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JustNuts

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  1. My mother keeps on pushing for me to try it, usually because “it’s supposed to be amazingly effective for autism” or similar bullshit. Not interested in ever touching it. I’ve read too many research studies on it and am well aware that it’s far from the harmless medical panacea that the general public seems to believe it is.
  2. I was going through my room recently and found the documents from a extremely brief (literally one day long) psych hospital admission a year ago. When I was there I saw a psychiatrist all of once, who said “the only medication that works for treatment resistant depression is Effexor”, then got irrationally pissed off when I politely disputed his laughably incorrect claim and indicated that I was reluctant to take venlafaxine in particular because of its well-known severe withdrawal symptoms. He accused me of being unwilling to be treated at all (rather amusing, given how I was there voluntarily in the first place, had been voluntarily seeking out psychological and psychiatric help for quite a while, and voluntarily trying medications even after some spectacularly bad experiences (like my little encounter with serotonin syndrome the very first time I tried a SSRI!) and entirely too many therapeutic failures, etc) and promptly discharged my still-very-suicidal ass. I obviously ended up back in the hospital within days (this time at the significantly better psych ward that I usually got sent to). What a utter waste of time and money. Anyways, I was surprised to notice that the documentation for that extremely brief stay had a diagnosis of schizoaffective disorder on it. Schizoaffective disorder? I don’t even come close to meeting the DSM-V criterion for that! And of course they never bothered mentioning this diagnosis to me. The first time I was ever in a psych hospital I was diagnosed with BPD. I was never told, it wasn’t until I saw the discharge paperwork that I found out. When I saw my regular long-term psychologist and told him about it, he thought it was a hilariously inaccurate misdiagnosis and said I was nothing like the BPD patients he had. When I eventually switched to a different therapist and we reexplored the borderline diagnosis, she took a different approach, looking at it more strictly from the DSM-V criteria. Eventually we concluded that I did actually technically fit the diagnostic criteria, but not in a very typical fashion at all. We started DBT and I was referred to a DBT group in the hopes that DBT would help with it, which was all somewhat helpful, and thankfully my psychiatrist didn’t give up on treating me or treat me any differently because of the BPD diagnosis (which both my therapist and psychiatrist agreed was only one small part of a complex diagnostic picture, each part of which should be addressed individually). However I remain painfully aware of the stigma associated with BPD, and always cringe when I get to that point in my list of diagnoses.
  3. Experiencing a massive amount of irritability, possibly continued akathisia, and odd tiredness even on Adderall with caffeine (caffeine definitely isn’t solely to blame for irritability, it seems to be mostly from something else or a complex combination of things) and (still) no Saphris/Vraylar (outside of whatever is still lingering in my system, which may be significant). Also, I’m observing that the benzos haven’t been working as well as they used to in general since resuming them, although they’re being asked to do more than they did before, so maybe that’s part of the reason for that? The Adderall's efficacy has also been more variable than usual. I’ll try taking a minimum day-long tolerance break from the Adderall, which should at least temporarily improve the efficacy. Not sure what to do about the rest. I’m feeling depressed and have been tempted to resume one of the antipsychotics, but when I think of the Saphris I just have to glance at the sheet with the partial list of side effects I was experiencing written on it to dissuade me from pursuing that option further (although the thought always crops up again later). The Vraylar I’m just ignoring for now because of the nausea, sleepiness, screwiness with Adderall, etc. I’m hoping that this will just stabilize somewhat with time, but that's probably far too optimistic. My PCP ideally wants me to get an orchi (orchidectomy) so that I can go off of the anti-androgen (bicalutamide) and at least partially lower the dose of estradiol, but: I don’t think there’s any way I could afford/pay for an orchi right now (it’s like optimistically $5k but could be anywhere from $3k to $10k+). An orchi is all but guaranteed to cause additional problems down the road if I ever manage to save up the money for SRS (problems like poorer outcomes, additional costs, and the issue that some surgeons flat-out won’t even perform SRS at all if you have had an orchi). Theres a good chance it would not be covered by insurance (or would only be covered by an in-network provider) => this could also potentially make me ineligible for insurance-covered SRS in the future. It can be quite difficult to find a trans-friendly surgeon willing to perform an orchi (significant travel is usually involved) To reduce future SRS-related issues (and complications in general), I’d have to find someone who can do an inguinal orchi, which is even harder to find. Different providers require differing levels of documentation from trans patients getting an orchi, which is often just as stringent as the documentation for fucking SRS (i.e. letters from two separate therapists and documentation of 1+ year of RLE (real life experience, i.e. “living openly as the gender you are transitioning to”, which is ambiguously defied and reinforced to varying degrees - some clinicians want this to involve being the most stereotypical over-the-top fake idealization of what idiots think all trans women are like, while others are content with proof of you living in a vaguely female role, and still others don’t give a shit as long as you've been on hormones long-term and have two therapists vouching for you)). There are of course various benefits to an orchi, but you can achieve much of the same effects with much less trouble just using anti-androgens and estradiol. However if the issues of cost, documentation, and downstream negative effects for SRS didn’t exist, I’d go for it without a second thought, the benefits would absolutely be worth it.
