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About mikl_pls

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  • Birthday 09/11/87

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  1. Have you tried any antiglutamatergic drugs? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4425334/ http://www.medscape.org/viewarticle/778119_8 Lamotrigine, topiramate, zonisamide, memantine, amantadine, pregabalin, riluzole, N-acetylcysteine, stimulants, lithium, etc.
  2. Makes me wonder what the difference between combining clomipramine and fluvoxamine and just administering supratherapeutic doses of fluvoxamine is (> 300 mg/day). As for the interaction between CYP1A2, luckily most of the population are rapid CYP1A2 metabolizers.
  3. Great article! The only thing I foresee is increased levels of clomipramine from coadministration with fluvoxamine, so low doses of clomipramine would need to be used, and probably even routine blood work to monitor the levels of clomipramine to make sure they're within therapeutic range and not in toxic range.
  4. Apparently, they've used up to 400 mg sertraline before in treatment-refractory patients. https://www.ncbi.nlm.nih.gov/pubmed/16426083
  5. It's true! I swear! Stahl indicates it in his Prescriber's Guide.
  6. That's very unfortunate! Saphris usually doesn't do that to people, but I understand how it is when you get a side effect from a medicine that no one else seems to get! Especially when it comes to weight gain! (Jeez! It sure sucks!) That's also unfortunate... Geodon is a really tricky antipsychotic to take, especially for psychosis. It needs to be dosed higher, 120-160 mg/day, sometimes even up to a maximum of 320 mg/day. The key to making sure this antipsychotic is successfully taken is taking each dose with at least 500 calories of food to ensure proper absorption; otherwise, if there is inadequate caloric intake to go along with it, it will decrease its absorption, effectively decreasing its dose to a less-than-efficacious therapeutic level, causing breakthrough psychosis and/or mania (whichever one is taking it for). That's good that the Abilify worked well enough for you that you were able to go home! It just seems unfortunate that you say it seems like it might not be effective anymore. There are actually case reports of people needing up to 60 mg of Abilify, so it isn't unheard of to take much higher doses than 30 mg. You'd have to speak with your pdoc about whether that would be worth pursuing, especially with your combination, or whether increasing it could allow you to consolidate your combo. Wow, 5 mg 3x/day of Haldol to start with? In my opinion, that's kind of a hefty dose to be taking on top of another antipsychotic... I think that would be appropriate for monotherapy, but even with monotherapy, I would think you would start lower and go up slower, that is unless your psychosis was very severe. But still, as an adjunctive agent, I still don't think that much Haldol would be necessary to start with, maybe eventually to work up to, but start low and go up slowly to see if you respond to a lower dose so you could potentially be dosed more conservatively. According to Stahl's Prescriber's Guide, Haldol can be initiated anywhere from 1 mg to 15 mg/day given once daily or in divided doses. According to Epocrates, it says "Start: 0.5-2 mg po bid-tid for moderate symptoms, 3-5 mg po bid-tid for severe symptoms." This is my uneducated opinion, but I would be inclined to believe that if Haldol were to be combined with another antipsychotic, the "moderate symptoms" dose range would be used first, then if needed, titrate up to the "severe symptoms" range. Other typicals exist that may not be as TD-inducing as Haldol (I think Haldol is regarded as the worst offender of TD...). Prolixin, for example, is a decent one with high potency, and while it does have a high incidence of EPS, I don't really hear too much about TD as a result of it as I do from Haldol... Stahl says initial dosing is 0.5-10 mg/day in divided doses, and Epocrates says to start 2.5-10 mg/day divided every 6-8 hours. Trilafon, another high-potency phenothiazine, also has a high incidence of EPS, but for some reason, I haven't read about TD as much coming from it. Stahl says "4-8 mg 3x/day," Epocrates says the same thing. As an add-on, though, you might need a lower dose, like 2-4 mg 2-3x/day? I'm just guessing based on how multiple drugs inhibit each others' metabolism. Stelazine (my favorite...), high-potency phenothiazine: Epocrates: "Start: 1-2 mg po bid, dose: 2-5 mg po bid." Stahl: "initial: 2-5 mg twice a day, increase gradually over 2-3 weeks." Navane, a high-potency thioxanthene: Epocrates: "2 mg po tid if mild/moderate, 5 mg po bid if severe; dose: 2-5 mg po bid-tid," Stahl: "initial: 5-10 mg/day" Another