How to tell you're overmedicated?

[jarn]

I currently take 6 psych meds, plus a type II diabetes drug to help with side effects, not because I have diabetes.

-Zyprexa (30mg)

-Loxapine (20mg)

-Lamotrigine (300mg)

-Gabapentin (900mg)

-Zoloft (100mg) (this is new)

-Ativan PRN

-Rybelsus (14mg) (to help with side effects)

 

Started Zoloft to help with depression and intrusive thoughts as yet another 'one last thing before clozapine'.  

Not that I'm anxious to go on clozapine, you understand, but I do feel like I take an awful lot of medication.  

Is there anything in particular to say if someone is overmedicated?

[CrazyRedhead]

10 hours ago, jarn said:

Is there anything in particular to say if someone is overmedicated?

"Overmedicated" is sort of difficult to define.....Pdocs differ in their opinions, as you probably know.

I take 5 medications, so I'm not that different from you.

In my personal opinion, if you are receiving a benefit from the meds, and none of the meds are interfering with your basic day-to-day functions, I don't think you're overmedicated.........I realize that pdocs and tdocs might define "overmedicated" differently.

If you think you're overmedicated, you could seek a second opinion from another pdoc.

Edited October 11, 2021 by CrazyRedhead

[DogMan]

if you feel better on a med than off, or function better, then i'd keep that med

 

if a med interferes more than what it was treating, i'd ditch that med

 

2c

[jarn]

@CrazyRedhead @DogMan 

Thanks so much guys!

I do feel comfortable talking with my pdoc about this - he's pretty responsive - and I think we can work together on this.  

The newest med (Zoloft) I think is still a bit too early.  I am feeling a lot better but still have some intrusive thoughts.  Depression has improved but some of that may be work stress improving.  I had a 'too depressed to get work done, depressed because I'm behind at work' feedback loop going on.  

The rest I've been on for ages.  If Zoloft doesn't help it's clozapine (and I assume ditching zyprexa and loxapine), and I know pdoc wants to be careful about that.  

 

[jarn]

@Iceberg in your experience of clozapine, have you had to take medications to deal with its side effects (peeing, constipation)?  I would want to continue on rybelsus.

[Iceberg]

2 hours ago, jarn said:

@Iceberg in your experience of clozapine, have you had to take medications to deal with its side effects (peeing, constipation)?  I would want to continue on rybelsus.

Managing weight has been rough, but easier than zyprexa so ive been able to at least control the damage and even have lost some weight. I am still hungry most of the day, but i think the adderall helps with that, which wasnt the intention. The adderall ended up really helping me, but at first I started it to manage sedation which was ridiculous at higher dose. As in trouble going up the steps without falling over. that is much more manageable at my current dose. For awhile I tried some meds for nighttime drooling, which was so bad my family was concerned that i was choking. Cogentin was marginally effective and scopolamine didnt really do anything. High dose Benadryl actually worked better than both. The drooling is still uncomfortable some nights, but it has lessened over time. I have pretty nasty IBS-D brought on by lithium, so i was actually taking immodium and then lomotil on a regular basis (everyday actually) but i wouldnt go by that   

[jarn]

4 hours ago, Iceberg said:

Managing weight has been rough, but easier than zyprexa so ive been able to at least control the damage and even have lost some weight. I am still hungry most of the day, but i think the adderall helps with that, which wasnt the intention. The adderall ended up really helping me, but at first I started it to manage sedation which was ridiculous at higher dose. As in trouble going up the steps without falling over. that is much more manageable at my current dose. For awhile I tried some meds for nighttime drooling, which was so bad my family was concerned that i was choking. Cogentin was marginally effective and scopolamine didnt really do anything. High dose Benadryl actually worked better than both. The drooling is still uncomfortable some nights, but it has lessened over time. I have pretty nasty IBS-D brought on by lithium, so i was actually taking immodium and then lomotil on a regular basis (everyday actually) but i wouldnt go by that   

Thanks so much!  That's helpful.  What dose do you take?

I eat a lot of fiber (often) so am hopefully I could minimize constipation.  

It sounds like the sedation is the worst.

I am wondering if I could get off lamotrigine (or zoloft) as well as zyprexa and loxapine.  Ativan is a PRN which I use mostly for sleep anyways.  That's...5? meds including rybelsus.

 

 

[Iceberg]

1 hour ago, jarn said:

Thanks so much!  That's helpful.  What dose do you take?

I eat a lot of fiber (often) so am hopefully I could minimize constipation.  

It sounds like the sedation is the worst.

I am wondering if I could get off lamotrigine (or zoloft) as well as zyprexa and loxapine.  Ativan is a PRN which I use mostly for sleep anyways.  That's...5? meds including rybelsus.

