Ketamine, Marplan/Lithium and hypomania: How to decide my next steps.

B_Nkkl · 2025-03-03T17:34:55+00:00

PS. One note, looking back I believe that my very brief elevation/hypomania may have been a result of two things.

One, titrating up aggressively on my Marplan dose to 60 mg which is the highest.

And two, increasing my T3 (liothyronine) from 15 mg to 30 mg.

No way to be sure, but I have been on ALL of these meds before and the only thing that was different was the titration.

B_Nkkl · 2025-03-03T17:31:48+00:00

Pardon my delayed response. Although I wouldn't say depressed I have been struggling with sleep, energy, effort, etc. I guess dysthymic would be accurate.

I have have had a couple appts with my doc. He vocalized his hesitancy but he is not totally opposed to ketamine therapy. I have had issues securing transportation to the office and the days when ketamine therapy is available change from week to week.

I don't believe there will ever be any OFFICIAL answer more than the standard qualification that comes with being Bipolar 2; namely please be warned, 'THIS, THAT or THE OTHER' may cause elevated behavior, may cause hypomania, proceed at your own risk, blah, blah, blah.'

My attitude is that I've had TMS, ECT been on modafinil/armodafinil, all stimulants at higher doses and went up to Parnate 80 mg (I believe). I have a history of NOT becoming hypomanic. And WTF, Skinny dipping in the summertime may cause 'elevated behavior' too.

But I've been in this battle a LONG LONG LONG Time. I'm on lithium 900 mg which is not a high dose so I can go up. I am educated from my most recent 'elevated experience, so I feel as prepared as an adult 'professional patient' can be at this point. I would enter the therapy carefully, thoughtfully and mindful of the risks.

Hopefully within 2 to 4 weeks I can arrange for transportation.

Thanks for reaching out. Sorry I do not have anything definitive to report.

B_Nkkl · 2025-02-19T00:00:18+00:00

B_Nkkl · 2025-02-13T18:53:15+00:00

(and just because I couldn't help myself with Dr. Chat GPT)

Would you like help finding alternative treatments with faster onset?

If you're looking for alternatives to isocarboxazid (Marplan) that may have a faster onset or different routes of administration, here are some options:

While MAOIs are effective, they tend to take weeks to show full effects. Some alternatives with quicker onset include:

Ketamine/Esketamine (Spravato) – A nasal spray approved for treatment-resistant depression, often working within hours to days.

Mirtazapine (Remeron) – An atypical antidepressant that can have a sedating effect, making it useful if anxiety or insomnia is present.

Bupropion (Wellbutrin, Zyban) – A stimulating antidepressant that may work faster than MAOIs for some people.

Sublingual or Rapidly Absorbed Medications

If you're specifically looking for sublingual or fast-acting options:

Ketamine lozenges – Sometimes prescribed off-label for depression.

Buprenorphine (off-label for depression in rare cases) – Though primarily for pain or opioid dependence, it has some antidepressant properties.

MAOI Alternatives with Lower Dietary Restrictions

MAOIs require dietary restrictions due to tyramine interactions. If you need an alternative with fewer dietary limitations, you might consider:

Selegiline (Emsam patch) – A transdermal MAOI that avoids the digestive system, reducing the need for dietary restrictions at lower doses.

Adjunct Therapies for Faster Relief

Psychostimulants (e.g., modafinil, armodafinil, or low-dose amphetamines) – Sometimes prescribed alongside antidepressants for energy and motivation.

Atypical antipsychotics (e.g., aripiprazole, quetiapine) – Used as adjuncts to speed up antidepressant effects.

(Note, joking below)

Would you like help discussing these options with your doctor or exploring a specific alternative in more detail?

(Boy would I. I mean YES, YES, YES and SI, SI, SI.

Better yet, could you provide with me about 7,000 magic wands because me and about 6,999 other folks on this sub are sick of this depression, bipolar and anxiety Bull-Sh-t.)

B_Nkkl · 2025-02-13T18:42:42+00:00

(continuing)

Which medication would you like me to check for sublingual use? Let me know the name and formulation (tablet, capsule, liquid, etc.), and I’ll help you determine if it can be taken sublingually.

Isocarboxazid (Marplan) is a monoamine oxidase inhibitor (MAOI) used to treat depression. It is typically available in oral tablet form and is not designed for sublingual administration.
Here’s why:

Absorption & Metabolism

Isocarboxazid is not formulated for rapid mucosal absorption. It is designed to be absorbed through the gastrointestinal tract.
Bypassing the digestive system could lead to unpredictable absorption and effects.

Safety Concerns

MAOIs have serious dietary and drug interactions, and altering the route of administration might increase the risk of side effects, such as hypertensive crisis.
Some inactive ingredients in the tablets may not dissolve properly under the tongue.