typical, which I've been very interested in trying (my pdoc won't let me try it) is loxapine (Loxitane), because at low doses, it behaves like an atypical antipsychotic (it has a higher affinity for 5-HT2A than D2 receptors, but apparently affinity for D2 exceeds 5-HT2A in higher doses, making it more "typical" again). It also produces the tetracyclic antidepressant amoxapine (Asendin) as an active metabolite, which could help with depressive symptoms. According to Stahl, when dosed < 50 mg/day, especially 5-25 mg/day, it behaves the most like an atypical. But above 50 mg/day, it loses its "atypicality." This could be another possibility for an adjunctive agent, though where in your regimen it may fit I don't know. I just thought I would mention it for interest. I don't know for sure if lower doses of typicals would keep TD from occurring, keep it at bay longer, or have no effect on when it would develop (if it were to develop) at all. Supposedly the atypicals can have just as much of a risk of inducing TD as the typicals do if they are dosed high enough, and even though TD isn't as much of a problem with the atypicals (or at least that's the common perception/belief), it's still very possible for TD to develop from atypicals (and does in a population of patients). So I really don't know if lower doses of typicals mean less risk of TD... I do know that they are dosed much lower now than they were back in the day, which is when the reports of TD were really coming in. Maybe if they did some long-term studies on the use of first-gens with more conservative dosing, it might reveal some insight, but unfortunately, there's a huge stigma about the typicals AND the majority of the interest lies in the newer atypicals, and while it just so happens that some people don't respond adequately to the atypicals, can't tolerate them, or do better on the typicals, it's highly unlikely that any real studies will ever be done on the typicals ever again, I don't think. Tegretol is a pretty nice medicine, but it does have a risk for some pretty severe side effects. I'd read up about it and/or ask your pdoc about them before really considering going on this drug. Again, you'll have to double your Lamictal dose if you take Tegretol to maintain the same plasma levels of Lamictal in your system since it speeds up Lamictal clearance from your body. In fact, you'll have to double the dose of Abilify, too, and possibly many of your other medications. So this would definitely be worth some major planning and consideration between you and your pdoc. I don't blame you one bit whatsoever on the lithium and Depakote... I've steered clear of those for those very reasons myself. Tegretol is usually weight neutral for just about everyone. Certainly! The first time I took it, only when I got to 200 mg/day, I had a short-lived albeit marked improvement in mood, but also my tremor and Tourette's almost vanished completely. Then with a slight med tweak, everything went back to hell in a handbasket again. I continued to take it, didn't try 400 mg/day, until I got kidney stones from it. I switched to Zonegran and haven't looked back. Unfortunately, I didn't get weight loss benefits from either... :x I think I've read females are more prone to getting the weight loss and anorexigenic benifits from Topamax and Zonegran than males are. I'm not sure, but you might also have to increase the dose of Topamax if you take Tegretol. No, you have nothing to apologize for! It's me who's leaving the long replies... XD Hopefully you can successfully come off of it this time without having relapses in symptoms and having to be hospitalized! It really might be worth a shot... Maybe not necessarily Haldol, but certainly a high-potency first-gen + Abilify (or even Vraylar or Rexulti, eventually, don't want to switch things up too much all at once), maybe with an increase in dose of Abilify to 40 mg for now? Or like you said Abilify + Invega, maybe try an increase in Abilify here to 40 mg as well? You'll probably have to get your pdoc to write a PA to your insurance company to let you fill 60x 20 mg for a month... You could also ask about switching the Seroquel for Loxitane and keeping the Abilify and Invega, but then you'd still be on 3 antipsychotics... but if you were on Loxitane, at least you'd probably be on a lower dose, and not on a full dose like on Seroquel. Best of luck to you! Let us know what your pdoc says. I'm really curious as to what your pdoc decides to do.
  7. Nope. I didn't, but it does have the possibility of causing nausea (as well as a bunch of other side effects, apparently...) Zofran helps me a lot if I have problems with nausea, so maybe your doctor would be willing to give you some along with it if you wanted to try it but were afraid you might be sick from it.
