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mikl_pls

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  1. You're right, I didn't think about that, sorry. It isn't known whether MAOIs enter breast milk, but they should be avoided when nursing.
  2. MAOIs tend to be good for atypical depression, whereas TCAs tend to work best for melancholic depression. It's not a bad thing to "skip" the TCAs and go to a MAOI for this reason.
  3. I've asked my pdoc for Cognetin before and she gladly has written me scripts for it.
  4. I have really treatment-resistant insomnia, so my pdoc gave it to me to try. It doesn't require you to try other meds and fail to my knowledge. Some insurance companies don't really cover it. I somehow got it for $30/month even though my insurance doesn't cover it. You can get samples, but they only include 3 tablets per package... It's also a schedule 4 substance I think. For me, it works hit or miss about 50% of the time. Sometimes all it does is make me yawn a lot to the point where I can't get to sleep from that; other times, I fall right asleep. I usually have to include a benzo like temazepam, plus doxepin with it, sometimes even trazodone.
  5. I hate to see discord, but sometimes it's necessary for people to talk things out. I sincerely hope we can continue to get along here. I love all of you. <3 I'm looking forward to giving this med a trial (if my pdoc lets me). I believe my signature proves that I have tried enough meds... lol (and they were adequate trials at that).
  6. This article discusses augmentation of clozapine with Abilify (in schizophrenic patients). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3004715/ One case report is about a young woman who was a partial responder to 800 mg clozapine. She gained 45 lb and had sialorrhea, the latter just like you have. Aripiprazole was added up to 90 mg/day!!! This allowed her to decrease the clozapine to 700 mg. This combination reduced side effects dramatically. She was able to lose 40 lb and start looking for employment. It could be that an increase in your Abilify (which I know is already beyond max dose) to perhaps 40 mg would allow you to reduce your clozapine slightly if not by a lot. Vraylar and Rexulti are also possibilities, which I would lean towards Vraylar for you. They're soooo expensive though is the only thing! You may even need supratherapeutic doses of one of those if you tried it, like Rexulti > 4 mg, or Vraylar > 6 mg, which of course would require an act of congress to get your insurance to pay for (if it pays at all). Hell, it'd be an act of congress to get your insurance to cover one prescription of Abilify for 40 mg/day, for example (2x20 mg) as it exceeds the quantity limit. But this is just an idea. If your pdoc was really committed to it, she would be able to do a letter of medical necessity or something like that. Also, either increasing your Lamictal to 400 mg/day, adding lithium (which I know can also cause weight gain), or both, could also probably help you. The addition of carbamazepine may also be a possibility in lieu of lithium, but you'd have to double your doses of almost every medicine... especially lamotrigine (300 mg --> 600 mg to stay the same in your system, would need 800 mg for a 400 mg normal dose). That would mean you would be on 3 anticonvulsants though, which might not be ideal. But lithium would need blood tests (as would carbamazepine I think maybe, some pdocs prescribe based mostly on clinical response... same for lithium...), so that would double up on the number of blood tests you'd need to get. But it might be worth it to have mental stability and possibly to reach a higher level of functioning. I'm not sure if you'd need a low dose or high dose of lithium though. Probably low dose to help your depressive symptoms, but schizoaffective disorder is indicated for high dose lithium maintenance treatment. I hope these ideas and the article provides some sort of help...
