Question: Now that Pristiq has been out for awhile, what has been the clinical response with your patients compared with the Effexor XR formulation? Rumors have said it is more tolerable and less sexual side effects, although I have tried some samples, and it doesn’t seem to be as calming as Effexor, and I am unsure what the Pristiq 50mg dose is compare to a similar Effexor XR dosage?

Also what SSRI/SNRI tends to have the fewest sexual side effects?

Thanks

Answer:

Pristiq and Cymbalta seem to have less sexual side-effects than Effexor
and if Pristiq at 50mg is an adequate dose it should have the least
sexual effects. 90% of the first 570,000 treated with Pristiq have
stayed with a 50mg dose. This dose has the same efficacy in control
studies as 75-150 of Effexor with better tolerability. The drop out
rate due to side-effects is essentially the same as placebo.

When most people (normal metabolizers) take Effexor – 70% of the benefit
comes from Effexor being metabolized so the effects are very similar.
Pristiq does have a slightly higher ratio of norepinephrine effect
relative to serotonin than Effexor and this could account for your
impression that it’s not as calming – that is most likely a temporary
effect.

Because Pristiq doesn’t require the same liver metabolism as Effexor
there are less issues with drug drug interactions and tolerability for
those people (7-10% of Caucasians) who are poor metabolizers. Poor
metabolizers don’t usually do as well on Effexor and don’t usually
tolerate doses above 75mg. Some people do better on 100mg of Pristiq.

Pristiq is also more cost-effective, especially at 100mg dose – since
there is a 100mg tablet – whereas Effexor frequently requires 225mg or
more necessitating multiple capsules.

Wyeth is also getting ready to launch a program where they will pay 1/2
of your cost (copay or cash) as long as you take it on a continual
basis for life if necessary.

Question: Dear Dr. Jones, I treated with you about 15 years ago for agoraphobia–and was helped very much by your keen insight into this condition. Would you have time for a quick question? I’ve had a problem traveling long distances from home for most of my adult life. I’ve had periods of remission, lived well despite the condition, working as television reporter, etc. But the problem is, in short, I’ve always limited my travel fearing “the big one.” Now, I want to go to Europe before I’m too old to enjoy! Klonopin works well for me. Do you think if I just plain old up and flew off to Italy, I would not have a “breakdown” if I brought Klonopin?— even if when I got there, I became extremely panicked by facing such a long trip after a life time of fearing it? In case you advise to “work up to it” with smaller trips first–I do note that whenever I force myself to take a trip I always have some degree of panic/pain (although also enjoy the trip!) and one time I had violent panic one week driving 30 miles away–then, flew 1000 miles the next week with less fear! Then, came back and panicked again going 30 miles! For me, sucessive approximation doesn’t seem useful. Thanks so much for any information! Best,
Kate

Answer:

Dear Kate,

Congratulations for not letting Agoraphobia/panic attacks control your life
to any large extent. Although I can’t make specific treatment
recommendations, there are several general principles that apply to your
situation.

First, panic attacks associated with travel in cars, planes, etc., are the
claustrophobic kind which are related to hypersensitivity to increasing
levels of CO2 in your blood – conditioned fear responses and anticipatory
anxiety results in shallow breathing and a build up of co2. The best way to
prevent this is to breathe properly – out first…see my website section on
panic attacks for the full technique. http://www.askdrjones.com/wp-content/uploads/handouts/HO%20Anxiety%20Handout.pdf. Practice this periodically and always use this technique when you
start to get anxious or panicky.

Klonopin is the strongest panic preventer but like most medications needs to
be taken in the right dose. Panic patients tend to take as little as they
can get by with instead of as much as they need. Usual daily dose is 2-3mg
but can be higher. It’s ok to sedate yourself on long flights if necessary.

Desensitization is situation specific – so that being able to fly 1000 miles
doesn’t mean you can necessarily drive long distances. Avoidance or using
escape makes you worse, as does hanging in there but having a horrible
experience. Using proper breathing and or adequate medication to get
through it makes you better. Some people need to add an SSRI or SNRI to
facilitate full desensitization. Positive self-talk and having distractions
can also help.

Good luck!
Dr. Jones