  8. I agree, you definitely need to streamline. You are on the max dose on two antipsychotics and 5 mg past the max dose on another. It's best to try to be on one antipsychotic if possible, but if you must be on two antipsychotics, a strong, therapeutic dose of one plus a low dose of the second is usually indicated, which means the adjunctive antipsychotic must be of antipsychotic potency at a low dose (in other words, not something like 100 mg Seroquel...) So you need prophylaxis against highs, lows, and psychosis, and doing without Seroquel has equated to psychosis, mania, and hospitalization, even with two other max dosed antipsychotics on board... Seroquel is a very low-potency antipsychotic, but has high-potency 5-HT2A antagonism relative to its D2 antagonism, especially its active metabolite, norquetiapine. I wonder if this has something to do with the ratio of 5-HT2A to D2 antagonism... Quetiapine's ratio is 1.0779:1 Norquetiapine's ratio is 4.0889:1 Paliperidone's ratio is 4.947:1 (And aripiprazole's ratio, which isn't really contributory, is 1:18.421) I wonder if you would do better with an antipsychotic with much stronger 5-HT2A antagonism? Have you ever tried Saphris or Geodon? Another thing you could probably try is slowly titrating off of the Seroquel and one of the other two as well (one at a time of course, but if it were me, I'd titrate off the Invega and keep the Abilify), and add a high-potency first-generation antipsychotic, like Haldol, Prolixin, Trilafon, Stelazine, Navane, etc. It wouldn't have to be dosed that high... The reason I would keep the Abilify is that it's a dopamine partial agonist, and combined with a typical antipsychotic, the pharmacological profiles make them compliment each other well (that's what I've read about this combination technique anyway...). Something else you might try is to add another mood stabilizer. Carbamazepine (Tegretol) is often added to patients with treatment-resistant psychosis with mood elevation. Of course with it being a CYP-inducer, you'd have to double your Lamictal dose to 600 mg if you were to take that... Depakote/Depakene are also an option, but weight gain is a major risk with those... Lithium also, but again, weight gain, but also other problems like kidney, thyroid, etc. You also could try an increased Klonopin dose, which itself has mood-stabilizing properties. What's the Topamax doing for you? That's a LOT of Vistaril! Is that for sleep, anxiety, agitation, mania?
  9. https://www.moodscope.com/
  10. Lamictal makes me break out in horrendous cystic acne all over my back and shoulders... I don't respond to doxycycline 100 mg bid (200 mg) at all and barely respond to minocycline 100 mg bid (200 mg). I've used PanOxyl 10% wash in the shower, then adapalene gel (Differin) 0.3% + clindamycin lotion 1% twice daily. I used to use benzoyl peroxide/clindamycin gel (BenzaClin) 5%/1% but it was impractical to use on my shoulders and back and would stain my clothes. Erythromycin gel 2% burned like fire when I tried it for a brief while instead of clindamycin lotion, so I just went back to the clindamycin. I also used tretinoin cream 0.05%, but it didn't seem to do anything at all. Then @ByePolarCoordinates told me about Bactrim DS (trimethoprim/sulfamethoxazole 160 mg/800 mg) and it has been a complete game changer for my acne! I take it once every 12 hours for 14 days at a time and go back to minocycline for another 14 days and cycle back and forth. They said I can't take Bactrim DS constantly or it would cause blood dyscrasias and vitamin deficiencies and things like that, so after a while of taking it they will want to do some blood work, but worth it in my opinion. I still use the PanOxyl in the shower as well as the adapalene and clindamycin, but the latter two I've been able to reduce to using only once daily if even every other day and still have clear skin. The only problem is when I switch back to minocycline, I'm "spoiled" from the Bactrim, so I don't step up the care with the topicals and my acne catches back up with me while on the minocycline. It's definitely not a first-line agent for acne, but if you've tried most or all of the tetracycline antibiotics without any response or at best a very partial response, I would definitely recommend giving Bactrim DS a trial.
