February 7, 2023

Welloft a clever name for a medication combination commonly used in depression treatment. This view will discuss the mechanisms of each medication and explain why this combination might help improve depression more than other individual medications or combinations.

What’s up everybody dr rossi shrinks and sneakers.com so in this video i’m going to continue with my theme of psychotropic drug combinations with interesting names or interesting combinations so this is going to be the story of two medications zoloft and wellbutrin to create the medication combination well off so we’re going to go ahead and crack into the video

I’m going to discuss each one individually and what is interesting about their mechanism of action in the end i’ll kind of wrap it all up with why i think this particular drug combination might be beneficial for treating patients with depression on my screen here that i brought up the basic information on sertraline also known of course as zoloft it’s the part

That gives us the well-off portion of the name so zoloft is an older medication very commonly prescribed medication both in psychiatry as well as in primary care for treating a lot of different disorders so if we look here you can see you know the brand name of course is zoloft and it is available now in generic form and it’s in ssri and i’ve talked about these

Things before in the past but that’s a selective serotonin reuptake inhibitor it’s commonly prescribed for things like major depressive disorder obsessive compulsive disorder panic disorder ptsd pmdd as well as social phobia and if we look here at the mechanism of action you can see that it boosts the neurotransmitter serotonin and blocks the reuptake pump so

That hence the reuptake inhibitor concept of these ssri drugs in general one of the more interesting points about circulane that i want to direct your attention to is that it has the ability to block dopamine reuptake pump so what makes that interesting is not only are you getting the effects of you know enhanced serotonin transmission you’re also getting some

Increased dopamine which is different than many of the other ssris so that’s an interesting kind of caveat with surgery lean medications the other thing to think about is the dosing of this medication so generally anywhere in the range of i’d say 25 to 200 milligrams a day and that’s more so with the elderly and younger patients you might start at 25 milligrams

A day just to make sure that they tolerate this medication appropriately the next thing to say is the 200 milligram dose is not in absolute sometimes we go higher than 200 milligrams in things like ocd which generally require much higher doses of these medications but 50 to 200 milligrams is a reasonable dose range so this talks more about you know how to dose

It some of the general advice about that some of the tests you have to do um that you’ll notice there’s no tests necessarily for healthy individuals it’s not habit forming so it’s not like a benzodiazepine that you have to worry about um and then of course the side effects are are kind of the typical things that we talk about with a lot of these medications which

Would be gi distress and nausea dry mouth diarrhea constipation sexual side effects particularly for men delayed ejaculation erectile dysfunction etc and reduced sexual desire for women along with anorgasmia so these are some things that you definitely worry about siadh we worry about a little more in the elderly patients and in some cases because serotonin is

Involved with platelets and platelet aggregation you have to worry about bleeding in some rare cases so just going back though to the idea of why sertraline is a good medication again it’s a typical antidepressant medication selective serotonin reuptake inhibitor and it has this added benefit of also blocking the dopamine reuptake pump so sertraline has some a

Couple of different mechanisms by which it may be helping to and to improve a patient’s depression so in the next clip we’re going to talk about wellbutrin or bupropion and we’re going to see what type of mechanism that is and why again the combination of these medications might be beneficial for medication in this combination is buprion also known as welbutrin

And it comes in a couple different forms there’s a sustained release an extended release and then there’s a couple of different names associated with it probably the most common one being zyban because this medication that’s the way it’s branded for smoking cessation but i really want to turn our attention to the mechanism of action as well as the class of the drug

Because i think that’s where we start to see what the real reality of this is and why again this combination of searcher lean and bupropria might be beneficial so this is what’s called a norepinephrine dopamine reuptake inhibitor and it works as an antidepressant and for smoking cessation so if we look at the reasons that this medication is usually prescribed it

Would be prescribed for things like major depressive disorder seasonal affective disorder and nicotine addiction the mechanism of action bupropion works by boosting neurotransmitters uh norepinephrine and dopamine so if we go back and just think for a second about sertraline now we have serotonin and dopamine with the sertraline we know and we have norepinephrine

And dopamine with wellbutrin or bupreprion so it’s going to block the norepinephrine uh reuptake pump and this is beneficial because there’s not really many of those pumps in the frontal cortex so this can lead to enhancing dopamine transmission in the frontal cortex which we think may be related to the antidepressant effects as well so similar to what we talked

