[ergwyn]

I have a question for anyone familiar with Abilify or Cymbalta, or both:

For the past six months, I've been taking Cymbalta (60mg daily). This was prescribed by my GP to help control my blood sugar. However, he knows that I have chronic depression, and he told me that Cymbalta would also work as an antidepressant. In general, I have found my moods more manageable since I started taking Cymbalta.

I have recently been diagnosed as bipolar, although I should have figured it out 40 years ago. Earlier this week, a different doctor (a psychiatrist) put me on Abilify (5mg daily, the minimum dose). I neglected to tell him that I'm on Cymbalta. After I took the prescription, I looked up Abilify in PDR and I discovered that it is not recommended for use with other antidepressants. Now I wonder if I should stop taking Cymbalta while I'm on Abilify. Since my dosage of Cymbalta is significantly larger than my Abilify dosage, I wonder if the Cymbalta will "drown out" the Abilify.

I will consult my GP -- I don't have regular access to the psychiatrist -- but for now I am asking anyone in this forum: are you aware of any problems in combining Cymbalta with Abilify?

Also, does anyone here have any experience -- good or bad -- with Abilify by itself?

[Pamster]

Hi ergwyn,

Welcome to the Bipolar forum on Neurotalk! I have been taking abilify for a few years now and had good luck with it at the full 30 mg a day dose. You work up to that dose slowly though of course but I started feeling full relief of the racing thoughts and bad BP impulses around 20 mg's. It's probably a good idea to call your pharmacist though, and ask them about the cymbalta/abilify combination. I used to take wellbutrin with it with no major problems, only stopped because it was 'activating' me, meaning making me a bit racy again in the thought department.

I take paxil and trazadone now which are both antidepressants, but I have never taken Cymbalta so I have no experience there to offer you. Other's here have mentioned taking it before so check back and see if they have left any additional info about their experiences with it. Do you have an official diagnosis of BiPolar I or II yet? I know I was miserable with the racing thoughts and it was only when I started abilify and it began to work that I really accepted the diagnosis of BP II.

Welcome to the board ergwyn, hope you stick around and share more about yourself and your experiences with us.

[Mari]

Dear Ergwyn,




I'm not familiar with why Cymbalta and Abilify cannot be mixed. Call a pharmacist (any pharmacist) because they often know more about med interactions than the pdocs do. Also, they probably have some data bases handy to check on these questions.

Your gp can probably put in a call to the psychiatrist. Or you could call the psychiatrist yourself.

You cannot make inferences based on the size of the dose.
Some drugs might need a high number of mgs to take effect and some might need only 3 or 4 mgs to take effect.
It's like comparing two elephants with two rabbits.
Or better -- comparing two animals and having no idea how big either one is.

How do you feel on the Abilify? Is it helping with sleep or racing thoughts or anything like that?

Mari

[lrkott]

Originally Posted by ergwyn

I have a question for anyone familiar with Abilify or Cymbalta, or both:

For the past six months, I've been taking Cymbalta (60mg daily). This was prescribed by my GP to help control my blood sugar. However, he knows that I have chronic depression, and he told me that Cymbalta would also work as an antidepressant. In general, I have found my moods more manageable since I started taking Cymbalta.

I have recently been diagnosed as bipolar, although I should have figured it out 40 years ago. Earlier this week, a different doctor (a psychiatrist) put me on Abilify (5mg daily, the minimum dose). I neglected to tell him that I'm on Cymbalta. After I took the prescription, I looked up Abilify in PDR and I discovered that it is not recommended for use with other antidepressants. Now I wonder if I should stop taking Cymbalta while I'm on Abilify. Since my dosage of Cymbalta is significantly larger than my Abilify dosage, I wonder if the Cymbalta will "drown out" the Abilify.

I will consult my GP -- I don't have regular access to the psychiatrist -- but for now I am asking anyone in this forum: are you aware of any problems in combining Cymbalta with Abilify?

Also, does anyone here have any experience -- good or bad -- with Abilify by itself?

