

Edited by nupi, 03 December 2012 - 08:44 AM.

[Mr Kebab]

Do NOT mix SJW with either other anti depressants or opioids - big risk of Serotonin syndrome:

https://en.wikipedia...ic_interactions
Also, Tramadol is (among other things) a Serotonin releaser so should not be mixed with antidepressants (especially not SSRI, SNRI or MAOI, not sure about TCAs). Frankly if you doctor lets you mix Escitalopram and Tramadol he should have his license revoked (it even says not to mix them in the patient leaflet)- if you did not tell him you are mixing them, faults on you, obviously.

I tried SJW for a while almost a decade ago during a MDD episode. Did absolutely nothing for me.

Hi,

Thanks for your reply. If you can find me any case of someone inducing SS at 5mg of Lexapro (or equipotent dosage of other SSRI) and 50mg oral of Tramadol I will eat my hat. Same goes for Tramadol + SJW.

I am being treated by my city's pre-eminent specialist on sleep and mood disorders so I am confident in his judgement. When he put me on this current combo I asked about SS and he said "stop reading scare stories on the internet". He told me a) he has treated hundreds of patients with similar combos (more common for him is amitryptiline + tramadol for fibro though) with zero issues, for many years and b) seizure risk using tramadol is much more of a concern than SS and at the doses I take both are as unlikely. Subsequently, at certain times I have used 10mg Lexapro + 50mg Tramadol for a period of time with no issues either.

I think people confuse actual risk with the warnings that companies need to put on leaflets to cover themselves for every conceivable medical outcome. If anyone can pull out a peer reviewed journal showing a statistically significant risk of combining SSRI + Tramadol then I will change my position. However all I have been able to find are warnings and rare incidences of people having issues after receiving large intravenous doses (300mg+).

However your response does highlight what I was curious about in my original question (which also highlights my skepticism over claims linking SJW to SS) - if SJW is proven to dramatically increase clearance of most drugs metabolised by cytochrome P450 (and therefore the effectiveness), how does it create a risk for SS? If the effect is significant, you are essentially losing a percentage of the serotonergic effect of the stronger substance (SSRI) and replacing it with what is claimed to be a mild effect (SJW).

thanks for any insightful replies

[nupi]

Even so I find it a strange choice to go for an opioid with serotonergic properties when there are others that do not have that issue (Tramadol is a weird analgesic anyhow).

I think one of the concerns with SJW is that its production will never be quite up to the standard of RX meds and hence you are not quite sure how standardized you're extract really is. It also sounds like somewhat bad idea to mess around with an SNDRI (herbal or not) if an SSRI can do the job...

BTW, have you considered trying Cymbalta (I would stay away from it if you have OCDish tendencies though) instead of Lexapro and see if you can do without a separate analgesic? Although in fairness I have to say that Cymbalta had the worst sexual side effects of all ADs I've tried.

[Mr Kebab]

Even so I find it a strange choice to go for an opioid with serotonergic properties when there are others that do not have that issue (Tramadol is a weird analgesic anyhow).

I think one of the concerns with SJW is that its production will never be quite up to the standard of RX meds and hence you are not quite sure how standardized you're extract really is. It also sounds like somewhat bad idea to mess around with an SNDRI (herbal or not) if an SSRI can do the job...

BTW, have you considered trying Cymbalta (I would stay away from it if you have OCDish tendencies though) instead of Lexapro and see if you can do without a separate analgesic? Although in fairness I have to say that Cymbalta had the worst sexual side effects of all ADs I've tried.

Actually, if you have any suggestions for appropriate alternatives to Tramadol I would be interested - Tramadol has one single drawback for me - it impairs my sleep quality - whereas other opioids I have tried enhance my sleep (codeine, dihydrocodeine). I assume it is due to the weak noradrenal activity. I thought about LDN or Buprenorphine. I am also concerned about the exact opposite of SS - I feel like Tramadol reduces my serotonin levels or messes with my receptor up and down regulation in an unhealthy way.