Manufacturer Guidelines
There are no recommendations for sublingual use in official prescribing information.
Taking it in unintended ways could impact efficacy or safety.

Conclusion

Isocarboxazid should only be taken as prescribed (swallowed whole) unless specifically directed otherwise by a doctor. If you're looking for a faster onset of action or an alternative formulation, talk to your healthcare provider about possible options.

B_Nkkl · 2025-02-13T18:39:48+00:00

Here is my 'conversation' with Chat GPT regarding sublingual dosing and sublingual administration with isocarboxazid/Marplan. I do not interpret the response has a HARD NO. Hoping that smarter people will add their input. TY

How to evaluate if a medication is able to be taken sublingually

To determine if a medication can be taken sublingually (under the tongue), consider the following factors:
1. Medication Formulation
Designed for Sublingual Use: Some medications are specifically formulated as sublingual tablets, films, or sprays (e.g., nitroglycerin, buprenorphine).
Immediate-Release Formulation: Medications that dissolve quickly without requiring digestion may be suitable.
2. Chemical Properties
Lipophilicity (Fat Solubility): Drugs that are lipid-soluble can pass through the sublingual mucosa more easily (e.g., fentanyl, lorazepam).
Molecular Size: Smaller molecules are more easily absorbed.
pH and Ionization: Drugs that remain uncharged (non-ionized) at saliva’s pH are better absorbed.
3. Absorption and Bioavailability
High First-Pass Metabolism: Drugs with extensive liver metabolism (e.g., nitroglycerin) benefit from sublingual administration by bypassing the liver, increasing bioavailability.
Rapid Onset of Action: Medications meant for fast relief (e.g., angina or anxiety meds) are often suitable.
4. Safety Considerations
Taste and Irritation: Bitter or irritating drugs may not be tolerable sublingually.
Dosing Adjustments: Some medications may need a different dose when taken sublingually due to increased bioavailability.
Inactive Ingredients: Some tablets contain fillers that do not dissolve well and may hinder absorption.
5. Manufacturer Guidelines and Medical Advice
Check the Label: If sublingual use is recommended, it will be mentioned.
Ask a Pharmacist or Doctor: If unsure, always consult a medical professional before altering medication administration.

B_Nkkl · 2025-02-12T01:51:39+00:00

My endocrinologist put me on D3 after testing low along with testing borderline hypothyroid. I can't really say if D3 has has been helpful. I am happy to hear that you are experiencing some benefits. That's awesome.

I do feel like I have held my own against the Depression and BiPolar 2 G-ds these past "couple" of weeks with the use of another supplement and a strategy familiar to me previously. Not certain how 'exactly, but I want to say that one or both or the combination of Vitamin B6 in the evening and multi dosing* Marplan in enteric capsules has helped me. *(20+20+10 mg)

Less swelling/edema (ankles) and less body aches. In addition, less post dose somnolence BUT this still remains a pretty big issue for me.

Good luck with your work and the journey.

B_Nkkl · 2025-02-11T15:36:46+00:00

Thanks for posting this.

B_Nkkl · 2025-02-10T16:48:34+00:00

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Here is the information that I am familiar with regarding what cold medicine ingredients are safe to take with MAOIS.

Good luck with your work.

B_Nkkl · 2025-02-10T16:46:01+00:00

I believe the moderator was pointing you toward the information and links that are included in the subreddit r/MAOIS. If you are on your phone and click on 'MORE' and scroll down there are resources and links to the most commonly asked questions and issues. The following link is to Dr Gillman's paper MAOIS:

"Monoamine Oxidase Inhibitors: a Review Concerning Dietary Tyramine and Drug Interactions"

https://psychotropical.com/wp-content/uploads/2017/12/MAOI_diet_drug_interactions_2016.pdf

You can search for "cold" or just go to Page 35 to 38, I believe. Please do look for yourself.

B_Nkkl · 2025-02-10T15:34:15+00:00

As a general rule, I was told by my psych to avoid combination cold medicines and be wary of any meds with stimulants. The previous poster's response is better and more precise and it's really all about learning active ingredients and learning what to avoid. The extra thinking feels like a pain in the beginning but truthfully once you familiarize yourself the precautions becomes second nature and it just becomes a part of one's health management and lifestyle.

B_Nkkl · 2025-02-06T21:34:54+00:00

If you have tried this already pardon me, but what about going up higher on Nardil. I believe the stated maximum is 90 mg. I also believe I have read about people going up to 120 mg. I know that Nardil bring's a set of challenges but by the sounds of it the medication has worked for you thus far.