 

 

Just be careful to avoid the pitfall of dropping to many things at once and then not knowing what the issue is if you start to feel bad. I am at 150- been up to about 400, which is a period of time that i literally can’t remember. It’s like two or three months of my life is literally gone because the sedation was so bad. But part of that was I had just started with that pdoc and we weren’t quite on the same wavelength yet and he was trying to respect my wish of not being hospitalized. Does the lamotrigine cause you side effects? I don’t even notice it’s there so we just leave it  

[jarn]

@Iceberg That's a good point.  Pdoc will definitely want that too, one thing at a time (though I would hope zyprexa/loxapine could go in lockstep).  

To be honest, lamotrigine is so side effect free I don't notice it.  WITH that said - it has rarely been enough on its own for my depression.  A few years back I decided to lower the dose (without pdoc's help) and very quickly got depressed.  So it does something.

[Gearhead]

As noted, there are a number of different ways to decide if you’re overmedicated or not. A lot of questions to ask.

Consider whether the meds, singly or in combination, are having a deleterious effect on your physical health. How does your blood work look, your liver and kidney function, cholesterol, etc? How is your BP? Are you gaining or losing too much weight?

Think about how much a given med helps you vs. what the side effects are. If X med has pulled you out of a deep depression, are you willing to put up with managing, say, perpetual constipation? How about sexual disfunction?

What does your doctor say? Does s/he think the cocktail is safe? Safe for now? Safe long-term?

And ask why exactly do you want to reduce your meds? Do you think you’re not getting a distinct benefit from each one? Are they interacting in a way that gives you hard to manage side effects? Do you find it psychologically challenging to accept that you need to take meds?

For me, at this point, I don’t know why I’m taking topiramate. It was originally prescribed to me as a mood stabilizer, but it didn’t work. It made me sick as a dog for two or three months when I first started taking it. I can’t manage more than 75 mgs a day or the sedation is untenable. That’s supposed to be a subtherapeutic, but I’m not sure I believe in that concept anymore. Maximum doses make more sense, but if a med works at a low dose, why up it just because it says to on the package?

I’ve been on it since about 2007. A dozen drugs have come and gone since then. By the time my stomach adapted to 75 mgs it was clear that it wasn’t going to be the mood stabilizer for me, but it did seem to cut down on the headaches I got. So I stayed on it. Eventually we found lamotrigine.

Now I have a totally different med for headaches, not even a psych med, that works really well. So do I need the Topamax? Should I stop taking it and find out?

I’m not going to. Why? Because I’m in a pretty good place. I don’t want to rock the boat. It isn’t worth experimenting on myself. Getting myself back on an even keel once I’m destabilized is hard. My bloodwork all looks great. Whatever the side effects are, I’m so long used to them I’d only notice if they stopped.

So I’ve come to the decision that it’s best to keep taking it. And there you have a peek into my thought process.

 

 

[jarn]

Thanks Gear.  My cocktail now is working well with minimal-ish side effects (high lipids and weight gain, thank you zyprexa - but cloz is not likely to fix those).  

It's funny, I'd come to a similar place in my process.  I will raise it with pdoc as something to keep in mind, but yes.  My depression and OCD are better since I started zoloft.  That could be psychosomatic, could be work stress getting better (for now) - but I've been on zoloft for...2 weeks - at 100mg for a week - and I think things are better.  I just feel like a pill popper.

[psychwardjesus]

As others have said already, the term overmedicated is a relative term — relative to both the prescriber prescribing the medication and the person taking it — so it's difficult to decide where to draw a line in the sand and then develop an action plan to combat that. You're much more likely to hear or read a term like polypharmacy, especially in the context of a person being prescribed more than one antipsychotic at one time.

What was the logic behind putting you on loxapine? Was that to help manage any overflow psychotic symptoms that weren't managed by the olanzapine? Do you feel like it actually does something for you or are you like me and a lot of other people — taking medications that may have done something in the beginning, but you've been taking for so long you don't notice anymore or can't remember anyway. I don't know how crucial it is for you to take the loxapine or if you've tried other antipsychotics in place of it, but have you and/or your prescriber considered other medications for the residual depression/intrusive thoughts, like aripiprazole, quetiapine, lurasidone or even another typical like haloperidol or perphenazine if you wanted to stay in the same family, etc.? I would understand if you were reluctant to try, or had already tried, the first two, as, even though Otsuka has claimed that it's weight neutral, I've found that with few exceptions that's pretty much across the board bullshit. Sure, some people may have less metabolic side effects or less weight gain overall as compared to notorious weight gainers like olanzapine, but that's not exactly a comforting thought in my opinion. And quetiapine ... again, typically a weight gainer (although frequently not as bad as olanzapine) and at higher doses its first pass metabolite has antidepressant properties. You'd also have to talk to your prescriber about any interactions between the quetiapine metabolite and sertraline or any of the other drugs to make sure it doesn't put you at an increased risk of serotonin syndrome or anything like that.