  4. Loxapine's primary receptor binding affinities aren't very favorable at first glance — too much H1 activity, too much mACh activity, some concerning α-receptor activity, etc. However, the SERT/NET/DAT activities for the active metabolites are very intriguing. I'll definitely consider it. I know, it's bizarre that it'd be sedating. I can kinda put together a very rough hypothesis for why it'd be somewhat sedating based on receptor activity (H1, maybe α1A, maybe some of the 5-HT receptors, and a somewhat too strong bias towards antagonism instead of agonism for the D2L/D2S/D3 receptors (where it's a partial agonist)), but it's nowhere near clear-cut (and this is for an antipsychotic with one of the cleanest receptor binding profiles I've ever seen)... The intolerability to higher doses than 1.5mg is also somewhat odd, but I've never tolerated antipsychotics well, so maybe it's just an extension of that?
  5. I'm not sure if it's helping or how much it did help...its efficacy has always been something I was unsure of. It's causing some pretty significant nausea already, hopefully this will go away like it did last time... Thank god for Zofran. I'm still quite concerned about the estradiol as I do feel like my mood has gone a bit downhill since resuming it, although I don't feel that my mood was really all that great prior to resuming it either... Not sure what to think. I switched from sublingual/oral estradiol to transdermal patches in late August, which is also roughly when I first started the Vraylar following a particularly nasty bout of suicidal ideation. The Vraylar seemed to pull me out of the depression, and the estradiol didn't seem to be an issue at all... My memory is a bit blurry, but I think I finally returned to work part-time again in mid-September, and was doing very well in general (at least by my standards of "very well") until I suddenly hit a huge unexpected stressor/incident in mid-October that utterly ruined my motivation, turned the depression up to 11, and brought the suicidal thoughts back with a vengeance... I took a week off of work because of this, managed to return to work again the next week, but at that point I was in really bad shape and after seeing my therapist on the 27th I ended up in the hospital. I suppose that proves that the issue lies less in the hormones and more in the mid-October incident, which is still unresolved and definitely part of the reason why I'm feeling depressed. But maybe the hormones are still worsening the depression even if they didn't cause it? Stahl's Essential Psychopharmacology makes it clear that depression and estrogen levels are well correlated, and due to my hospitalization I was unable to get the planned follow-up blood testing done to determine how the switch from sublingual/oral estradiol to transdermal patches affected my hormone levels, so I have no idea what those are like -- maybe we overshot the target a bit? Those labs were rescheduled to December 11th, so now I have to wait 3+ weeks to find out...which unfortunately is an unavoidable delay since we're not going to get valid results without waiting until my serum levels of everything are at least somewhat stabilized... I know there are also a handful of other (new/upcoming) major stressors that are worsening the depression right now, so that helps explain things a bit more... The fluctuations in hormone levels due to having recently resumed the estradiol/bicalutamide after an extended break can directly worsen things, and probably are, but the uncertainty remains. I should probably shut up and take some diazepam. But I'm already feeling sedated from the two different antipsychotics in my system, so adding benzos will just put me to sleep, and unfortunately I don't have the luxury of being able to sleep away the next few weeks no matter how badly I want to. The sedation in and of itself was still a significant issue with Vraylar anyways. I remember that I had to resort to taking days off of the drug here and there in order to function well enough to work. Maybe I should just dump the antipsychotics entirely - I've certainly had more than enough failures and unpleasant experiences with this entire category of drugs, and I'm only taking them for depression/mood stabilization anyways... The only ones I've ever tolerated for more than a few days before ditching were