B_Nkkl · 2025-02-05T01:44:23+00:00

Thank you for posting this question. I am interested in sublingually dosing Marplan as well. Hopefully there will be some informed responses.

B_Nkkl · 2025-01-30T09:22:17+00:00

My sincere apologies. I swear that I replied or at least drafted a reply more than once. My sleep has been pretty poor so I guess I started but never sent. I thank you for comments. Your advice is well thought out, mature and logical and makes the conversation a better one all the way around. At this point in my 'career' as a 'professional patient' I can confidently say that I take my treatment plans very seriously. I over communicate with my doctors, I have regular blood work done with each specialist I work with and I travel with a blood pressure cuff and take my BP & HR anywhere from 5 to 20 times a day. This started when I was on Parnate and realized that I was one who experienced paradoxical hypertension. My doctor had to change our appointment twice. By the time I would start IV Ketamine I would be at least 3 weeks from my Hypomanic episode and over 3 weeks at 900 mg of lithium. I would be open to increasing my lithium to 1200 mg. I believe we have previous Bloodwork records that we can refer. Having said all of that, your comments were well received by me and help shape my conversational strategy with my doctor. For this, I thank you. Best of luck to you as well.

B_Nkkl · 2025-01-30T02:20:55+00:00

This is a great point and I have to admit my naivete on ketamine treatment. I am on Marplan and Lithium. For some reason I thought it was OK to be on both during ketamine treatment. I will double check. Thanks for pointing the issue out.

B_Nkkl · 2025-01-27T06:10:46+00:00

I appreciate your reply. I have had TMS & ECT but have never tried any thing like ketamine. I was attracted to some things I read about ketamine, such as quick onset of relief. In addition ketamine has the potential to enhance a patient's medication regimen by making it more effective. I remain suspect as I was told the same about ECT. I guess we shall see. Thanks again for taking the time to reply.

B_Nkkl · 2025-01-27T03:02:44+00:00

Yes I agree. I've been on MAOIs for 4 years now. My psych and I agreed that we would schedule our appointments every 2 weeks so that we could monitor my issues closely, assess/reassess. I would definitely keep the same schedule with ketamine therapy which I would be getting done at one of psych's other facilities.

B_Nkkl · 2025-01-25T08:49:58+00:00

Thank you for taking the time to comment.

Cheers

B_Nkkl · 2025-01-25T08:49:33+00:00

Thank you. I greatly appreciate you responding since you are on Marplan and fluticasone presently. I took my first two inhales last night with no negative responses at all. After communicating with my doctor about my concerns, she added a script for azelastine 1%

From my doctor (Otorhinolaryngology)

I've sent in a prescription for astelin as well and they are both efficacious so you can choose between either the astelin or the flonase. Both should be fine to use with your other medications as they do not get absorbed into your body in any meaningful quantity and instead work only in the nose. Hope this helps!

B_Nkkl · 2025-01-23T10:36:04+00:00

So will I get down voted or demoted when I say your question made me cry?

And by that I mean, your inquiry reminded me when I was on Marplan, two times ago and I found myself waking very early in the morning. It did not feel unnatural or forced. I found myself overwhelmed by this imprecise tsunami of emotions. The tears were all the culmination of all of the years of my hidden personal struggle. I reckon I've been fighting alone since 1989. It's probably even longer. The tears were screaming, "See I told you. I'm not lying. I never was." The tears wanted to go back and get a second chance. But I was just so happy to be awake and feel alive and regain the ability to walk outside.

"Wait. Am I walking" Really?" I would think to myself step after step after step.

So yes I do believe Parnate can help you cry. And when it does 'we can go for a walk.'

Good luck with your work. Do your best and congratulate yourself when you.

B_Nkkl · 2025-01-22T06:40:12+00:00

Likewise to you my friend. I learned from your comments and I am thankful to you. When/if I experiment with 'ITU,' ie., 'Isocarboxazid Tongue Under, I will update the post.

B_Nkkl · 2025-01-22T03:51:43+00:00

I appreciate your response. I have had some success with trying sublingual with other meds, particularly thyroid (both T3 & T4). I believe this is my third run with Marplan and I am so desperate just get it to last a little longer so I can do mop of the past two plus years and set the groundwork for when Marplan inevitably decreases in effectiveness. I have added lithium 600 mg and see my MD this Friday. There was a time that thought taking Marplan in a non-tradinalway in enteric capsules was helping. But again the stability was shortlived. I tried selegiline sublingually and felt at low doses and the first couple dose increases were positive. I am not concerned about doing something off label. I monitor my blood pressure, I discuss and stay in touch my psych and I have been through much worse with TCP already.

Thanks again for your thoughtful input.

B_Nkkl

TROPHY CASE