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I'm currently on a lot of duplications, as my signature suggests. I'd like to change that.

My current change is reducing zyprexa and seeing if I do okay with just fanapt.  that may not work because I may need the sedative properties of zyprexa.  but it doesn't work as an AAP for me....we tried going off fanapt and I was hallucinating within a wee.

I'm debating next trying to consolidate benzos.  but I'm not sure which ones.  klonopin helps with the parasomnias (I think), but doesn't put me to sleep.  This may just be a situation where multiples are needed.  on a related note, I had a speech slurring issue with ativan, but that could have been because i t was combined with other benzo (I don't know which one).

anyone have any thougts?

Edited by dancesintherain
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26 minutes ago, dancesintherain said:

I'm currently on a lot of duplications, as my signature suggests. I'd like to change that.

My current change is reducing zyprexa and seeing if I do okay with just fanapt.  that may not work because I may need the sedative properties of zyprexa.  but it doesn't work as an AAP for me....we tried going off fanapt and I was hallucinating within a wee.

I'm debating next trying to consolidate benzos.  but I'm not sure which ones.  klonopin helps with the parasomnias (I think), but doesn't put me to sleep.  This may just be a situation where multiples are needed.  on a related note, I had a speech slurring issue with ativan, but that could have been because i t was combined with other benzo (I don't know which one).

anyone have any thougts?

I think, as annoying as it is, you have to try and stick to the “one thing at a time” mentality. Since your just starting zyprexa lowering you have no idea where that will you end up or what your symptom profile will be if you can actually get off it or have a low dose. Since you don’t know what symptoms will stick/appear, I think it will be very hard to plan out other reductions now because they would basically be guesswork until you get a handle on what your “post-zyprexa” status is 

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@Iceberg, when do you call it quits?  It’s been 5 days at 17.5mg and 2 days at 15mg and I’ve had sleep issues every night.  Some more drastic than others.  But I’ve had to pull out benadryl and leftoiver meds that I’ve had (temazepam, lorazepam, etc.).  My pdoc is aware I resort to that. 

Do I just call it a quit and say I need the 20mg to sleep?  I see my pdoc Wednesday, so I can try holding off until then. 

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3 minutes ago, dancesintherain said:

 

 

@Iceberg, when do you call it quits?  It’s been 5 days at 17.5mg and 2 days at 15mg and I’ve had sleep issues every night.  Some more drastic than others.  But I’ve had to pull out benadryl and leftoiver meds that I’ve had (temazepam, lorazepam, etc.).  My pdoc is aware I resort to that. 

 

Do I just call it a quit and say I need the 20mg to sleep?  I see my pdoc Wednesday, so I can try holding off until then. 

 

It seems like it might make sense to try until Wednesday if possible so you can give a defininte report 

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I can taper more slowlyif that's what my pdoc wants.  This has been pretty miserable.

We went through the med go round on sleep drugs once (fanapt was giving me insomnia) and came up with nothing, which is why I ended up bck on zyprea.  So I'm not sure thre's one ring to unite them all out there,  they're mostly ih my signature

 

Temazepam at 15mg was actually reasonably helpful for me.  Maybe t's worth trying again. It has to some patt be that I'm going od zypexxa iwhtout trying to get up on something.

Edited by dancesintherain
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part of the problem is that I sometimes end up with PTSD nightmares (Belsomra), paraspmnias (something durrent, amxien, and accorig to my signature, temazepam_.  O've had an allergic reaction to traodone, get EPS with ridperdal, seroquelXR, serquel, ad abilify. 

maybe remeron?

 

worry for typing, my brain is tired

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my brain is tired too, but just some things that I didn't see listed, obviously maybe none are what you're looking for. 1) Halcion - very fast acting benzo, good if your problem is falling asleep but you're ok staying asleep. 2) Could you do a super lox doxepin dose just for sleep? there was a "3" but I forgot what I was going to say 

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thanks all.

Iceberg, I have tried halcion and I can't remember why we ditched it.  Obviously not something bad or Ii'd remember it.  Doxepin didn't make me sleepy, strangely.

butterfly, Clozapine is a step I'm not willing to take.  Not a dumb suggestion in the slightest.  Just not one i can do.

saintalto that's what this feels like.  highly dependent on zyprexa.  I went five days at the firs 2.5mg switch and I may need to do it longer.

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sorry I've been writing from my phone at "work," so my replies have been shorter than normal (For better or for worse).   I think I still want to try to get off Zyprexa.  So having something like halcion to knock me out in the interim might be beneficial. 

that said, if fanapt is causing this tremor, I'm screwed.

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Hopefully I'm not barking completely up the wrong tree.  I just feel like zyprexa as a sleep med is pretty heavy.  The problem is that I won't know what else it's doing until it's gone.  I've gone off before and needed to go back on, but that was because of sleep issues.  There's also this vague memory of it serving as "brain glue," and that's what I'm worried about losing.  But I need to reduce something and it seems like the safest to start with. 

I may leave it at 15mg and try to ditch the tremor first though.

Though getting something like halcion to knock me out while I'm at zyprexa 15mg might be a good plan.

