ALH, Tamoxifen tailspin

kkshedevil
kkshedevil Member Posts: 6
edited June 2014 in High Risk for Breast Cancer

Hi, I'm new here and would really appreciate some feedback about my situation.  In June, my mammogram showed microcalcifications that turned out to be ALH. Since my mom died of breast cancer (April 2007) the oncologist recommended tamoxifen. (Plus the whole 6-month follow up, etc., standard stuff.)

I started taking it in early August.  After about three and a half weeks, I felt like someone pulled the rug out from under me.  At first I thought it was stress--lots of other stuff going on in my life, including finding a lump in the left girl (the ALH is in the right), that turned out to be a cyst.  

I take Lamictal and Wellbutrin for a mood disorder.  When I consulted my psychiatrist about the depression, she found that there is an interaction between Wellbutrin and tamoxifen--I've read some posts about that here.  I still don't know if the tamoxifen messed up the Wellbutrin's efficacy or just caused depression independent of affecting the Wellbutrin.

Anyway, I was too depressed to go to work all of last week.  The oncologist took me off tamoxifen but he told me there was no correlation between the tamoxifen leaving my system and an improvement in my mood.  I'm back at work half time, feeling irritable and overly sensitive. (And not entirely pleased about being given incomplete information about possible interactions of the meds).

Yesterday, my psychiatrist increased the Wellbutrin to try to pull me out of the depression.  I just started the higher dose todayand it's always worked well for me. This doesn't sound entirely rational, but I worry that the tamoxifen screwed me up permanently and that Wellbutrin isn't going to work any more.  Then there's being back to high risk status again.  Yippee.  

I would appreciate any advice, similar experience, etc.  

Thanks!

KK. 

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  • leaf
    leaf Member Posts: 8,188
    edited April 2011

    Oh, KK, I am so sorry this is happening to you.  

    I am not an MD, and you must not regard this as medical advice.  But I am a  hospital pharmacist, I have ALH, LCIS (and nothing worse), and I'm on sertraline and tamoxifen (among other things.)

    In this NIH paper, you will see that bupropion (Wellbutrin) is listed in the 2nd column under 2B6.  Tamoxifen is NOT listed in this column, though tamoxifen is listed in other columns. I cannot find any columns where BOTH tamoxifen and buproprion are listed together.

    http://medicine.iupui.edu/flockhart/clinlist.htm 

    This would imply tamoxifen and bupropion are metabolized by different P450 enzymes.

    On the other hand, this Pubmed citation appeared when you type in 'tamoxifen + bupropion'. http://www.ncbi.nlm.nih.gov/pubmed/17101742

    However, I do not have access to the full article.  Neither tamoxifen or bupropion are mentioned specifically in the abstract.

    So I do not know for sure if there is any professional/academic citation out there for an interaction between tamoxifen and bupropion.  If there is, I think this is the sole citation in Pubmed. And maybe there is a citation that is too new to get into Pubmed, but I would be somewhat surprised if this was the case. This paper is also IN VITRO - in other words, this happened inside test tubes.  It does NOT document something that has happened in actual human beings.  There are many things that can happen in the test tube that do not happen inside human beings.  They MAY be happening inside human beings, but we do not know.

    I hesitated to go on paroxitene because of the potential interaction with tamoxifen.  But my onc said he didn't think it mattered.  I did go on sertraline instead.

    I would like to say something about drug interactions in general.

    1.  If there is a drug interaction between 2 drugs, there can be a big range in the degree of interaction.  For some pairs of drugs, essentially the entire action of one or both drugs is wiped out, or enhanced, and for other pairs it is a small interaction.  Many interactions are merely theoretical, and they haven't found actual cases of the interaction in humans.  That doesn't mean it won't happen in the future, but we don't know any for now.

    2.  Interactions can vary in frequency.  In other words, its very uncommon for an interaction to happen to everyone who takes these 2 drugs. There have been some major drug interactions (up to and including fatality) where when you notify a physician about an interaction, they say they use this combination constantly, and have never seen this interaction, let alone any mild symptoms of this interaction.

    I don't see any case reports cited in Pubmed about a tamoxifen + bupropion interaction.  That doesn't mean that it can't happen.

    We are just learning about these cytochrome P450 interactions (these are certain enzymes in the liver that metabolize different things).  We don't know if they are clinically relevant - I don't see any case reports of hazards between the two.

    The reason why published accounts in professional journals may be more accurate than hearsay here is because  there is hopefully more screening and peer review done in professional articles. We don't know if there are other reasons why some people have a bad outcome.

    Just on a theoretical basis, these enzymes do regenerate themselves, and they are not permanently disabled after having an interaction.

    I have been on tamoxifen for 2 years, and a tertiary specialist (at a major university) is proposing to take me off of tamoxifen because  of a potential worsening of another disease (scleroderma), that from what I know so far has not been documented in the literature.

    The interaction we are talking about is NOT about harming the liver; its because that one single enzyme is being 'overloaded' in trying to metabolize 2 drugs. The enzyme is a catalyst and should not be harmed in the process. 

    Maybe there is an interaction, and I haven't accessed it.  But almost all academic papers get into Pubmed. http://www.ncbi.nlm.nih.gov/sites/entrez?db=PubMed 

    So,my bottom line is - I'm so sorry you are going through this and I hope your Wellbutrin works quickly to get you out of this depression.  From what I understand about the tamoxifen interactions, the interaction should NOT be permanent - the liver enzymes regrow.  (Surprisingly, people who have parts of their liver cut out can regenerate their liver to their normal size in 1-2 weeks if the rest of their liver is healthy and not cirrhotic.) 

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  • roseg
    roseg Member Posts: 3,133
    edited September 2008

    It sounds to me like you were under care for a mood disorder before all this started up?

    Maybe tamoxifen isn't right for you. Six month check-ups would show any problems before they spread, or maybe you'd do better with a bilateral mastectomy.

    I'll second what Leaf has said about tamoxifen and antidepressants. Also, it takes about 8 weeks for tamoxifen to reach levels where it's working. You might try hanging on for 6-8 MONTHs and then quitting. Sometimes women find that the initial side-effects diminish over time. 

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  • Ked1019
    Ked1019 Member Posts: 122
    edited September 2008

    Oh I am so sorry you are going through this. I am having my 3 month follow up next month for my ALH. I will have a MRI, mam/us and will meet with the oncologist about tamox. I am also on wellbutrin but I don't think it is the right drug for me. I just have not made an appointment to get it changed. I am always on edge. I have been concerend about going on tamox and reading about your experienece I am even more concerned now. I don't have history in my family so I agree with roseg; if you can't take tamox please consider discussing other options with your doctor. I think the stress of going through these follow ups can wear on you. good luck.

    KED

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  • kkshedevil
    kkshedevil Member Posts: 6
    edited September 2008

    Thank you all so much for your replies, advice and concern. Leaf, that was such a thorough explanation.  Thanks for going to the trouble of researching this.

    Rose, I've been on medication for seven years for bipolar disorder. During that time, and especially the past two years, I've had a lot of life challenges that I've managed to get through.  But when the ALH came up, I decided I was really tired of being a good sport. It helps to talk to people who really "get it."

    Ked, I really hope my experience doesn't scare you off from something that might help you!  I think if my doctor had told me this could cause depression I still would have tried it, but I would have been more vigilant about watching my mood and doing something before I hit rock bottom.

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