I also noticed in your signature that you were previously in some form of therapy. Did you find that helpful and/or would you ever consider trying it again? Psychotherapy is obviously generally a good non-pharmacologic tool to add to the toolbox and may be worth re-considering.

[jarn]

@psychwardjesus Thanks for weighing in.

I have been on Seroquel multiple times, Abilify I ended up in the hospital, same with Haldol.  I don't remember much about Latuda other than that eventually it stopped working.  

I was Loxapine for years, had elevated prolactin (and pdoc doesn't feel meds to lower that are a good long term solution) and some mood instability.  He put me on Haldol which went VERY badly.  I have taken most of the AAPs and Haldol and Loxapine for APs.  

I can't remember if we held the small dose of Loxapine after I started Zyprexa (went back on Loxapine after Haldol) or if it was being Zyprexa needed a top up because it wasn't working well enough on it's own.

But I suppose that is one thing we could eliminate, I can ask about that.

I've never had a great experience with therapy.  Behavioural activations (from CBT) are about the only thing I've ever found helpful.

[Wonderful.Cheese]

@jarn

I understand how you feel. I take 8 psych meds.  

-Abilify (30 mg)

-Zyprexa (30 mg)

-Rexulti (2 mg)

-Prozac (20 mg)

-Gabapentin (1,200 mg)

-Topiramate (200 mg)

-Vyvanse (60 mg)

-Klonopin (1 mg PRN)

 

 

Edited October 18, 2021 by Wonderful.Cheese
scared

[jarn]

@Wonderful.CheeseThanks Cheese.  I think I am going to talk to pdoc about reducing meds, without clozapine (hopefully).  The good news is my depression seems to be lifting, so I think zoloft is doing something.

We had a friend over who turns 50 on Tuesday last night (Saturday).  I made a vegan chocolate pie that looked a little funny but was delicious.  Previously I would've melted down but I stayed calm and was fine.  

[jarn]

So 'saw' (virtual) pdoc this morning.

I told him I felt like I was on too much medication, and wondered if there was any room on my current cocktail to change things - or, failing that, would clozapine accomplish that for me (my main concern with clozapine is the sedation since I have stuff to do in the mornings and solo camping trips I drive myself for).

We agree the zoloft needs more time - it's been about 3 weeks.  I am better than I was - mood varies, but my intrusive thoughts are pretty well gone.  

I also realized since increasing zyprexa back to 30mg I've gained 5.2kg back. I'm still down (2.8kg from highest) but it's trending badly and affects my mood.  He said since zoloft is helping we can decrease zyprexa - he wants to go slow, so down to 25mg for now.  I am guessing he won't necessarily reduce the # of medications (though I think he's open to getting rid of gabepentin??) but that he's okay with reducing the dosages so I'm not AS medicated.  

 

[Iceberg]

3 hours ago, jarn said:

So 'saw' (virtual) pdoc this morning.

I told him I felt like I was on too much medication, and wondered if there was any room on my current cocktail to change things - or, failing that, would clozapine accomplish that for me (my main concern with clozapine is the sedation since I have stuff to do in the mornings and solo camping trips I drive myself for).

We agree the zoloft needs more time - it's been about 3 weeks.  I am better than I was - mood varies, but my intrusive thoughts are pretty well gone.  

I also realized since increasing zyprexa back to 30mg I've gained 5.2kg back. I'm still down (2.8kg from highest) but it's trending badly and affects my mood.  He said since zoloft is helping we can decrease zyprexa - he wants to go slow, so down to 25mg for now.  I am guessing he won't necessarily reduce the # of medications (though I think he's open to getting rid of gabepentin??) but that he's okay with reducing the dosages so I'm not AS medicated.  

 

For better or worse, it seems like many docs feel that lowering dosages of many meds but not ditching them is better than maxing some out and dropping some others. I understand the sentiment, but it never worked well for me, I think mainly because I just ended up having to Max all of the meds without dropping any 

[jarn]

I wonder about that too @Iceberg

I know he thinks zyprexa works well for me - and it does - but I've needed high doses for stability (I really don't think it does much for depression, but what do I know) (edit:  it's worked well for my psychosis).  I hope the zoloft continues to work well and get better as I'm on it for a longer period of time.  I'm hoping to counter act the zyprexa weight gain and lipids with more workouts and a low-fat diet (which I SUCK at).

I would ideally like to drop lamotrigine (second after zyprexa, but the alternative to zyprexa scares me a bit, so who the heck knows what my optimal thing is).  I think it does do something, but does not manage my moods - especially depression - particularly effectively.  I've been on it for like 16 years now or something.

Edited October 21, 2021 by jarn

[Goofball]

You’re on a a fair number of meds, and the zyprexa dose is a big one. But I know people who have taken many more, inlcuding meds at high doses. My maximum was 8 psych meds, plus cogentin to deal with akathisia. Now I’m only on one, though. I suggest you discuss your concerns with your pdoc. 

Edited November 4, 2021 by Goofball