  7. Depakote both increases appetite and modulates endocrine activity (acting as a PPARγ agonist, I believe, which actually increases insulin sensitivity but at the cost of causing increased adipose tissue formation and peripheral edema). I took just 500 mg ER for 2 weeks, and not only was I in a complete zoned out, zombified state the whole time (actually lost track of the whole time I was on it), I gained an enormous amount of weight within those two weeks without really changing what I ate. I ditched that as quickly as possible, but at the expense of becoming manic again. I assume you've tried Topamax/Qudexy XR/Trokendi XR and/or Zonegran already, right? They can help migraines and also cause weight loss. Tegretol is sometimes used, but it comes with a host of side effects to its own, and Lamictal would have to be doubled in dose, as would the rest of your meds, likely, because of hepatic induction of CYP450 system. Adding a tricyclic (TCA) like amitriptyline (Elavil) in low, low doses can help many. Nortriptyline (Pamelor) may be more tolerable and just as effective. SNRIs like Effexor or Cymbalta have indications for migraine prophylaxis, but may or may not be that effective. If you've never taken one, a beta-blocker may help too. Something like propranolol (Inderal/Inderal LA), metoprolol (Lopressor/Toprol-XL). There's also a new form of metoprolol called "Kapspargo Sprinkle" that come in capsules, but I don't know how willing your insurance would be to cover that. It's just metoprolol ER in a sprinkle capsule. Nadolol (Corgard) and atenolol (Tenormin) are other beta-blockers that may help. Lamotrigine itself is supposed to be able to help migraines in some people... High-dose riboflavin (400 mg) may help some people. Aimovig is a brand-new migraine medicine that may help people who have treatment-resistant migraines. It's a monthly subcutaneous injection.
  8. In addition to the possibility of trying 150 mg XL, you could also try 100 mg SR twice daily for 200 mg as it would be a slightly smaller decrease in dose. Another possibility would be to switch the Lexapro out for something else that may have a little better efficacy for anxiety and OCD. I see you've already tried the ones I would suggest though, so I guess that idea is kinda scratched off the list already. I will say that Zoloft + Wellbutrin is a very great combo because you get a boost on all three main neurotransmitters. (Zoloft: dopamine and serotonin, Wellbutrin dopamine and norepinephrine...) I do see that you're on a supratherapeutic dose of Lexapro, which makes perfect sense for OCD. Going up to even 40 mg may be another option to see if it helps your OCD and anxiety more. I will say that when I first started Wellbutrin, it actually lowered my anxiety, and the higher in dose I got, the better my anxiety got. This was attributed to it helping my ADHD symptoms according to both my gdoc (who originally put me on it) and my pdoc when I eventually started seeing her. No problems with OCD either, but eventually my OCD did get bad enough to where I had to take something for it. Counterintuitively, you could even try 450 mg Wellbutrin to see how it effects your anxiety... it might actually improve it, or it might make it worse. I've been on up to 500 mg before, and along with Adderall, that was what worked the best for me until it pooped out and also started causing seizures (which I'm prone to having). Trazodone is actually known for worsening OCD and anxiety via its main metabolite, mCPP, which is a 5-HT2C partial agonist as well as a serotonin releasing agent. The 5-HT2C partial agonism is what is believed to cause the worsening in anxiety and OCD symptoms. (Strange because Abilify is one also and it doesn't trip my OCD or anxiety at all...). The higher in dose of trazodone you go, the higher the levels of mCPP, the higher exposure to mCPP you get. Nefazodone also metabolizes to mCPP as well as several other active metabolites based on nefazodone. Depending on your methylation cycle genes, the methylcobalamin may also be contributing to anxiety (or at least may be causing some undesired stimulation) if you aren't very tolerant to methyl donors (dependent on your COMT and MAOA genes' statuses). Also, I believe the VDR gene has something to do with it. You may try either hydroxocobalamin, adenosylcobalamin, or a combination of methylcobalamin with one of the other two. Also, cyanocobolamin, while it's not really the best source of B12, metabolizes to all three forms of B12 aforementioned. P-5-P may also ramp up your anxiety as it increases the rate at which dopamine is produced (increasing tyrosine hydroxylase activity I believe?). Zinc can act as a dopamine reuptake inhibitor at a specific zinc-binding site on the DAT (so it works a little different from typical DRIs). It could be enhancing the DRI MoA of Wellbutrin, which may possibly ramp up your anxiety. After all is said though, if you feel your anxiety levels are still where they were before you started Wellbutrin, or even better than baseline, I personally don't see any reason to remove it. OCD may or may not be affected by it. Yet more possibilities would be to try glutamate-modulating medications for the OCD (which may or may not benefit the anxiety, however). Such medicines include Lamictal, Topamax, Namenda, Symmetrel, and Rilutek. Zonegran theoretically could go in there too as it reduces glutamate release. The Risperdal should theoretically be doing something to help both, but sometimes it takes a lot of it to actually work, doses at which hyperprolactinemia and even galactorrhea may become a possibility or reality. It could be that switching antipsychotics would be another option. Something like Latuda may help, as I see you've already tried Abilify and Seroquel. I'm not about to endorse using Zyprexa regularly. No thanks... But I hope you find something that helps you!
