I was wondering if anyone knows whether or not using Clomipramine (Anafranil) instead of amitriptyline (elavil) is a viable option?
I have OCD and I was wondering if I could try Clomipramine to help with my OCD as well as TN type 2.
I didnt find much info on this but i found this publication that had some information on the interchangeability of the two medications: http://www.ncbi.nlm.nih.gov/pubmed/489262
Also after a search on the TN forum it seems that the only person on this forum who seems to be using it is "tamzee" (I dont know how to tag her). but other than that I didnt find any information.
haach, the only way of "tagging" tamzee is either with a PM (you will have to request friendship first, but you can message her at the same time) or by commenting on her page (which will probably send her a notification, depending on how she has her setting done). I'd do both if I were you.
From RxList.com, we learn that Clomipramine is one of the class of tri-cyclic antidepressants, like Amitriptyline and Nortriptyline. This entire class of meds are considered candidates for treatment of chronic trigeminal neuropathic pain and atypical TN. It may be an option worth discussing with your care providers.
Thank you for the reply. I know they are both TCAs but there are always slight differences in their efficacy. But regardless, I will be asking my doctor for a prescription. He insists that I should start with the tegretol since its the first line treatment of TN, but I rather take clomipramine because:
1) I have atypical TN, and i think TCAs are a good choice
2) i have a job where i need to be focused and "on" and i think tegretol would be a lot worse than clomipramine with respect to maintaining one's mental sharpness (not sure actually, just nightmare stories i have read about tegretol)
3) i have OCD and clomipramine could address that as well, so two birds with one stone,
Haach, you asked me what I think. While the TCA meds are often used in ATN, be aware that they can have sedating side effects in some people, and a few don't tolerate other side effects well. This is pretty much a trial and error business. So you are best to work with your prescribing physician to assess both effectiveness and side effects on an individual basis.
Tegretol is effective for many people in typical TN and for some in atypical TN. I haven't seen evidence that anyone knows quite why some folks with ATN do well on it and some don't. But it is known that a fraction of the population has genetic factors which reduce the effectiveness of the entire class of anti-seizure meds. Others are resistant to opioid meds. New research is being published every year in these areas.
I wish you well. Do let us know how you are doing as you work up on whatever medications you are taking. There are many knowledgeable patients here.
Regards, Red
haach76 said:
hi Red,
Thank you for the reply. I know they are both TCAs but there are always slight differences in their efficacy. But regardless, I will be asking my doctor for a prescription. He insists that I should start with the tegretol since its the first line treatment of TN, but I rather take clomipramine because:
1) I have atypical TN, and i think TCAs are a good choice
2) i have a job where i need to be focused and "on" and i think tegretol would be a lot worse than clomipramine with respect to maintaining one's mental sharpness (not sure actually, just nightmare stories i have read about tegretol)
3) i have OCD and clomipramine could address that as well, so two birds with one stone,
wow very interesting discussion! so let me tell you how Anafranil worked for me. I checked into the hospital when my atn began and the neurologist on call prescribed me anafranil. She had never even heard of atn so she was clueless about which meds are best. It was kind of a shot in the dark...but it worked. Within a few days I was doing so much better. Im lucky as I had minimal side effects, just dry mouth, weight gain, bit twitchy but I didn't feel sedated at all and it has helped with my mood as well. But of course every body is different. I went to see an expert in London and he said the first line of defense in the uk for atn is usually amitryptaline and lyrica. But anafranil was working for me and I didn't want to rock the boat. So I have been on it for over 3 years now, at about 2-3 level pains, totally manageable.I'm very happy with the results.
As it happens, This week I had a medical checkup required for my new job and the doctor noticed my pulse rate was high (its supposed to be on average between 40-100, mine was 129) I dont have palpitations so I wasn't aware of this at all. I went to my GP yesterday and he said its probably a side effect of long term anafranil. So now I am at a cross roads and thinking of switching to amitryptaline. Its a newer drug, less side effects.Im seeing my neurologist next week to decide what to do. Otherwise, anafranil worked really well for me, took away the burning, aching, crushing, stabbing etc.
Btw, Im sorry to hear you are suffering from OCD as well. Atn is already such a heavy burden. My sister has OCD she was on paxil and it had horrible side effects. She's not on meds now but if she ever feels the need again she wants to try anafranil. So I really hope that if you try it, it will help on both fronts. Hope this helps. Please keep us updated! and feel free to msg if you have any questions or need to talk :)
Thank you so much for the reply, i am happy you saw the thread!
It's great that anafranil has worked for you. I have no idea why elavil (amitriptyline) is preferred for neuropathic pain. I tried to search journal papers to see if there is any reason for it. The only thing i found was here: http://www.ncbi.nlm.nih.gov/pubmed/489262
If you are going to try a newer medication also consider asking your doctor about cymbalta (duloxetine), it is definitely a newer medication and apparently has less side effects than either elavil and clomipramine.
