SSRIs, reboxetine, and AF - Help please!

Some time ago, a discussion in the conference room centred on antidepressants and AF. Hans put forward the idea that the norepinephrine reuptake inhibitor reboxetine might be beneficial for vagal AFrs of which I appear to be one. I am accordingly considering changing my current SSRI citalopram (known to cause bradycardia in some patients - not good for a vagal AFr) to reboxetine.

I just read, however, that:

"A number of antidepressants with increased, but varying, selectivity for the noradrenergic system have become available in recent years, including MIRTAZAPINE, bupropion and, most recently, the first truly selective noradrenaline reuptake inhibitor, reboxetine." (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12817153&dopt=Abstract)
I am accordingly alarmed at the prospect of trying reboxetine in the light of the above paragraph, since I once tried mirtazipine and found it most unpleasant.

In further researching reboxetine, I came across the following 3 abstracts at:

[www.ncbi.nlm.nih.gov]

1: Tank J, Schroeder C, Diedrich A, Szczech E, Haertter S, Sharma AM, Luft FC, Jordan J. Related Articles, Links
Selective impairment in sympathetic vasomotor control with norepinephrine transporter inhibition.
Circulation. 2003 Jun 17;107(23):2949-54. Epub 2003 Jun 09.
PMID: 12796139 [PubMed - indexed for MEDLINE]
2: Agelink MW, Ullrich H, Baumann B, Strum S, Majewski T. Related Articles, Links
Effects of reboxetine, a selective norepinephrine reuptake inhibitor, on sympathetic and parasympathetic outflow to the heart: preliminary data.
Psychopharmacology (Berl). 2002 Sep;163(2):151-6. Epub 2002 Jul 19.
PMID: 12202961 [PubMed - indexed for MEDLINE]
3: Penttila J, Syvalahti E, Hinkka S, Kuusela T, Scheinin H. Related Articles, Links
The effects of amitriptyline, citalopram and reboxetine on autonomic nervous system. A randomised placebo-controlled study on healthy volunteers.
Psychopharmacology (Berl). 2001 Apr;154(4):343-9.
PMID: 11349386 [PubMed - indexed for MEDLINE]

Having severely braincramped myself, I'd be MOST grateful if Hans, PC, and others could have a look and share their conclusions with me as to whether or not reboxetine would likely provide a vagal AFr with some benefit.

Cheers,

Mike F.

Mike,

Sorry to hear, of yet another episode. Mike, have you ever thought that the med could be more your problem, coupled with drinking. I'm not saying you're an alcoholic, but drinking could be conflicting with your SSRI. Read this, but read the link in its entirety (not too long), by James South:

Chronic alcoholism may also have a serotonin component. Research with animals and humans has shown that alcohol initially increases serotonin nerve activity; yet chronic alcohol use impairs tryptophan entry into the brain. This chronic alcoholism may involve a vicious spiral of a brief alcohol induced increase of serotonin neural activity, with consequent sense of well being, combined with an ever worsening baseline state of serotonin nerve activity due to alcohol's impairment of brain tryptophan transport.
[www.smart-drugs.com]

Have you ever spoken with your doctor about the simple addition of tryptophan, rather than drugs. If he can prescribe SSRI's, then I would think that he could prescribe tryptophan, if you push for it.

Richard

Mike--

I agree with Richard, entirely.

When I was using an SSRI I had no problems with afib. I am convinced that the higher serotonin levels provided by an SSRI are protective agains afib.

Every SSRI I have used had a warning to limit use of alcohol.

It would seem to be worthwhile to cut out alcohol for a period of time, say six months, and to continue on the SSRI, to see what the effect on afib might be for you.

After such a trial period, you might find that you have a different perspective on the role of alcohol in your life.

Mike

Sorry about the latest attack. I'm used to the 3am Vagal ones.
I gave up alcohol for 6months at the start of this year. I then had far more ectopics than the usual, approx 50 a day however I still had AF once every two weeks. I started drinking again (moderatley) the ectopics stoped for a week before coming back and the AF would become more frequent depending on what and how much I drank. Recently the ectopics (2months) have gone away probably due to magnessium. Obviously Alcohol is a trigger for me and therefore I pay the price if things get out of hand .
However I 'm glad I proved to myself that there were other triggers .The main being late night eating. I'm going alcohol free again soon and apply all I've learnt so far and see where I lie now.
Who do Voodoo WE do Voodoo.
Chris H

I just cut down my dosage of Paxil CR from 50 mg to 25 mg and have had continuous chest pain for 3 days now. I know SSRI has to have something to do with AFIB. Should I go back to 50 mg?

Richard and Michael,

Point taken gents. I've quit alchohol and have just this minute got a prescription for tryptophan to replace the citalopram SSRI (which has bradycardic tendences - not good for VMAFrs). Thanks as ever for the helpful input.

Mike F.

Mike,

SSRIs work on different parts of the nervous system (1). Citaprolam is highly selective in blocking serotonin reuptake rather than norepinephrine reuptake. Mirtazapine is not very effective in blocking anything except the reuptake of histamine and serotonin 5-hydroxytryptamine. The histamine reuptake blocking would probably make it a very poor choice for vagal afibbers. Buprion is primarily a blocker of dopamine reuptake and is not at all effective in blocking norepinephrine reuptake. Reboxetine, on the other hand, is a potent blocker of norepinephrine reuptake which is why I suggested it as possibly the best choice for vagal afibbers. The Penttila article supports the idea that reboxetine decreases vagal tone relative to adrenergic tone - but whether this is a long term effect is unclear.

I think the only way you are going to find out if reboxetine works for you is by trying it. I don't believe your experience with mirtazapine has any bearing on how reboxetine would agree - or disagree - with you.

Hans

(1) Richelson, Elliott. Pharmacology of Antidepressants. Mayo Clin Proc 2001; 76:511-527.

Hans,

Thanks for the input: greatly appreciated. I'm going to taper off the citalopram and try some 5HTP or tryptophan (my local surgery says that they can't get the latter - but as far as I can ascertain, Merck do 500mg tabs. Whatever, %htp is probably better since it is the precursor to serotonin whereas tryptophan is the precursor to 5HTP.)

Thanks for the clarification on mirtazapine: god I felt LOUSY on that stuff - LOADS of ectopy and short palpitations whilst on it for a fortnight. Very interested to learn that it blocks histamine reuptake. I have just got a prescription for cimetidine partly for my gastritis and partly because cimetidine has an antihistamine and therefore an anticholinergic effect.

Cheers,

Mike F.