================================================== ================================================== ================

Dear Ergwyn -

I just joined and noticed your post and felt compelled to reply.
You SHOULD consult with you psych. re: taking Cymbalta and Abilify. If you were referred to him/her by you GP, he would have your medical records and knows you're taking Cymbalta. I've been taking it for the past year for "depression" AND pain and found it effective for BOTH. There are two classifications of antidepressents: tricyclic antidepressents, affecting a neurotransmitter called "norepinephrine" and the "SSRI's", affecting a neurotransmitter called "serotonin." These are the only two neurotransmitters which have be identified as important for use on people, as of now. Cymbalta is the first an ONLY med. that has been approved for usage by the FDA that affects BOTH neurotransmitters, "norepinephrine" AND "serotonin." It is ALSO the ONLY medicine that is approved for usage and can be given for BOTH "mood" disorders, like depression AND pain. For some time there has been some thinking that giving a "norepinephrine" AND a "serotonin" medicine could be more affective than just taking either one; and 'voila!' Cymbalta is the FIRST medicine that has both proporties (although many insurance companies think NOT.)
At any rate, your primary physician gave you this medicine for a mood disorder, depression, and not blood sugar.
Along come the "mood stabilizers," like Abilify. I think that the original thinking was "DO NOT MIX" with other "mood drugs," however more recently the manufacturers of Abilify have been allowed, by the FDA, to give these new "mood stabilizers" in conjunction WITH antidepressants in cases of bipolar disorder and these two medicines would work together to help resolve bipolar depressions. The only other "first line" drug to treat bipolar disorder was lithium, fort a LONG time and many people would stop because of side effects.
ALSO, a previous post was correct when they said that you CAN NOt compare medicines on a milligram per milligram basis. Most time there is NO basis for comparison between one medicine and another, but when there is, there is absolutely no basis to compare them mg. for mg. "Science" hardly knows how medicines affect each other, but is just finding out, i.e. taking Abilify WITh antidepressants, that it is not only NOT a bad idea to take Abilify with Cymbalta, but it might be MORE effective than taking one or the other alone!
If that psychiatrist was referred by your GP, he/she has your medicine records and knows what you are taking; if not it would be very irresponsible to give you a "neuroleptic" medicine WITHOUT knowing what other meds you're taking.
ALWAYS feel free to contact any doctor you've seen by calling and asking the sort of questions regarding medicines perscribed to you! They would much rather hear from you and make sure you're taking the correct combination of meds. PLEASE, if you've learned anything from contacting this "forum," BE SAFE and remember that!

GOOD LUCK! Sorry for the VERBOSE reply.

L.R. Kott

[mrsD]

Is now being promoted on TV and in magazines in low doses as an adjunct to other antidepressants.

I do not understand it however.
http://www.medpagetoday.com/MeetingCoverage/APA/5734

So far it is only in the lowest 2 doses, as I understand.
You cannot compare doses of drugs, the way you are doing.
Cymbalta starts at 20-30mg a day (the lowest).
60 is average, but 90 and 120 are often used.
You CANNOT STOP CYMBALTA easily. It requires a taper.
Do not do this without medical supervision.

However, I don't understand why someone would be taking
Cymbalta for "sugar control"--

For the past six months, I've been taking Cymbalta (60mg daily). This was prescribed by my GP to help control my blood sugar.

Abilify RAISES blood sugar as a side effect.

Cymbalta is very similar to Effexor in action, but with one distinct important difference--- Cymbalta has severe liver warnings that other antidepessants do not. Cymbalta is only being used now,
because Lilly is promoting it. It really is not much different than Effexor which is far less toxic.
Effexor however, also requires a careful taper when stopping.

I think you need to sit down and have a complete talk with your doctor.

[Bdix]

I know that Cymbalta has been prescribed off label for quite awhile for diabetic patients who have diabetic peripheral neuropathy, (nerve pain) and that the FDA finally went ahead and approved it for treatment. Some doctors have reported that there was a lowering of blood sugars because extreme pain can cause blood sugaar spikes and ketones. (diabetics also have a higher risk of despression anyway)

I would write down all your questions and call the p-doc and ask them. (Have him at least clarify why you are taking it) If he is not immediatly available have him call you back asap.

[mrsD]

last year:

Diabetes Care. 2007 Jan;30(1):21-6.Click here to read Links
Does treatment with duloxetine for neuropathic pain impact glycemic control?
Hardy T, Sachson R, Shen S, Armbruster M, Boulton AJ.