aripiprazole (dumped it after a short time due to side effects), asenapine (trying to dump this now due to side effects), and cariprazine (can only tolerate at absolute lowest dose of 1.5mg, and still had to skip days even on that dose to function). I've tried several of the more traditional mood stabilizers, but they were mostly useless and had nasty side effects. I'm relatively happy with the rest of my cocktail, I just seem to need something extra to help with mood. I guess there's technically the option of adding bupropion to burn through the sedation from Vraylar and augment everything -- I swore I'd never take that damn drug again last time I stopped it, but maybe in combination with Vraylar it would be tolerable? Not sure. It'd probably be too much additional NET inhibition to handle with the Fetzima... I don't particularly want to try lurasidone, but it's one of the few last remaining options until esketamine and ALKS-5461 are approved in mid-2018 (esketamine in particular is something my pdoc has previously brought up as a future option to try once it's available, and it looks relatively promising for my case in particular)... Well, I think I'm going to skip the Vraylar tonight and see if that changes anything. If my previous experience holds true, I'll be able to stay off of it for a few days at most before I start veering too far towards depression and decide to resume it. That will at least let the asenapine work its way out of my system without the Vraylar complicating things. And if I don't veer too far towards depression, maybe I can stay off it entirely for a while, although I'll of course resume it if the depression overtakes things too much (and switch back to asenapine if Vraylar doesn't work).
  6. 1.5 mg, the same dose I was on before being switched to Saphris. The amount of akathisia from the Saphris far outweighed any akathisia I've ever experienced on Vraylar, even with benzos blunting it, so I'm not worried about that particular side effect. My primary concern is the depression - and I'm quite worried about it. To make matters worse I was off my HRT for weeks thanks to being in the fucking hospital (off of the bicalutamide for ~2 weeks, off the estradiol for ~3 weeks), and have only been back on those for ~1 week (bicalutamide) & ~3 days (estradiol). While resuming the HRT has definitely improved some things already even though it'll be a while before my serum levels of bicalutamide and estradiol fully stabilize again, I was instructed by my doctor to watch carefully for signs of depression after resuming the estradiol in case it's actually contributing to the depression, so I have to be paying very close attention there as well... Of course any depression can be situational as well (and part of it quite definitely is!), or from various other meds, or from the massive fluctuations in my hormone levels (since any change in those can cause transient issues), so teasing that all apart is an utter bitch. All I know for sure is that independent of everything else, Saphris persistently caused entirely too many side effects and problems while seemingly doing very little to actually help me (and in fact I was off of it entirely for roughly 4-5 days after being discharged from the hospital due to insurance issues, during which time I actually felt better than I did when resuming it again, so I'm quite suspicious about how helpful it really was). Either way, Saphris should be essentially gone from my system within 5 half-lives (i.e. 5 days since it has a 24 hour half-life), so I guess how the next week goes will determine my next move. I guess I need to move my next pdoc appointment up as well since I'm screwing with my antipsychotics.
  7. After far too many frustrating side effects, doing some research, reviewing Stahl's Essential Psychopharmacology yet again, and nearly loosing my shit a few times too many, I have concluded that Saphris is definitely not at all a good med for me, and have (possibly foolishly) returned directly to Vraylar. While I'm not convinced that Vraylar is the right med, I am very convinced that Saphris is not the right med at all and have no desire to ever take it again (although if I deteriorate significantly on the Vraylar I suppose I will reluctantly resume the Saphris temporarily as a stopgap measure). Hopefully this won't blow up in my face.
