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Side effects - Tramadol use with Fluoxetine (prozac) - a warning

Discussion in 'Tramadol' started by Oneiromancer, Apr 19, 2011.

  1. Oneiromancer

    Oneiromancer Titanium Member

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    Howdy All

    Just wanted to post a story on here about a friend of mine

    Basically this guy thought that the so called Serotonin Syndrome (S.S) was practically a myth when it came to using Tramadol with certain drugs. He found out though - to his Alarm - that perhaps he should have paid more attention to what people said about it on-line.

    He had used Tramadol in the past with venlafaxine and thought no big deal.

    What he didnt do though was take large ammounts of Tramadol , so his theory that you cant get S.S from taking Tram with anti-depressants was basically a load of bollocks.

    Not so long ago he was put on Fluoxetine (prozac). He was also taking Tramadol and to start with things were fine. He used to take the tramadol recreationally (250mg - 400mg per dose - 3 times a day - not clever! - seizure risk) as well as clinically (he has sciatica - like me).

    After taking the prozac for about 5 weeks ( and the prozac was starting to really kick in and inhibt the re-uptake of serotonin efficiently - ( he guesses) , he started to get unpleasant sensations in his face.

    He had muscle spasms - like ticks - in his mouth , which caused the corner of his mouth to twitch up and down quite rapidly. he said it was very strange. He also experienced an overall sense of anxiety and an unpleasnt feeling - which is perhaps best described as a state of hyper-vigilance - ( he would jump out of his skin if someone sneezed..)

    Having a half decent knowledge of psychiatric medicine he realised what was probably happening and immediately phoned the duty doctor.
    After he explained to the doctor what he thought was happening and that he had symptoms of Serotonin Syndrome - he was amazed to find out that the doctor did not know that tramadol and fluoxetine could react in this way!

    The doctor actually advised to stop taking the prozac and carry on with the tramadol - which seemed a bit daft to my friend. he decided to stop the tramadol instead (knowing full well that tram has a much shorter half life than the prozac and stopping the prozac whilst continuing to take the tram could result in a further case of S.S)

    in the end my friend came off the tram and the prozac - he is now on mirtazapine and co-codamol.

    i just wanted to share this story with others on here because

    a: - he wanted to point out that S.S can really occur - and that tramadol does react with other serotonerigic drugs in this way

    and

    b: to warn others in general in case their doctors are as "good" as mine
     
  2. Davevanza

    Davevanza Silver Member

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    Hi,

    Tramadol is a pro-drug that requires liver enzyme called CYP450 2D6 to convert it a stronger active metabolite, called O-desmethyltramadol ( which is 6 times stronger in binding to the "mu' receptor in the brain)

    Tramadol, besides binding to "mu" receptor to produce Analgesia, it's molecular structure resembles Effexor ( Venlafaxine).
    So, Tramadol is actually an SNRI.

    Venlafaxine has negligible inhibitory effect of this particular enzyme, CYP450 2D6.

    I have been using them in combination with positive effect, for 2 yrs.


    Prozac ( Fluoxetine) actually is an inhibitory of this particular enzyme, so making Tramadol to be less effective, as Fluoxetine blocks the transformation of Tramadol into its stronger active metabolite ( which is 6 times stronger).

    SWIM also had tried this combination, with NO negative effect AT all.
    The only thing SWIM noticed was, the effect of Tramadol was less effective with Fluoxetine compared when he used it with Effexor-XR.




    S.S is sometimes mistakenly diagnose as Neuroleptic Malignant Syndrome( caused by anti psychotics).

    I had several times been given antipsychotics, in 1999 was Zyprexa ( Olanzapine) 5mg, and SWIM get Extrapyramidal syndrome, his eyes rolled upwards, mouth twitched, muscle spasm.
    in 2005 I was given Risperdal 2mg ( Risperidone), and by the first dose, he straight away got muscle spasm, his neck bent sideways, pacing around, restlesness. So he stopped it, and called the doctor.