  9. It depends on to what dose she wants to lower you. If she wants to take you down to 600 mg, she might actually lower the night-time dose and make it an even 300 mg/300 mg, or may prescribe 600 mg all at night, whether it be Eskalith (IR) or Lithobid (ER). However, if she wanted to, she could decrease it in smaller increments by giving you a bunch of Eskalith 150 mg capsules and take 300 mg AM + 450 mg hs (750 mg/day) or something like that. Alternatively, Eskalith 300 mg AM/Lithobid 450 mg hs. Also, switching to Lithobid for 600 mg/day would also be a possibility, either with 300 mg bid or 600 mg hs. The possibilities are pretty open, I suppose is what I'm trying to say here.
  10. A combination of Lamictal, Wellbutrin, and Adderall was my very first psychiatric med combo when I first started being medicated for my bipolar and ADHD. My OCD wasn't really effectively being addressed (yet), but I didn't feel it was that bad (little did I know...) I did extremely well with this combo for quite a while until I started having other symptoms emerging... Later on, Latuda 40 mg was added (almost a year after I started seeing my first pdoc) and it definitely took some getting used to as I'd never been on an antipsychotic before, especially a stimulating one such as Latuda. I took it at that dose for a year and a half until I suddenly got akathisia out of nowhere. But I've tried it since then again, and was put at first on 60 mg, which seemed to help my depression a little better without causing any unwanted agitation or stimulation (that's what the Adderall was for... lol). She bumped me up to 80 mg and it helped a little better, but I also was taking Stelazine, which I felt was helping me more than the Latuda, so I ditched the Latuda and just took the Stelazine. Lower doses of Latuda (20-40 mg) tend to be more stimulating, 60 mg is rather neutral grounds, and high doses (80-160 mg) tend to be either just relaxing or even sedating, yet akathisia becomes more of a problem at these doses. So if you wanna keep the Latuda, I might recommend a dose change (either decrease or increase, depending on your needs). I agree that a trial of Lamictal and possibly even Wellbutrin (one or both) would be possibly advantageous. I had not so great experiences with lithium (seizures, increased depression, weight gain, even at 300 mg/day). Not trying to scare you away from it, I'm just letting you know my experience--YMMV. If you can somehow get your pdoc or gdoc to prescribe you a stimulant (low dose at first), it would probably really help you as you have ADHD. And WTF did your doc mean by the "learning disability" symptoms? I mean, yes, ADHD does impair learning ability, but it isn't regarded as a learning impairment or disability. That to me sounds like an excuse to not prescribe you a stimulant.
  11. Haha no wories! I can understand that, definitely! Aww thank you, and you're more than welcome!
  12. Really? It's still in the NDC directory as being manufactured by two companies: Breckenridge and Glenmark. It could be on extreme back order, but then again I haven't tried to get it again since I had that first prescription. I'm having the same issue with Stelazine and Navane... no one is making it... Really?! I had no idea about that with doxepin and not taking within three hours of a meal. Remeron you gotta be careful with because of its weight gain side effects but I'm sure you knew that already. I just wanted to throw that caveat in there since I know you're into fitness. Yeah, I require high, high doses of Klonopin to do anything and if I take it for more than two weeks at a time, I get depressed, and Ativan is like a dementia pill to me... No benefits and all cognitive side effects. Never taken flurazepam before, but I can certainly see how it would cause you to feel hungover--the half-life of both it and the metabolite are extremely long! Perhaps temazepam or estazolam would be a better choice for you to try at nighttime if you did a benzo? Man I just don't get it with Ambien and causing people to hallucinate and sleep walk and all that! It was like a sugar pill for me lol. I wish I had at least gotten something out of it! lol. Yeah, zaleplon is suuuper short acting--its almost like triazolam. Eszopiclone (Lunesta) might be a good option, but according to notloki, it's underdosed in the US even at the max dose of 3 mg. You could probably try the 2.5 mg tablets and see if they are less sedating. Who knows, you may be even more resistant to sedation than me! lol Well, if this is tardive dyskinesia, it could become permanent if it's being induced by your antipsychotic. Interesting, that's a lower equivalent dose to the Adderall dose you were taking. Ideally you shouldn't be having those reactions but then again I do say "ideally..." I'm really not sure what to say about that. Amphetamines can cause it, but antipsychotics are more likely to do it. Have you tried the Ritalin-based medicines? Any time!
