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Avatar universal

Psychiatric Prescription

I was diagnosed as hyperthyroid and with medications I am now clinically euthyroid. But I used to get panic attacks in form of tachycardia and palpitations. I have been taking Propranolol for last 3 months and have tapered it off to 5 mg 2 times a day. Because of the persistent symptoms of panic attacks, my endocrinologist referred me to a psychiatrist. She diagnosed me as having Mixed Anxiety Depression. She prescribed me:
25 mg Sertraline - Once in a day
0.25 mg Clonazepam - Twice in a day
Pantocid (Antacid in tablet form) - 30 minutes prior to taking Sertraline

She also asked me to continue with Propranolol like I did. Also, I am taking 30 mg Carbimazole.

I have not yet started with the new psychiatrist prescriptions as I am getting worried. I read Sertraline reacts with Propranolol. It makes Propranolol more toxic and can give me low BP and bradycardia. Recently my BP was a bit high (140/90) and pulse rate was 72.

Shall I take the psychiatric medicines and how should I schedule the medications without suffering a lot?
5 Responses
368886 tn?1466238884
MEDICAL PROFESSIONAL
Hello.

To find a well informed answer to your query about the Sertraline-Propranolol combination, you need to look for information/evidence according to the hierarchy. A systematic review (a review of a number of studies exploring the same issue) is considered the best as far as strength of evidence is concerned. Clinicians' experience, case reports and non-journal articles are lower level sources of evidence.

There is a mechanism known to us that explains why caution should be exercised while using a combination of Sertraline and Propranolol. Sertraline and other Selective Serotonin Re-uptake Inhibitors (SSRIs) inhibit a certain enzyme which usually metabolizes Propranolol. Due to this inhibition, Propranolol action may be enhanced. But it will not be appropriate to look at this isolated piece of information and ignore other evidences.

We do have a lot of trials and reviews exploring the combination. There is no conclusive evidence which allows us to deem this combination unacceptable. In clinical practice, it is rare to find cases where Sertraline or other SSRIs has led to Propranolol related problems. However, we have to exercise caution while using the combination as one cannot predict the outcome in each individual.

Propranolol is best known for its benefit in performance anxiety. If your anxiety disorder does not include performance anxiety as a major component, you may consider weaning off Propranolol, after consulting with your psychiatrist. Sertraline is expected to take care of the anxiety as well as the depression. Also, if you notice any changes in your blood pressure, pulse or other symptoms related to enhanced action of Propranolol, you can always adjust the dose to achieve the best possible outcome (again, with your psychiatrist's review).

I hope that helps with the first part of your question.

Sertraline can be taken any time of the day provided you take it the same time each day. Similarly, you can take Clonazepam at fixed time of the day. In practice, it is observed that individuals find out over a period of time which is the best hour of the day for Clonazepam. You can be flexible for a couple of hours initially, but please make sure you take the medicines according to a fixed schedule once you have settled in.

Hope this helps. Best Regards.

Avatar universal
Thank you Doctor for your reply.

What side effects should I watch out for when I start on these medicines?

I am planning to take 2.5 mg Propranolol with 0.25 mg Clonazepam after breakfast. Sertraline after lunch and 0.25 mg Clonazepam, 2.5 mg Propranolol and my regular thyroid medication after dinner. I am trying to wean off Propranolol. Is this correct schedule?

Would I become hypertensive or hypotensive after the initial dosage? Please do reply.
368886 tn?1466238884
MEDICAL PROFESSIONAL
The most common side effects of Sertraline that you should watch out for are nausea, diarrhea and sleep disturbances, in that order. There are a lot of other side effects listed for Sertraline, but these are the ones commonly encountered. Drowsiness and excessive sleep may be seen with Clonazepam. Other side effects are rare.

I won't be able to comment much on the effects of the initial dosage on your blood pressure, as it differs person to person. Please make sure you have an access to blood pressure measurement once you start the new medicines, just to be cautious. I hope you have decided to taper off Propranolol with your doctor's review. It is important to inform your doctor about it.

Avatar universal
One last question to you Doctor.

I was never ever depressed or anxious in my life. I used to encourage people and would be social and interactive.

It was only in June when I joined a new job which kept me tired and stressed. Then in July I got a panic attack that repeated continuously. This caused me several phobias. I stopped going out and felt low.

So, I would say that anxiety came first before depression. I am walking again and working. But I keep getting palpitations whenever I stop Propranolol. It may be due to hyperthyroidism.

All I am asking is shouldn't I treat my anxiety with some low dosage anti-anxiety medication instead of going for antidepressants?  As I know that if I never get the symptoms of panic attack, I will come out of depression too.
368886 tn?1466238884
MEDICAL PROFESSIONAL
Hello.

Sertraline, as other SSRIs, is shown to be effective for the mixed anxiety-depression. The evidence points towards more benefit from using the antidepressant than anti-anxiety medicine alone. Since we can not predict if your depressive symptoms will disappear after treating the anxiety, Sertraline seems to be a better option than anti-anxiety medication alone. With Clonazepam as an adjunct, you can expect a faster response.

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