[JoanB]

Hi all and thanks again for helping me figure out how far I wanted to go with finding a cause of my PN. I've pretty much accepted that I will probably never know and need to deal with managing the pain.

I have been taking Gabapentin and Ultram, which hasn't controlled the pain as much as I'd like. So I'm now trying Cymbalta and Ultram. The neuro said that it can take up to a few months for Cymbalta to really work for this type of application. If Cymbalta had worked for any of you, did you find that it took that long or did it kick in much sooner? I have my doubts about this particular neuro's knowledge in this area because he gave me a puzzled look when I said something about the Cymbalta/Ultram cocktail (he was going to prescribe only Cymbalta). I thought that the cocktail approach was pretty well known with PN.

[mrsD]

There is an interaction between Cymbalta and Ultram:

http://www.drugs.com/interactions-check.php

GENERALLY AVOID: Due to its serotonergic activity, coadministration of tramadol with serotonin-enhancing drugs such as SSRIs, SNRIs, nefazodone, trazodone, and mirtazapine may potentiate the risk of serotonin syndrome, which is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5-HT1A and 2A receptors. Symptoms of the serotonin syndrome may include mental status changes such as irritability, altered consciousness, confusion, hallucinations, and coma; autonomic dysfunction such as tachycardia, hyperthermia, diaphoresis, shivering, blood pressure lability, and mydriasis; neuromuscular abnormalities such as hyperreflexia, myoclonus, tremor, rigidity, and ataxia; and gastrointestinal symptoms such as abdominal cramping, nausea, vomiting, and diarrhea. Patients receiving tramadol with serotonin-enhancing drugs may also have an increased risk of seizures due to additive epileptogenic effects of these agents.

MANAGEMENT: In general, the use of tramadol in combination with highly serotonergic agents should be avoided if possible, or otherwise approached with caution if potential benefit is deemed to outweigh the risk. Patients should be closely monitored for symptoms of the serotonin syndrome during treatment. Particular caution is advised when increasing the dosages of these agents. The potential risk for serotonin syndrome should be considered even when administering serotonergic agents sequentially, as some agents may demonstrate a prolonged elimination half-life.

It depends on the doses used for both and the person, however.

Cymbalta should start to show effects within a week, I'd think.
The slowest onset antidepressant is Prozac which has a long half life. Cymbalta is faster acting. As far as PAIN relief goes, that is individual also.

[JoanB]

Thanks mrsD. Yeah, I knew about the interaction warning with these two, but then again, it seems like most of the combinations folks here are taking are not really recommended. I wonder if this serotonin syndrome is something that would happen right away if you were prone to getting it or if it's something that could result from a cumulative effect.

Doses I'm currently taking: 60mg Cymbalta 1X a day and Ultram 50mg 6X a day. My neuro said that when using Cymbalta for PN, it's not usually effective until you're up to 90mg a day. So far I haven't noticed any effects at all, good or bad. I have found that my brain seems a lot clearer now that I'm not on 3600mg of Gabapentin, though.

Anyway, I wonder why he said that it would take a few months to help...but as I indicated before, my confidence level with this guy is not all that high.

[mrsD]

I have been to 2 very sophisticated advanced pain conferences in the past 2 yrs. Both of them show the central pain circuit in the brain, that these antidepressants are supposed to intercept. This is typically the introduction for the 10hour seminar. This second time this spring, I really paid more attention and still it is a complex concept.

It is complex... very. I think many doctors don't even understand it. (these conferences were mostly doctors attending)

SSRI drugs like Prozac take about 3 weeks to get to the brain.
But the newer SSNI/SSRI combo drugs like Effexor and Cymbalta (they are very similar), are much faster acting.

That Ultram dosage is high. (300mg/day) So you are up there with that drug. The risks are personal and varied.

Personally I think amitriptyline is a better choice. It shows benefits for peripheral neuropathy healing...that no other drug shares. (this is fairly new). But that is only my opinion.

[filipe]

Hi,

I'm gonna start a new treatment with Neurotin and Amitriptiline. No more thinking that this is psicossomatic. What do you think? By the way where do you read that Amitiptiline helps nerve grow? Is it really true?

Do you think Neurotin could cure Neuropathic pain? Or is it only a painkiller?

Thank you,

Filipe

[mrsD]

I thought I gave you this link?

http://neurotalk.psychcentral.com/sh...=amitriptyline

[Raglet]

Originally Posted by JoanB

Doses I'm currently taking: 60mg Cymbalta 1X a day and Ultram 50mg 6X a day. My neuro said that when using Cymbalta for PN, it's not usually effective until you're up to 90mg a day.

Wow, 90mg seems quite high to me, I am on 30mg as an antidepressant which does the trick for me, though maybe I am just weird (wouldn't surprise me at all).

Hope it does the trick for you

cheers

raglet

[JoanB]

Originally Posted by Raglet

Wow, 90mg seems quite high to me, I am on 30mg as an antidepressant which does the trick for me, though maybe I am just weird (wouldn't surprise me at all).

Hope it does the trick for you

cheers

raglet

Nah, you're not weird, raglet. The neuro told me that 30mg is the typical dosage for depression, but to have much effect on PN, it has to be at least 90mg. High or not, I'm not noticing any new effects good or bad on the 90mg. But I'll still try to give it some time. Having a bad day and we're supposed to be having a fun day so I'm trying to put my brave, happy face on. I know you all are well acquainted with that.

[aussiemom]

Hi
I was on an extremly low dose of Cymballta. New PM said up it a little bit. I did, felt better the next day. I'm in a job where random drug tests are a way of life, so am limited as to what I can do for the pain. Cymballta has been a blessing for me.

[JonAlex]

I have been on Cymbalta for about a month and a half. I started with
30mg/day for one week followed by 60mg/day, the recommended maintenance dose. There hasn't been a time when I thought, finally it's working. There probably has been some subtle psychological improvement. I think it has helped more with minor neuropathic pain. I have read others who said it worked immediately but that has not been my experience. I suppose everyone will have a different reaction. My doctor said to give it time to work. Apparently a lot of people give up because they don't see an immediate result. Hope that helps.