  11. arteI have OCD and what my pdoc refers to as "history of GAD" (a pdoc in the ER diagnosed me with GAD but she seems to think I have something else and isn't telling me apparently). I have panic attacks from time to time, social anxiety, etc., but haven't been officially diagnosed with panic disorder of social anxiety disorder or anything. However, Wellbutrin was the first antidepressant that I responded positively to (before I knew I was bipolar and took an AD without a mood stabilizer). Personally, it never did anything for my libido or sexual function, even when I went all the way up to 500 mg/day. But it also never increased my anxiety; rather, it decreased it, especially when Adderall was added to it, paradoxically. Now Adderall, on the other hand, when I first started it, did... lots of... things... (I cannot mention here) plus increased libido and all that stuff. Stimulants aren't a first-line option for this indication, but they are used for antidepressant-induced sexual dysfunction. I will also say that when I was on Effexor, it was physically impossible for me to get off. My interest was drastically decreased, but when I wanted to, it was hopeless, but Effexor helped me so much that the benefits outweighed the negative side effects it gave me, until I started gaining tons of weight, which is a deal breaker for me. The SNRI Cymbalta, on the other hand, didn't give me any problems in the sexual function department, even when I went all the way up to 120 mg (maybe a little trouble, but not much). Pristiq, the synthetic active metabolite of Effexor, I seem to remember actually increased libido and sexual function, but even at 100 mg had no effect on depression whatsoever. Fetzima... I didn't have a good experience with it, so I wasn't on it long. Savella is related to Fetzima (the racemic version of it). I haven't tried it, but it's only indicated for fibromyalgia, but that doesn't mean it can't be prescribed for depression/anxiety, because it's used for that pretty much everywhere else around the world. There are alternatives to adding Wellbutrin for SSRI/SNRI-induced sexual dysfunction: SARIs (Serotonin antagonist and reuptake inhibitor) Trazodone (Desyrel) Nefazodone (Serzone) NaSSA (Noradrenergic and specific serotonergic antidepressant) Mirtazapine (Remeron)—major weight gain, carb cravings, and sedation with this one, so watch out if you try this one! Higher doses (≥ 30 mg) are said not to have as much of the sedation and carb cravings, while lower doses (≤ 15 mg) cause more sedation and carb cravings. Either way though, you will gain weight. PDE5 inhibitors Sildenafil (Viagra)—I think Viagra is still brand-name only, which you may be able to get a coupon for, but under the brand name Revatio, which is the same medicine, just for a different indication (pulmonary arterial hypertension), I think you can get it as a generic. Also, I think this is the only one studied for SSRI/SNRI-induced sexual dysfunction. Other PDE5 inhibitors, which would likely be beneficial (don't see why not if sildenafil is...) Cialis (tadalafil) Levitra (vardenafil)/Staxyn (vardenafil ODT) (Staxyn is an orally disintegrating tablet) Stendra (avanafil) α2 antagonists Yohimbine (Yocon)—available as prescription or OTC supplement. Is a prescription, it's 5.4 mg 3x/day, and if side effects occur, decrease to ½ tablet 3x/day then back to 1 tablet 3x/day. Antihistamines Cyproheptadine (Periactin)—take only as needed because it can interfere with the mechanism of action of SSRIs/SNRIs, also increases appetite and can cause weight gain Probably more I can't remember
  12. Link: NIH rat study suggests amitriptyline temporarily inhibits the blood-brain barrier, allowing drugs to enter the brain "a provisional patent application has been filed for methods of co-administration of amitriptyline with central nervous system drugs." I can't help but wonder if amitriptyline will become a brand-name only drug once again or something, or if some generic drugs for these aforementioned CNS conditions will be paired with amitriptyline to form brand-name combination drugs and be pushed for profits. But still, this is a pretty neat discovery. Regardless of what happens with patents and whatnot, hopefully, amitriptyline and any generic drugs for any of these conditions will remain separate and generic so that they can just be prescribed separately and taken together to achieve the same potentiating effect as a 2-in-1 drug. I understand that research hasn't been done on humans, but I'm curious about what dose it would take for this to happen for humans. It doesn't mention the dose used for the rats, but I wonder if just a low dose could be used, like 10, 25, or 50 mg, or if it would take higher doses like 150-300 mg, or supratherapeutic doses above 300 mg?
  13. Is sertindole available in your country? I think it's pretty similar to amisulpride but has less of a chance of inducing hyperprolactinemia.