Thank you for the kind words. I used to be so ungrateful and unhappy that i had OCD, well, now i miss the days when OCD was my only problem! lol .
H
tamzee said:
Hi Haach76,
wow very interesting discussion! so let me tell you how Anafranil worked for me. I checked into the hospital when my atn began and the neurologist on call prescribed me anafranil. She had never even heard of atn so she was clueless about which meds are best. It was kind of a shot in the dark...but it worked. Within a few days I was doing so much better. Im lucky as I had minimal side effects, just dry mouth, weight gain, bit twitchy but I didn't feel sedated at all and it has helped with my mood as well. But of course every body is different. I went to see an expert in London and he said the first line of defense in the uk for atn is usually amitryptaline and lyrica. But anafranil was working for me and I didn't want to rock the boat. So I have been on it for over 3 years now, at about 2-3 level pains, totally manageable.I'm very happy with the results.
As it happens, This week I had a medical checkup required for my new job and the doctor noticed my pulse rate was high (its supposed to be on average between 40-100, mine was 129) I dont have palpitations so I wasn't aware of this at all. I went to my GP yesterday and he said its probably a side effect of long term anafranil. So now I am at a cross roads and thinking of switching to amitryptaline. Its a newer drug, less side effects.Im seeing my neurologist next week to decide what to do. Otherwise, anafranil worked really well for me, took away the burning, aching, crushing, stabbing etc.
Btw, Im sorry to hear you are suffering from OCD as well. Atn is already such a heavy burden. My sister has OCD she was on paxil and it had horrible side effects. She's not on meds now but if she ever feels the need again she wants to try anafranil. So I really hope that if you try it, it will help on both fronts. Hope this helps. Please keep us updated! and feel free to msg if you have any questions or need to talk :)
Regarding Cymbalta: please be aware that the pharmaceutical manufacturer for this medication is being sued by multiple patients on grounds that the company deliberately downplayed information which showed the med to have horrendous withdrawal symptoms when used and then dropped. There is an active discussion underway in several Facebook Groups reporting the experience of individual patients.
I took cymbalta for a week and probably gotta ten hours of sleep that week. I had complete insomnia. I emailed my Dr and told her I couldn’t do it anymore no way.
There are subtle differences among the tricyclic antidepressants. Amitriptyline and clomipramine have more side effects of sedation compared to the other tricyclics. Amitriptyline has been tested most extensively for pain compared to the other TCAs, which is why it is considered a first line med. Clomipramine has been tested most extensively for OCD. They have a high likelihood of causing sedation, dry mouth, and orthostatic hypotension, which could affect daytime performance.
I read over the Cymbalta lawsuit and it is very misleading for patients. What laypeople don't realize is that drug lawsuits are often based little on the drug itself compared to other drugs of its class and more on how the company advertised the medication. For example, Pfizer got in big legal trouble over gabapentin but the medication is still quite safe and effective for neuropathic pain for many - they just over-represented how many people it could help and they never got official approval for neuropathic pain as an indication. Cymbalta is a SNRI - it selectively inhibits serotonin and norepinephrine reuptake. There are already many SSRIs and other SNRIs on the market, the oldest one being Effexor, which is now in generic. It is well known among medical professionals that abrupt cessation of antidepressants can cause discontinuation syndrome. Cymbalta is a newer medication that is still under patent, and it is the first SNRI to have a neuropathic pain indication - it makes it a good target for lawyers.
In general, SNRIs like Cymbalta are safer than TCAs because they are more selective in the their pharmacology. Most side effects are more severe in the beginning of therapy and tend to wear off after a few weeks. Discontinuation syndrome can be minimized by a slow tapering of the medication and supportive therapy. ALL antidepressants, including TCAs, can cause discontinuation syndrome if stopped abruptly.
I agree that the lawsuits dont reflect the efficacy of these psychotropic medications. I have been on many for my OCD and even the best one's have had plenty of lawsuits. For example zoloft's manufacturer, pfizer, has been hit by plenty of them (and most would agree zoloft is the best ssri for depression/anxiet).
Also what doctors say doesnt always reflect the reality in regards to these drugs. I think most doctors now dont consider a TCA as a first line treatment for anxiety because of side effects. However, this is based on some statistical average of user experiences. I know plenty of people who have had better experiences on TCAs than SSRIs. Experiences on SSRI/SNRI/TCA is so variable that its hard to draw very concrete statistical conclusions wrt their efficacy; just general guidelines. (the distribution has fat tails, for the statistically inclined).
And as someone who has gotten on and off SSRIs i can tell you that it is a nightmare every time! however i have a system now and i titrate down over a very long time (2-3 months). And then i brace myself for a month :S
ps what do you think is the least mind altering medication for TN ? (least amount of cognitive effects or drowsiness). I am really worried these days about losing my job.
ps I am not seeking medical advice, just asking your opinion (i will discuss all recommendations with my doctors of course).