    I have been using Tramal SR 200mg twice daily, prescribed for his chronic type headache by his Neurologist, and after a long consultation, his Neurologist wrote a letter to his GP, to prescribe 60 of the Tramal SR 200mg ( taken twice daily). And every month SWIM just goes to his GP, to get as what his Neurologist adviced. It has been years SWIM taking it, in combination with SSRIs and SNRIs.

    Well, theoretically correct, but again, everyone reacts differently even to the same medication.

    S.S is characterised by :
    -Increased heart rate ( Tachycardia)
    -Shivering with Paraesthesia ( Pins and needles sensation)
    -Dilated pupil
    -Hyperthermia, could be above 40 degrees
    - and Hyperkinesia ( over responsive reflexes, but mainly more on the lower limbs than the upper limbs).

    I hope this info is useful for others too.

    Kind Regards,
    Davevanza
     
  3. Oneiromancer

    Oneiromancer Titanium Member

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    Thank you, for your comments Davevanza.

    I'm sure some of the information that you have posted here is educational to some of the members. I actually knew all of that already however ;)

    You have only made a couple of errors.

    To start with I was'nt taking anti-psychotics ( or any dopamine antagonists ), so it cant have been neuro-leptic malignant syndrome.

    Also Tramadol isn't quite an SNRI , it is an SRA serotonin releasing agent and an NRI noradrenalin reuptake inhibitor.

    The Symptoms of serotonin syndrome include :

    Myoclonus - Twitching or jerking.

    Hypervigilance - On edge , jumpy , anxious.

    So as you can probably tell, It was indeed Serotonin Syndrome ( also known as serotonin toxicity , it comes with varying degrees of intensity )

    One last thing, you are so right in what you say regarding all people re-acting to all medication in a different way. When I was taking fluoxetine and tramadol (or codeine) , even though fluox is a cyp-2d6 inhibitor it did not make any noticeable difference to the high. Weird right?

    Still nothing surprises me about medicine nowadays. After having studied neuro-psycho-pharmacology for 10 years , its amazing what you find out.

    I am sorry to hear that you have had Neuro-leptic malignant syndrome, that is serious shit. What i find equally scary about neuroleptic anti-psychotics is the fact that after a period of use they can cause tardive dyskinesia which from what i remember is permanent ( or at least can be )
     
    Last edited: Sep 4, 2011
  4. Davevanza

    Davevanza Silver Member

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    Sorry about that.

    Kind regards,
    Davevanza
     
  5. Oneiromancer

    Oneiromancer Titanium Member

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    no problem man - the information of neuroleptic malignant syndrome will be of use to some members though!

    Maybe you should start a thread - warning others about it?

    That would be a great Idea :)

    take care my friend

    O
     
  6. roo-keeper

    roo-keeper Silver Member

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    Just tacking on to the end of this old post. Last week my pet kangaroo skippy was in ICU after suffering a grand mal seizure. He has taken 300-400mg tramadol with 50mg Fluoxetine for a nice buzz weekly for about 13 years and two or three times a week for the last 4 years. A few times he had suffered extreme body heat with a lot of heavy sweating, mainly from his face, but this has always occurred after he'd had his paw in the first aid box for several days running. We are blaming this for the seizure, although he has been playing with Lyrica (pregabalin, a neurological pain killer as well as anti-convulsant) for the last couple of months. I half saw something on TV a couple of years ago that indicated to me that the playing with tramadol and ending up in hospital was not uncommon. I've done a bit of finding out since, being wary but that's it. This kind of thing always happens to other people's pets.

    Of course it hasn't stopped Skippy from playing, leaving only a week between seizure and trying again (with no apparent bad effects on the day or few others since). I think he must be very bored to be doing this, in full knowledge that he may well be playing with fire.
     
  7. CaptainUber

    CaptainUber Silver Member

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    My friends, brothers, cousins uncle takes 20mg Fluoxetine every morning and has been for 1+ years. Now please note this is only in his experience and yours could differ vastly. He reports no problems except decreased potency due to Fluoxetines Inhibiting CYP2D6. His doses of Tramadol have been as high as 700mg. (Please note the risk for seizures is very high at this level and He would advise against it!)