About with the serotonin selective serotonin reuptake inhibitor similar type of thing going on only it’s working now on different neurotransmitters specifically norepinephrine or noradrenaline and dopamine now the dosing there’s a bunch of different forms again it depends on which one you’re using right so you can see here that there’s a bunch of different doses

Uh generally speaking if i can use it i will use at the xl or extended release formulation and the reason i like extended release is this it allows for less dosing so once daily dosing a lot of people cannot remember to take medication uh even myself would have a difficult time if i had to take a medication you know three two three times a day it’s very easy

For people to remember to take then if it’s once a day and because the extended release does not result in the huge bump in serum levels of the drug which is often related to side effects it’s often how the rate of rise of the drug in your blood that causes the side effects not so much the um not so much the the amount for say in the dose so what you want to

Do with the extended release again is it provides a more sustained level in your blood than the immediate release or sustained release so that’s why i prefer that if i can use it now i mean there’s a bunch of different information here probably the main thing you want to look out for with these patients is if somebody has had a history of seizure because this

Medication at higher doses specifically 450 milligrams and above you start to see increased risk of seizures in people who are susceptible to them or if the person of course is abusing the medication in some way such as cracking a mopain snorting them crushing them up etc some of the notable side effects just to go over these are all almost the same in most cases

Again the gi distress dry mouth nausea constipation um the other stuff like insomnia headache agitation anxiety these medications work both for anxiety but can also cause anxiety so it’s something to remember what i put what i like about this medication is that’s weight neutral right in weight loss or anorexia is one of the actual side effects so a lot of our

Medications cause weight gain so this is a good medication to help kind of balance that out or if somebody’s concerned about weight gain this may be your go-to medication to start with in some cases another case where this may be a medication you start with is for somebody who’s very concerned about sexual side effects we know that this is the best medication

If you see the answer on your board exam or your usmle exam and someone’s having sexual side effect or is having sexual side effects or medication doesn’t want to have them switch them to ibuproprion if somebody is worried about sexual side effects but they’re depressed you might want to start with you program so that’s how we kind of think about this and yeah

It can it can be difficult so i’m going to talk in the next clip a little bit about you know this combination now and now that we’ve gone over both of the medications individually we can kind of see where this is going the idea that the more neurotransmitters and the more various types of neurotransmitters we decide to boost the better off the response is going

To be for the patient with depression and i’ll explain a little bit about what i mean all right guys so let’s wrap up this video on the medication combination well off and i’ll tell you just my briefly my thoughts on why i think this works and why these two medications work synergistically together so in the one clip we discussed sertraline or zoloft and we

Said that not only is there this serotonin reuptake inhibition there’s also dopamine reuptake inhibition which could be increasing dopamine in the prefrontal cortex leading to improved um antidepressant effects now you take wellbutrin or buprepreon and you have norepinephrine and dopamine reuptake inhibition so essentially if you go back to one of my previous

Videos where i discussed the biological basis for depression and a little bit about how these drugs came about i had said that maoi or mao inhibitors were the sort of original antidepressant in in this category right and so with those drugs they’re irreversible usually inhibitors most of them not all uh irreversible inhibitors of that enzyme which leads to an

Increase in all of these neurotransmitters serotonin dopamine so sort of the similar concept here the more of these neurotransmitters that we believe are involved in the or have antidepressant effects and are involved in depression the biological basis of depression the more we’re going to benefit from these drugs so the combination of these two drugs increases

Actually those same neurotransmitters be it in a different way than the maoi right so a different way of increasing serotonin or epi and dopamine but still kind of achieving that same general result and if you look at other drugs the earlier antidepressants things like tricyclic antidepressants they usually worked on serotonin and norepinephrine so two of the

Three neurotransmitters that we feel are strongly related to the neurobiological basis of depression so when you combine this all together essentially the more of these neurotransmitters that we are able to increase and alter in the in the brain the better the antidepressant effect at least theoretically because i’ve talked about maos and i said that you know i

Think those are actually underutilized underrated medications although they have a lot of side effects and potential harm they’re also very very beneficial for depression so that wraps the video if this is helpful to you guys please like and subscribe to the channel and we’ll continue to create content on the various psychotropic drugs

Transcribed from video
Psychotropics: The Story of Welloft (Zoloft and Wellbutrin Combination) By Shrinks In Sneakers