It's hard to say which medication would be least mind altering because there are very few head to head trials of different TN medications. Most medications compare against placebo, and because of differences in study design, randomization, and patient populations, we can't extrapolate the results to compare against each other very accurately.
In general, the dose of TCAs required for pain is much lower than the dose required for depression and anxiety. If you're trying to treat a co-morbid psychiatric condition, you would need a higher dose of the TCA than most pain patients and therefore be more likely to experience daytime side effects. Out of the different TCAs, the one with the least sedation potential is desipramine. Nortriptyline has a moderate sedation potential but it is tested more extensively for pain. Cymbalta, as I wrote earlier, is less likely to cause daytime sedation than all the TCAs. Effexor is another SNRI that is used off label for neuropathic pain. It probably does the same thing as Cymbalta for a fraction of the cost because it is available as generic (but again, no head to head trials...)
The other major class of drugs for TN is the anticonvulsants. Out of these, carbamazepine has the most evidence and that's the one that I'm on. I found that it hardly affected me cognitively when I was on a low dose (400mg/day) but now that I'm on 600mg/day, I'm drowsier and have more trouble concentrating, but not to a debilitating degree. It has worked very well for my trigeminal neuropathic pain (not type 1 TN). Another awesome perk about carbamazepine is that for me and many other patients, it starts working within a few hours. Oxcarbazepine is supposed to be better tolerated and work just as well, but it's rarely prescribed here in Canada so I don't have any experience with it. Gabapentin and pregabalin are the safest out of all the anticonvulsants because they're unlikely to cause serious side effects like liver dysfunction and blood dyscrasias, but they can cause cognitive impairment as well, especially at higher doses. Topiramate (topamax) is the most sedating and mind-altering and it is nicknamed "Dopamax."
This isn't a very clear cut answer. If I were you, I would ask to start low and go slow with any new med. Keep a journal of efficacy and side effects so you can figure out which one works for you. Keep in mind that many drugs require at least 2 weeks to start working and the side effects are more severe at the beginning of therapy.
1) clomipramine: could help with my ocd, but has side effects
2) amitryptaline: proven help with TN, but no help with ocd, and sedation side effects
3) nortryptaline: not sure if its as good for tn pain as the above two, but definitely lower side effects
4) cymbalta: not sure about effectiveness for tn, but less side effects than the tricyclics listed above.
Given the fact that I have bilateral TN2, with comorbid ocd, what do you think ? I have spoken with three pharmacists and they just say i should take tegretol because that the first line treatment for tn :(
I am on 75 mg of Amitriptyline now, and it has quieted my anxiety/ ocd as well. I was pleasantly surprised. I take Effexor, prescribed by my doctor for anxiety, but it is a low dose. I was still having issues, from back in November and then I recently went to my neurologist appointment, I had breakthrough pain. So he upped my dosage on the Amitriptyline. After three or four days I started feeling better. The pain isn't completely quelled, like before. But....summer is coming, so I am hopeful. Best Wishes to you, with whichever meds your doctor prescribes. :)
The thing with both TCA and anticonvulsants is that they do not play well with birth-control medications as its hard to maintain plasma levels, so patience is really critical getting it right. "Brekathrough Pain" my simply be a shift in hormone levels so some work in that area is helpful.
As toothache pointed out the levels of TCA used are very low compared to what "therapeutic doses" are. Most of what you read including side effects is based on a much higher dose.
thank you for the replies. My goal is to get a medication that can address both my ATN and Ocd while not affecting my productivity at work. I guess maybe thats greedy but i am trying to do my research before i tell my doc what i want.
I had another question, has anyone tried these two new SNRIs: Savella (Milnacipran) or fetzima (Levomilnacipran). They are both new SNRIs and they seem to have a strong impact on Norepinephrine (which i think is what gives tcas their ability to help with pain): http://primarypsychiatry.com/wp-content/uploads/import/0509PP_SNRI_Shelton.pdf
I did some research since I'm not too familiar with the treatment of OCD. First of all, other TCAs like amitriptyline and nortriptyline could also benefit OCD, but there's insufficient clinical trials to recommend them. Think of it like 3 brothers who went to the same med school, but only one got his medical license and the other two decided to be engineers. Maybe the other two brothers could practise medicine just as well, but they're legally not allowed to advertise themselves as doctors. They could still save your life in an emergency situation.
Venlafaxine could be a good starting point for you. It is in the same class as cymbalta and has evidence for both OCD and neuropathic pain (but not trigeminal neuralgia specifically). There are two trials comparing it to paroxetine (SSRI) and clomipramime (TCA) that show non-inferiority. The side effects are less than with TCAs. However, it's effectiveness for neuropathic pain isn't as great as the TCAs and the trials done aren't vigorous enough to give it official approval for pain. About 1 in 4 people experience significant improvement in pain from a TCA, and only about 1 in 7 do from a SNRI like venlafaxine. You really have to get in there and try different ones because the odds are not in our favour, unless you happen to be a really lucky guy and hit jackpot on your first try.