  8. I've also only taken it once (IM though, not oral) during a nasty little episode of EPS that happened when the inpatient psychiatrist briefly tried putting me on an extra 5mg of Saphris in the morning in addition to the 10mg at night (despite having previously changed me from 5mg BID to 10mg QHS because of intolerable sedation and EPS - I'm not sure WTF he was thinking). It worked pretty well and didn't seem to have any obvious side effects, but I know they only used a small dose, and I'm sure the IM route works differently from the oral route.
  9. I'm on 10mg QHS. My pdoc said to try managing the akathisia with the PRN diazepam for now, and if it's still enough of a problem at the next follow-up, she'll add a low dose of benztropine (Cogentin). I'm not sure if I would want to take benztropine though. I feel like I'm already on a ridiculous enough number of meds as it is.
  10. It's crazy, but I guess that's the price we pay for drug development these days... You'd think that long-term meds like antipsychotics or PrEP would cost less money though... I guess it depends on the market size and the value to the healthcare system, but the numbers still seem high. My insurer paid $318.36 for 30x 20mg Trintellix back when I was on that drug, so that's roughly in line with what yours is paying for 90x (yours seems to have a slightly better price). Yeah, taking it at night was the only way it was tolerable for me. The benzos probably did help, but I think much of it was just pharmacokinetics. I'm no longer on Vraylar anymore, the new drug is Saphris (asenapine), which is initially heavily sedating (had to take it QD PM instead of the normal BID because of the sedation and because BID dosing caused EPS), but later causes significant akathisia (more than the Vraylar ever caused) — however it seems to be working better than the Vraylar did as an antidepressant, so I guess it's fine for now...
  11. I just discovered that my insurer paid a whopping $1085 for 30x 1.5mg Vraylar. Holy fuck. That's makes it by far the most expensive drug I've ever taken at over $36 per dose.
  12. You should probably have highlighted the "divided doses" qualifier...
  13. Eh, I'd say the difference is more from measurement uncertainty than anything else given the extremely close quoted IC50 values and the broad range of Ki/IC50 values observed (I've read basically the entirety of the existing literature on the subject and was the one who selected the "representative" values for that table you're citing in the first place!). Like I said previously, this is something that has been tested in actual head-to-head trials, and there were no differences in effects or side effects, so any of the tiny differences in receptor/binding affinities are too subtle to detect in the real world (which is to be expected, given the values observed).
  14. If your insurer truly won't cover them at all under any circumstances, even with a prior auth, then I suggest looking into manufacturer programs for patient assistance ASAP. These usually have caps on income for eligibility (for example, household income must be no more than 4 times the Federal Poverty Level for Takeda's program), and your pdoc will have to complete some forms, but they will provide the medication to you for free if you meet the criteria. In the meantime, your pdoc may be able to give you enough samples to cover the gap while the application for the patient assistance programs are processed.
  15. I've been on Vraylar for about a month or so now (as a mood stabilizer, antidepressant, and treatment for obsessive thoughts - it's primarily prescribed because I was having really severe and persistent suicidal thoughts, but my psych thought it might help in some other areas as well due to the rather unique MOA). I wasn't able to tolerate 3 mg at all, but 1.5 mg has been more or less tolerable (there have been some annoying side effects), and it's definitely been helpful so far. After some experimentation I discovered that taking it at night instead of in the morning reduced the severity of the side effects enough for them to be much less of an issue. This definitely has worse side effects when you initially start it. It has a long half-life (and a active metabolite with a very long half life), so it takes a while for it to stabilize. The akathisia was more present initially and has reduced to very tolerable levels with time and the switch to night dosing. The insomnia was a significant problem until I switched to night dosing, although it lessened with time prior to that. With regards to the insomnia, I noticed that it generally caused more problems with disrupted sleep quality and too-short sleep duration than with directly falling asleep, although initially it was doing all three of those. There has been some minor weight gain but considering that I am actively trying to gain weight (a very difficult prospect when you're on this dose of Adderall/Fetzima and have other preexisting problems with eating), I don't think this data point has much value. Nausea was a minor issue initially but quickly faded away. Little to no difference. I am on HRT though so I am not the best person to evaluate this.
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