Edited by dancesintherain
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You may wish to try lowering the Fanapt a little if it's a pseudoparkinsonian tremor. It's a higher-potency dopamine antagonist than the Zyprexa, plus Zyprexa has additional anticholinergic properties that would likely help the tremor. Both Fanapt and Zyprexa have heavier serotonin 5-HT2A antagonism than dopamine D2 antagonism, so that would also mitigate EPS like pseudoparkinsonism. But assuming that tremor is pseudoparkinsonian in nature, less D2 blockade is likely going to be the answer, or replacing it with D2 partial agonism (i.e., with Abilify, Rexulti, or Vraylar, but I seem to remember you can't tolerate Abilify).

As for sleep-related issues, what makes Zyprexa so dang sedating is that it's such a potent antihistamine (H1 antagonist). There are other agents that can fill this role without the extra D2 antagonism, like doxepin (I know you had that in the past but was taken away apparently simply because it's a TCA... like it's literally a glorified antihistamine and don't let anyone tell you that otherwise lol).

Specifically for the case of doxepin... Here are its affinities for some receptors and trasporters:

(Ki = nM: the lower the number, the higher the affinity)

  • SERT: 81.5 ± 13.5 nM (inhibitor) (causes SRI)
  • NET: 44 ± 14 nM (inhibitor) (causes NRI)
  • 5-HT2A: 19 ± 8 nM (antagonist) (Anxiolytic, sedating, disinhibits dopamine release)
  • 5-HT2C: 200 nM (antagonist) (Stimulating—disinhibits dopamine and norepinephrine release)
  • 5-HT6: 136 nM (antagonist) (Stimulating—disinhibits dopamine, norepinephrine, acetylcholine, and glutamate release)
  • α1 (adrenergic): 24 nM (antagonist) (Sedating, can cause orthostatic hypotension, but can also mitigate EPS)
  • α2 (adrenergic): 1185 ± 85 nM (antagonist) (Would be stimulating if affinity were greater, would disinhibit noradrenergic and serotonergic neurotransmission)
  • D2: 360 nM (antagonist) (Sedating if affinity were greater)
  • H1 (histamine): 0.66 ± 0.57 nM (SEDATING!!! VERY HIGH AFFINITY!!!) (Sedation, weight gain, increased appetite)
  • mACh (acetylcholine, muscarinic): 51.5 ± 28.5 nM (sedating) (Sedation, memory issues, dry mouth and eyes, constipation, blurry vision)

Here are the relative ratios of these affinities in relation to the affinity to the SERT (blue and bold = greater affinity than SERT):

  • SERT:NET = 1 75⁄88 : 1
  • SERT:5-HT2A = 1 : 2 6⁄19
  • SERT:5-HT2C = 4 6⁄11 : 1
  • SERT:5-HT6 = 3 1⁄11 : 1
  • SERT:α1 = 1 : 1 5⁄6 
  • SERT:α2 = 26 41⁄44 : 1
  • SERT:D2 = 8 2⁄11 : 1
  • SERT:H1 = 1 : 66 2⁄3
  • SERT:mACh = 1 15⁄88 : 1

So at low doses of 10-50 mg (Sinequan) or microdoses of 3-6 mg (Silenor), it's pretty much going to be a selective H1 antagonist with additional 5-HT2A and α1 antagonism. Not much else. Maybe a little serotonin reuptake inhibition. But at 10 mg and an affinity for the H1 receptor over 66 times greater than that for the SERT, it's unlikely it will be significant to affect mood much.

Btw if the fractions don't look right, let me know, I had to use unicode to write them.

 

As for what to do with your antipsychotics... I'm pretty much stumped...

You've got a "-done" and a "-pine" going at the same time, which makes sense (you wouldn't want two "-dones" and definitely wouldn't want two "-pines" at once.

Maybe consider dropping the "-pine" (i.e., Zyprexa) and adding a "rip" pr a "zip" (one of the dopamine partial agonists). Abilify I see gave you akathisia. Its intrinsic activity (percentage of how much it activates the target receptor) at the D2L receptors (the postsynaptic D2 receptors) is about 75%, which is pretty high. Rexulti is about 43% at D2L, and Vraylar is about 40% at D2L (whereas at D3 it's 60%, which is supposed to be much better for EPS I believe as well as cognitive symptoms). Rexulti also has much more potent 5-HT1A partial agonism and 5-HT2A antagonism.

Or dropping the "-pine" (Zyprexa) and maximizing the "-done" (Fanapt)? The max dose of Fanapt is 24 mg/day, so you still have some room to go, but I seem to remember there was some reason you couldn't go any further (insomnia was it?). That and you've got the prazosin and Fanapt is a pretty potent α1 blocker... about as potent as prazosin actually, at the α1A receptor (0.36 nM for Fanapt vs 0.2 nM for prazosin).

Looking at your drug history and your reactions, I'm wondering if some of your EPS from antipsychotics is actually being induced by the 5-HT1A partial agonism (which is supposed to mitigate EPS, but may theoretically induce them IIRC...). @bronwyn may be able to help me out with that one as well as all this mess I've proposed here... lol.

Those are my guesses...

 

Edited by mikl_pls
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thanks @mikl_pls.  I think you have access to my blog?  things have gone crazy.  So there won't be any reducing of zyprexa in the near future.  With a small dose of seroquel (25-100) PRN for sleep.   Also an increae to 1.5mg klonopin. 

Short version is sleep walking, parasomnias, auditory hallucinations, and visual hallucinations.  More info on blog.

Sorry I didn't think to update here to save you the time.  If I was more with it, I would have thought to do a quick update.

Edited by dancesintherain
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