Eli Lilly, Lilly Corporate Center DC 2138, Indianapolis, IN 46285, USA. hardyta@lilly.com

OBJECTIVE: We examined changes in metabolic parameters in clinical trials of duloxetine for diabetic peripheral neuropathic pain (DPNP). RESEARCH DESIGN AND METHODS: Data were pooled from three similarly designed clinical trials. Adults with diabetes and DPNP (n = 1,024) were randomized to 60 mg duloxetine q.d., 60 mg b.i.d., or placebo for 12 weeks. Subjects (n = 867) were re-randomized to 60 mg duloxetine b.i.d. or routine care for an additional 52 weeks. Mean changes in plasma glucose, lipids, and weight were evaluated. Regression and subgroup analyses were used to identify relationships between metabolic measures and demographic, clinical, and electrophysiological parameters. RESULTS: Duloxetine treatment resulted in modest increases in fasting plasma glucose in short- and long-term studies (0.50 and 0.67 mmol/l, respectively). A1C did not increase in placebo-controlled studies; however, a greater increase was seen relative to routine care in long-term studies (0.52 vs. 0.19%). Short-term duloxetine treatment resulted in mean weight loss (-1.03 kg; P < 0.001 vs. placebo), whereas slight, nonsignificant weight gain was seen in both duloxetine and routine care groups with longer treatment. Between-group differences were seen for some lipid parameters, but these changes were generally small. Metabolic changes did not appear to impact improvement in pain severity seen with duloxetine, and nerve conduction was also not significantly impacted by treatment. CONCLUSIONS: Duloxetine treatment was associated with modest changes in glycemia in patients with DPNP. Other metabolic changes were limited and of uncertain significance. These changes did not impact the significant improvement in pain observed with duloxetine treatment.

PMID: 17192327 [PubMed - indexed for MEDLINE]

and this:

Vasc Health Risk Manag. 2007;3(6):833-44.Click here to read Links
Review of duloxetine in the management of diabetic peripheral neuropathic pain.
Smith T, Nicholson RA.

Mercy Health Research, Ryan Headache Center, St. Louis, MO 63141, USA. tsmith@stlo.mercy.net

Duloxetine is a balanced selective serotonin norepinephrine reuptake inhibitor (SNRI) which, in 2004, became the first agent to receive regulatory approval for the treatment of painful diabetic neuropathy in the US. This compound has no other significant receptor or channel activities other than the serotonin and norepinephrine reuptake inhibition mechanisms and works to diminish or control the symptoms of diabetic neuropathy. Duloxetine has no known neuroprotective or other effects which prevent the development of neuropathy in patients with diabetes. The purpose of this review article is to discuss the background of painful diabetic neuropathy, the pharmacology of duloxetine, and its safety and efficacy in clinical trials and long-term observations. The authors will also comment on its use in clinical practice. Results from controlled clinical trials reveal that duloxetine administered at 60 mg qd or 60 mg bid is efficacious in treating diabetic neuropathic pain relative to placebo. Positive treatment outcomes are also seen for other measures of pain and quality of life. A minor but statistically significant increase in blood glucose compared with placebo treated patients has been observed in controlled clinical trials. Otherwise, controlled and open-label clinical studies have demonstrated a high degree of safety and tolerability for the compound. These findings provide support for the proposed role of serotonin and norepinephrine as key mediators of the descending pain inhibition pathways of the brain stem and spinal cord.

PMID: 18200804 [PubMed - indexed for MEDLINE]

PMCID: PMC2350145

Cymbalta remains the only antidepressant in the SSRI/SSNI family that causes liver toxicity.

So in essence... both Cymbalta (duloxetine) AND Abilify raise blood sugar. That is something that should be
closely monitored.

This paper is interesting... it shows that the SSRI antidepressants, Prozac (fluoxetine) and Zoloft (sertraline) actually lowered blood sugar.

Ann Clin Psychiatry. 2001 Mar;13(1):31-41.Links
Use of antidepressants in treatment of comorbid diabetes mellitus and depression as well as in diabetic neuropathy.
Goodnick PJ.