  13. This is also interesting to me because my pdoc prescribed Zyprexa as a PRN to take with my Abilify. I asked to have it replaced with Geodon but I don't think it's as effective so I may go back to Zyprexa.
  14. You have two anticonvulsants on board, Lamictal and Topamax, which should ideally prevent seizures from happening. Abilify and clozapine is a good combo for polypharmacy with AAPs, but if your ultimate goal is to get down to just clozapine, that's more than reasonable I think. I don't personally see any reason why you couldn't ask for a PRN AP. Vistaril is kinda meh to me too... From the data I have been presented with, Vistaril has negligible affinity for the muscarinic acetylcholinergic receptors as an antagonist compared to other first generation antihistamines, so its risk of causing dementia wouldn't be as much as say, diphenhydramine, dimenhydrinate, meclizine, etc. The glycopyrrolate you take is an anticholinergic, but it doesn't pass into the central nervous system, so I don't really think that's a risk as it's working mostly on peripheral muscarinic acetylcholinergic receptors. I suggested a few PRN APs in your blog post about that, but I mentioned instead of Thorazine (which is a low potency antipsychotic and would hence require higher doses for antipsychotic action), maybe try a higher potency one like Haldol or Loxitane... (Well, really, Loxitane isn't that high a potency antipsychotic, but at doses < 25 mg, it supposedly acts a lot like an AAP, very similar to clozapine). Also, with Loxitane, you get the antidepressant amoxapine (Asendin) as a metabolite to boot, which also has antipsychotic properties! Zyprexa Zydis is also a good idea if you know it works well for you. Or, since you wouldn't be taking it regularly, just regular old Zyprexa...
  15. Yes, exactly! If serotonergic meds aren't working, why keep beating a dead horse? (I guess that's the strategy to ultra-high-dose SSRI treatment where they use like 40 mg Lexapro or 400 mg Zoloft...) There are plenty of new and rising treatment options. I agree, that is a great article! In case you need more for other types of meds (in case your pdoc doesn't go for the aripiprazole), here are a few I Googled about glutamatergic therapies like lamotrigine and memantine (as well as a few others): Lamotrigine Augmentation Versus Placebo in Serotonin Reuptake Inhibitors-Resistant Obsessive-Compulsive Disorder: A Randomized Controlled Trial: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947218/ Management of obsessive-compulsive disorder comorbid with bipolar disorder: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5100116/ This actually talks about many different treatment options that, IMHO, you wouldn't necessarily need to be bipolar in order to be able to be given a trial of. A selective review of glutamate pharmacological therapy in obsessive-compulsive and related disorders: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4425334/ This talks about many different disorders, but OCD is among them. I really hope this helps you! If I'm presented with reluctance from a health care practitioner to prescribe something for me for a condition when I really feel like something might be the right treatment for me, I try to present as much evidence as I can that presents evidence for the use of said treatment. But I have yet to get my pdoc to try riluzole yet for me (although I don't know if I really want to try it to be honest... lol) But it worked when I asked my pdoc for zonisamide for a mood stabilizer (at first she didn't want to do it, but when I showed her some articles from reputable sources, she started me on a small dose, and when I improved, she liked what she saw, so she increased the dosage... etc.). Fortunately though, my pdoc is actually one who is very outside the guidelines for the most part, and is open to suggestions. I really hope you are able to convince your pdoc to try something that really helps you out!
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