Going from Mirtazapine and Klonopin to Seroquel and (less) Klonopin

[thomasc93]

Hi everyone!

Just wanted to get some community input on the aforementioned combos.

I suffer from really bad generalized anxiety and racing thoughts at night, as well as insomnia caused by the racing thoughts (in addition to ADHD, but I have good old Adderall for that).

A few months ago, I had a really bad night where I just could not shut my mind of and my thoughts kept racing faster and faster, so I ended up in the ER at the request of my mother (I'm only 17, so I obviously still live at home). Before that night, I was just taking 1.5 mg of clonazepam a day. But that night at the ER, my pdoc (who is affiliated with the local hospital's addiction clinic as well as a private practice general psychiatrist) happened to be on call in the inpatient addiction ward, so he came over to the ER and checked me out. He gave me some Remeron and told me to try it for a few weeks.

I've been on that combo now (15mg mirtazapine and 1.5mg clonazepam) for the past three months. It's worked pretty well, but still at night I have a lot of trouble sleeping at night. I've been thinking about scraping the Remeron and switching over so Seroquel in addition to lowering my clonazepam use to breakthrough anxiety during the day. Does this sound like a viable option? Or would there be a worser side effect profile/more serious long term effects associated with something like Seroquel? If I did try Seroquel, I would request to my pdoc that I try a very low dose (like 25-75 mg). Also, do you think my pdoc would let me have a stash of Klonopin on hand for breakthrough daytime anxiety? Or would that be scrapped entirely if and when I start Seroquel?

Thanks for the input!

[Random Rabbit]

I've been on that combo now (15mg mirtazapine and 1.5mg clonazepam) for the past three months. It's worked pretty well, but still at night I have a lot of trouble sleeping at night. I've been thinking about scraping the Remeron and switching over so Seroquel in addition to lowering my clonazepam use to breakthrough anxiety during the day. Does this sound like a viable option?

For most people clonazepam is a maintenance medication. It can take from 1 to 4 hours to achieve peak serum levels from a single dose. That wait of up to 4 hours is not good for breakthrough anxiety. Add in that serum levels gradually increase over an approximately 5 day period with regular dosing and PRN clonazepam does not seem that helpful. Lorazepam (Ativan), alprazolam (Xanax), or diazepam (Valium) have a more rapid onset and are better for breakthrough anxiety. Albeit, diazepam also loads and is more effective after about 1.5 weeks of regular dosing.

That said, buccal and sublingual dosing of clonazepam is possible for breakthrough symptoms decreasing the onset time. Talk to your pdoc about this.

[jt07]

I'd say that this is where you need to talk to your pdoc. We really can't tell you what your pdoc will or will not do. That is between the both of you.

I can say from personal experience that the sedation properties of Remeron decrease as your body adjusts to the medication. So I can take mine now without becoming sleepy at all. I don't know anything about Seroquel. But from what I have read here and elsewhere, Seroquel at a dose from 25 to 75 mg is really just a strong antihistimine. But maybe that's what you need in order to sleep well.

BTW, are you taking your Adderall early enough in the day so that it has left your system by night?

[Random Rabbit]

Seroquel at a dose from 25 to 75 mg is really just a strong antihistimine.

This is not true, the active metabolite norquetiapine has a strongly significant affinity for the 5HT2A receptor (K_i = 2.9 nM) and a 12 hour half life. In my experience 5HT2A antagonism has a strong anxiolitic effect (removes the fingernails on a blackboard sensation I have unmedicated). I take Zyprexa at a low dosage for this 5HT2A antagonism to avoid the extreme anxiety I have. 5HT2A antagonism does next to nothing for every day anxiety, but it quells psychotic anxiety very effectively.