Discussed Cymbalta with specialist and it remains an option however in my case I average only needing Tramadol 1-2 times a week (2-3 times recently due to starting Lex again - it also impairs my sleep) so he didn't think I warranted Cymbalta. Plus due to my sleep issues if I was going to go serotonin + noradrenaline then a TCA would be more appropriate (I tried amitryptiline briefly but the cardiotoxicity freaks me a bit so I stopped). The similarities between Tramadol & Effexor had me interested in SNRIs for a while but never went ahead.

[nupi]

If you feel sleep is an issue (it was for me with Lexapro - I would sleep 14hours a day :-) then Cymbalta likely is not such a good option. I felt like it had three main side effects in my case
1) Sleep disruption (but I would still feel ok in the morning)
2) Nasty sexual side effects (though I could have dealt with that), similar to Effexor
3) Occasionally it would send my thinking into weird loops (not suicidal or violent but still quite scary) - this I did not want to deal with for a number of reasons I won't go into

It was definitely A LOT more activating than Lexapro, so if you feel sluggish with that one Cymbalta could be worth a try. As for opioids, my knowledge is fairly limited, I have had straight up Codeine occasionally as cough suppressant and first Morphine then Tramadol once over a decade ago after major surgery. Was Codeine not strong enough that you moved to Tramadol?

Effexor I find nasty, I refuse to take it again. It gets the job done, alright, but the side effects (chiefly significant weight gain in addition to the usual SNRI sexual side effects) are not at all worth it for me - they also kind of ruin compliance of taking it.

Edited by nupi, 03 December 2012 - 11:38 AM.

[Mr Kebab]

If you feel sleep is an issue (it was for me with Lexapro - I would sleep 14hours a day :-) then Cymbalta likely is not such a good option. I felt like it had three main side effects in my case
1) Sleep disruption (but I would still feel ok in the morning)
2) Nasty sexual side effects (though I could have dealt with that), similar to Effexor
3) Occasionally it would send my thinking into weird loops (not suicidal or violent but still quite scary) - this I did not want to deal with for a number of reasons I won't go into

It was definitely A LOT more activating than Lexapro, so if you feel sluggish with that one Cymbalta could be worth a try. As for opioids, my knowledge is fairly limited, I have had straight up Codeine occasionally as cough suppressant and first Morphine then Tramadol once over a decade ago after major surgery. Was Codeine not strong enough that you moved to Tramadol?

Effexor I find nasty, I refuse to take it again. It gets the job done, alright, but the side effects (chiefly significant weight gain in addition to the usual SNRI sexual side effects) are not at all worth it for me - they also kind of ruin compliance of taking it.

I think we may have opposite issues - my issue with Lexapro (at least during first 3 months at least) is light, fragmented, shortened sleep. Hence augmenting with Mirtazapine works for me (but makes me fat). I tend to be very energetic and outgoing by nature - this 'up' thing I have then occasionally turns into anxiety if I get too much stress. Hence I tend to gravitate towards more 'sedating' stuff than the SNRIs. Codeine works well but too short half life - whereas Tramadol I can take 50mg in the AM and I am good to go for the rest of the day due to the relatively long half life. A few times I tried MS Contin (sustained release morphine) which was perfect but seems like overkill for mild fibromyalgia!

At the end of the day all my stuff is pretty mild however Tramadol gives me near perfect relief from fibro pain and I am curious if I could kill my mild anxiety with SJW at the same time - I am thinking not - but curious about it.

[nupi]

In this case we really seem to be having opposite issues. Long story short, if sleep is a major consideration, any Norepinephrine related compound sounds like a bad idea (do not even get me started on how hard it is to sleep on Wellbutrin at least without any Melatonin/Bacopa/Gabaergics)

Edited by nupi, 03 December 2012 - 12:00 PM.