  14. Depending on what type of seizures you're having from the clozapine (absence, focal/simple, generalized, etc.) depends on which anticonvulsant to use, but one that would work well for focal seizures, I think especially in the temporal lobe, is oxcarbazepine, and it wouldn't cause much in the way of psychiatric side effects—if anything would probably help you. Carbamazepine is another good one, but it has a more serious side effect profile and is a stronger CYP inducer than oxcarbazepine. I take levetiracetam for complex-partial seizures and like it a lot, it doesn't have any interactions with my meds and doesn't have any side effects to speak of like sedation or depression (though depression is listed as a possible side effect). You may have tried lamotrigine before, but it's a good one, and is activating too, so may be good for your fatigue. Topiramate is also good, can be activating or sedating depending on the individual, but has a possibility of inducing agitation in some people. Zonisamide, one of, if not my favorite anticonvulsants, is fantastic. It's said to have a heavy side effect profile, but I have never experienced side effects from it personally. I honestly have no idea what to say about the SSRIs. The only thing I can think of is have you ever tried nefazodone? It can help some people who don't respond favorably to first line agents like SSRIs, but may not be potent enough to help with your anxiety. What dose of modafinil/armodafinil did you try? You could try half of a 100 mg modafinil tablet, or half to a whole 50 mg armodafinil tablet to start with to assess your tolerance, perhaps. What about a tiny dose of bupropion? Like half of a 75 mg instant release twice daily (37.5 mg + 37.5 mg)? The aripiprazole 2.5 mg idea sounds like it might work too, but if it will make you psychotic, then it's probably best not to do that. Are 2 mg tablets available where you live? If so, you could split a 2 mg tablet for 1 mg, perhaps.
  15. I was going to say the same thing... You are literally on one of the most synergistically sleep-inducing combinations I've ever seen. I'm assuming that because you're on clozapine that you've tried pretty much every other antipsychotic, is that correct? I'm also assuming that because you've read Stahl's Essential Psychopharmacology, you know that aripiprazole (Abilify), ziprasidone (Geodon), Rexulti (brexpiprazole) (for most), and Vraylar (cariprazine) generally have much lower rates of sedation and for some may even be stimulating. I was going to suggest something like this too. Antipsychotic polypharmacy isn't recommended most of the time, but aripiprazole and clozapine have complimentary pharmacological profiles. Maybe you could ask your pdoc if it would be possible to gradually lower your clozapine dose while gradually adding some aripiprazole? That is of course if you can tolerate aripiprazole and you don't have a bad history with it. Another possibility, if you haven't tried it yet, is to switch to loxapine (Loxitane). I've read many good things about it on this website and people seem to really like it. I've read it's really quite similar to clozapine but without the weight gain and metabolic side effects. I'm not sure about how it compares in regards to sedation, but perhaps it would be less sedating? It is also possible to add a eugeroic like modafinil (Provigil) or armodafinil (Nuvigil), or, if your pdoc is comfortable with it, a stimulant (read from a source on controlling sedation in patients with psychosis. It does not that "amphetamine-type stimulants could worsen psychosis, so their use in patients with persistent sedation is controversial.") Modafinil, 200 mg in the morning, has been reported to reduce total sleep time without adverse effects, but there was a case reported in which modafinil might have exacerbated psychosis in a patient with schizophrenia who was taking 200 mg qid (800 mg!!). This is also indicated as an off-label use for managing sedation in those with psychosis. 75-100 mg instant release bupropion once in the morning or up to twice daily might help you feel more alert. What is the valproic acid for? The reason I ask is so I might better make a recommendation for an alternative to bring up with your pdoc, but if you're attached to the valproic acid, then it's your cocktail. (For example, less sedating anticonvulsants might be lamotrigine (which is even stimulating for some), topiramate, oxcarbazepine, zonisamide...) A benzo is a benzo, and part of a benzo being a benzo is that it will be sedating. So if you need the clobazam, you need it. As far as the paroxetine goes, have you tried less sedating and even stimulating SSRIs or any of the SNRIs? Sertraline, fluoxetine, escitalopram, venlafaxine, desvenlafaxine, duloxetine?