Department of Psychiatry, University of Miami School of Medicine, Florida 33136, USA. goodnick@aol.com

After a brief review of epidemiology, the focus is on biochemistry of diabetes. Animal and human studies are reviewed in terms of the impact of alterations in catecholamines and serotonin (5-hydroxytryptamine, 5HT) on glucose utilization. Then, the implications of these experimental results for the choice of antidepressant in comorbid diabetes mellitus and depression as well as in diabetic neuropathy are discussed. Results of clinical investigations are then reviewed in terms of the above hypotheses. An Index Medicus Search for the past 10 years was supplemented by references from previous related reviews of the topic as well as by pending results, where available, not previously published. The range of prevalence of depression in diabetic patients has been 8-27%, depending on study criteria and procedures. An increase of catecholamines appears to increase glucose while both reducing insulin release and reducing sensitivity to insulin that is available. In contrast, increases in serotonergic function by increased precursor, increased release, or blocked metabolism and blocked reuptake in contrast seem to increase sensitivity to insulin and reduce plasma glucose. There have been six studies of fluoxetine, a selective serotonin reuptake inhibitor (SSRI), at a dose of 60 mg/day pursued up to 12 months that have demonstrated that medication's usefulness in diabetic patients, with reductions in weight (to 9.3 kg), in FPG (to 45 mg%), and in HbA1c (to 2.5%). In studies in comorbid diabetes mellitus and depression, nortriptyline, a norepinephrine reuptake inhibitor that produces increased synaptic catechols, has led to worsening of indices of glucose control. However, fluoxetine and sertraline, both selective serotonin reuptake inhibitors, in the same patient group, have produced results consistent with reductions in glucose levels. In diabetic neuropathy, perhaps due to the fact that catecholamines and serotonin may both be implicated in pain pathways, dual-action antidepressants appear more effective at lower doses than do specific serotonergic agents. The tricyclic antidepressants (TCA) (66.7%) have had success in double-blind studies, particularly imipramine, with a 81% response rate. Yet, there are positive reports concerning the SSRIs (paroxetine, citalopram, sertraline), as well as nefazodone, that focus on serotonin selectivity. CONCLUSIONS: In comorbid diabetes mellitus and depression, most evidence supports the use of fluoxetine in control of glucose handling. Other characteristics in terms dosing, drug interactions, cognition, and sleep make sertraline an attractive alternative agent. In diabetic neuropathy without depression, the best choices among non-TCAs may include sertraline, citalopram, and perhaps, venlafaxine, since the TCAs appear to increase cravings and increase FBG levels.

PMID: 11465683 [PubMed - indexed for MEDLINE]

[Bdix]

Duloxetine treatment resulted in modest increases in fasting plasma glucose

Correct. The fasting blood sugars (between like 1am and 4am) are a regular problem for diabetics and are very common. This is because of the sugar that is released from the liver; not because of any pain a person might be having. (Carbs cause the rise in bloodsugars after meals, and the sugar from the liver causes it at night) From personal experience - the fasting blood sugars (which oftentimes go undetected because the sugars return to normal by the time you are awake and testing) can raise your A1C. Been there, done that. During the day my sugars are controlled and stable.

However; when I am in a lot of pain, my blood sugars are high until well after the pain ends. In fact I was hospitalized last summer because of an ingrown toenail that I had absessed and threw me into DKA with unmanagable blood sugars. This has nothing to do with my fasting blood sugars; which are always high if I do not use medication to counteract it.

If this medication is being used to control pain, I could see where it would have an affect on blood sugars. (not the fasting ones)

I would still call the doc and ask. If you do not have pain perhaps he misunderstood the connection to the blood sugar control. And maybe it doesn't apply to you at all!

[mrsD]

are huge causers of increased blood sugars.

I know a person who went up to 800 with the flu (who was not a diabetic).

Stress and even extreme physical exertion like shoveling the snow, may also raise sugars (due to increased cortisol activity).

The original poster did not mention pain. Only depression. And the doctor=GP? that is just typical!

I think this thread is puzzling, and I just noticed, it is not a new thread, the the original poster has
not returned. I missed it during the summer, and if it had not been bumped, I guess it would have
remained in the past?

[Vowel Lady]

I knew someone who took an antidepressant at the same time she took Abilify. She only took a minimum dosage of both. She did not have a problem. I agree with Mrs. D, it doesn't seem to make sense to take Cymbalta for a sugar issue (however, everyone is different and maybe your doc switched you to this med as opposed to another because the other med caused a problem).

Many have mentioned taking Chromium Picolinate to help combat sugar issues. You can take 200 mcg. with no concern. Many people actually take more.