Hi Gregg I wish there was a way to know exactly how much one can get by with combing 2 things before getting serotonin syndrome but I’ve never seen anything. I guess since everyone might be different in how they are affected. I finally just decided to chance it - figured some folks take 2 tramadol every 4 hours and I’m just taking 1.5 twice a day so didn’t think a smaller dose of MB would tip the scale. I’ll ask my PCP but don’t think she’ll have a clue, but I’ll stick with 5mg of MB. I really don’t expect it to help with the chronic fatigue anyway since nothing else has, so will likely just be consuming this one bottle. Thanks for the warning/suggestion.
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Hi, I wish we knew more about MB and it’s interaction with other drugs. I take 5mg Monday thru Friday with a break on weekends.
Take care and be well.
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Do your own research and talk to a doctor. Include Tramadol in your query and demand references.
However, my research has only found one case in decades of oral methylene blue being associated with serotonin syndrome. And that case is suspect.
“The FDA and drug interaction databases explicitly contraindicate the combination of methylene blue and tramadol due to this risk.” This is based on theory, not any actual case study of Tramadol and MB that I can find.
The other cases all involve MB administered intravenously.
Even then, the actual number is very few, considering the large number of times it is administered in hospital emergency rooms.
IMO, compared to the number of users of MB, the number of cases of MB and serotonin syndrome are infinitesimal.
The amounts are enormous compared to the oral doses that people on the forum use.
Low oral dose MB is considered <1 mg/kg of body weight. Therefore, for my body weight, the calculated oral dose would be 70 mg. I am taking 15 mg five days a week.
Here is one of the most negative articles that I have found associating MB with serotonin syndrome.
This period this article covers suggests that the 13 cases of serotonin syndrome (out of the 14 reported cases of CNS toxicity) were documented roughly between 1996 and 2012, spanning approximately 16 years.
https://www.psychotropical.com/wp-content/uploads/4.0-Methylene-Blue-and-Se-Serotonin-Toxicity-1.pdf
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Thanks so much desertshores this relieves the little concern I had. Mine would be 60mg for a lower dose so taking 5 to 10mg along with the small amt of tramadol should be no issue whatsoever. The link didn’t work but per your research I’m not going to concern myself with it. I also take modafinil and stimulants are also on the no list but the reaction is just more anxiety, rapid heartbeat, or high BP and I have none of these on the 5mg. Just knowing that 60mg would be the lower end for me is enough to alleviate my concerns. Thanks again, this is such a helpful, generous forum.
Could I ask why you take 2 days off?
The half-life of methylene blue is somewhat dose and metabolism-dependent.
The terminal half-life of oral methylene blue in humans is reported to be in the range of 5 to 20 hours.
I take the weekend off so that I don’t accumulate too much in my system.
That’s quite a big range! I’ll do that too then if I ever go to bigger amounts. Thanks!
rephrased: 1) When MB reaches the skin, the blue is long gone, 2) MB is not directly reacting with the red anyways, blue or not.
(why would blue react with red??? absorption of a color leaves its complementary color, so if it were MGreen…but it is blue)
Thanks, I understand now. :-). Random comments below videos are never explained or backed up by anything but still question if any accuracy. Luckily I know where to come for that. 
All good points - the only thing I’d add is that this substance is actually used very rarely in the ER. So our experience with it is actually pretty limited with the IV formulation. It is an essential medicine for methemoglobinemia. After 30 years of work in a range of ER’s from large academic trauma centers to very rural facilities, I’m yet to use methylene blue (except on myself orally).
I suspect more doses might be used in ICU for vasogenic shock where in higher doses it acts as a nitric oxide synthase inhibitor in the blood vessels and helps support blood pressure in shock. I however, in my time rotating through ICU, I’ve never seen it used.
@KarlT Have you ever used this in the ER?
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An assumption on my part from reading various literature and the fact that it stocked by most hospital ERs.
“Evidence-based review of the existing literature ultimately recommends stocking of Methylene Blue (MB) as an emergency antidote in the United States. The same is reported around the world in Japan, Greece, Italy and Canada. The observation that MB is always present as the main antidote required in emergency and critical care units”
Based on your response, I must conclude that while MB has many applications in the ER, the conditions it addresses are relatively uncommon.
“Its use in the ER for shock unresponsive to standard vasopressors has gained more traction in critical care settings.”
“Methylene blue was explored as an antidote for cyanide poisoning in the early to mid-20th century, with successful tests reported as early as 1933.”
“The treatment of methemoglobinemia, which can arise from accidental exposure to various chemicals or medications (some local anesthetics, nitrates, certain antibiotics like dapsone)”
“Why Methylene Blue Have to Be Always Present in the Stocking of Emergency Antidotes | Bentham Science”
“Vasoplegic Syndrome and Noncatecholamine Therapies - StatPearls - NCBI Bookshelf”
“https://accessmedicine.mhmedical.com/content.aspx?bookid=2284§ionid=248385909#:~:text=Reversal%20of%20nitrite-induced%20methemoglobinemia,distress%20syndrome%20in%20vasodilator%20shock.”
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I’ve only used it once. During residency in the ICU. 30 years ago. lol. It would not normally be stocked in the ER, but rather in the hospital pharmacy.
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Desertshores I found some Scott Sher videos - he’s worked with MB for many years and said pretty much exactly what you told me. He’s not concerned about serotonin syndrome but is concerned about people taking large doses of MB and said that in his many years of practice he has found that folks actually do better with smaller doses so he keeps folks at about 15 to 20 mg some even less and now it takes a much smaller dose himself.
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