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10 hours ago, Iceberg said:

What was the docs concern about the controlled meds? 

My own fault, I was doing fraudulent and forging prescriptions. No bueno and psychiatrist didn't want any parts of it or be involved at all. 2nd pdoc this has happened with. I need to find some permanency in a providr but it is just so hard. It looks like I am doctor shopping like crazy because every month I am filling from a new psychiatrist.  

9 hours ago, HoozOnFirst said:

To be honest my head is so scrambled these days I can’t remember the twists & turns of my long history of med changes, diagnosis changes, therapy approaches etc etc etc. 

The adderall was started when pdoc thought it would help with MDD and my lack of engagement with life. It was very helpful & I was getting things done at home (eating, laundry, bathing etc). Great. Recently it’s been less effective which I strongly believe is related to the pharmacy’s switch to a different manufacturer. Pdoc said she thinks my diagnosis of treatment resistant MDD might not be correct (she had added that dx herself a year+ earlier) but wanted to go back to a previous dx of BP2 (which she had disagreed with initially). She had also added a dx if ADHD and hoped the adderall would help me focus. Which it did...until it didn’t. I wanted her to consider adding a second 20 mg dose of adderall ER midday because my morning dose helped a lot with mood & focus but pooped out early afternoon. She felt that was too much of the drug & wasn’t comfortable with prescribing it. 

So I’m not sure what the hell my dx’s are anymore nor what drugs are/aren’t appropriate. She decided my OCD (well established dx for decades) was probably hypomania. I disagree. She thinks the duloxetine is causing an increase in what she now feels is hypomania and is also contributing to my symptoms of what she feels is actually rapid cycling. She feels the lamotrigine is the one I should continue to take since it’s a mood stabilizer. So we’re back to BP2 and throwing out the OCD, treatment resistant MDD and ADHD. 

I am SO tired of this. I’m 65 years old & have had significant symptoms since I was five! Every shrink over the years has changed diagnoses & meds. Back & forth...up, down. I’m exhausted. And now this gal is leaving & I'm being handed off to someone else who will likely scramble things up yet again. Omg. 

Thanks for asking. I wish I could give a more concise answer. 

 

About the adderall and the generic manufacturers, don't be afraid to ask the pharmacist if they can order a specific brand of generic manufacturer, sometimes they can and sometimes they can't but it won't hurt to ask. If pdoc started it because MDD and now thinks it is something else, I would let her know how helpful it has been in all aspects of your life. I would maybe suggest getting on something that is more consistent than Adderall XR, and I mean possibly Vyvanse, Dexedrine, Zenzedi, etc. The drugs that vary very little in effect with different generics or drugs that do not have a  generic formulation as of right now. It sucks  that we have to do these things to get the most out of our medications, but to me I believe that meds improve my life so much that I have a huge out of pocket personal budget I'm willing to spend on medications I know I need to function like Vraylar and Rexulti. So you could maybe  propose that route to pdoc. 40mg a day of adderall isn't too much in my opinion, I would say 60mg might be closer to the ceiling or possibly 90mg. You could always take an instant release "booster" dose in the afternoon when you aren't feeling the initial XR working anymore. It's frustrating when we ourselves know what medications and dosages work for us but our pdoc doesn't or isn't really on board so to say. Like for example, I know that 120mg of dextroamphetamine a day is what works for me, but not many pdocs are comfortable prescribing anywhere near that high of a dose. I don't like taking 2 or 3  different antipsychotics because the side effects scare the living crap out of me but it's what works to be  honest. 

Sometimes focusing on your dx isnt  really important but what is is focusing on your symptoms and how the meds are working for you. I guess you need to focus on your dx somewhat but don't let it discourage or confuse you if your dx is changing or not fixed yet. It will be. Sometimes it takes a longer time, like in my  aunt's case almost 30 years, or in my case where it only took 2 years. It  is sometimes very depressing thinking of our mental health when we are unstable because we often get to thinking that something is so wrong with us that we will never be able to fix it. 

That could be true, about the cymbalta  causing mood changes, mixed episodes, or hypomania. I initially had my first bipolar episode of mania from being on Paxil. Even though it's  a more sedating SSRI it threw me through the damn wringer. It's al;so very common for us to be unable to explain how we're feeling or what the meds are doing to us, especially when there is multiple changes in medications at once. How can anyone expect a person to unencrypt the science of psychopharmacology on themselves and report back to the psychiatrist? Like what... this is just one example of the problems that there are in psychiatry. My saving grace at the time was lithium. I was willing to try anything to stop my manic symptoms and get my ADHD under control. After I was stable on that I told the pdoc I wanted to look for a more ideal long-term solution besides lithium, due to the mandatory blood tests, side effects on kidneys, liver, and cognition, not to mention thyroid problems. This is when we began trying any and alll of the antipsychotics, higher doses than usual, combinations that were out of the ordinary. I mean I was definitely a "lab rat" in a way and my family even tells me that. My dad gets so concerned about  me and my medications because it's not like hie is 100% confident that I am stable on  my current cocktail so he still worries about me being symptomatic. I'd recommend this to anyone, but I strongly suggest becoming actively involved in your treatment plan and medication management. Take this switching pdocs as an opportunity to be more assertive and communicate with them in a way that shows you mean what you say and are serious about it. Tell them what works for you and what doesn't. Yes, they also have say in this of course, but don't let them take complete control and have you whacked out, because it happens pretty easily and quickly, right under your nose. 

I wish I could give more of a solid answer as well, but try to hang in there even with all the medication changes and switching providers!

Edited by mmaryland
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On 4/18/2020 at 9:43 AM, mmaryland said:

My own fault, I was doing fraudulent and forging prescriptions. No bueno and psychiatrist didn't want any parts of it or be involved at all. 2nd pdoc this has happened with. I need to find some permanency in a providr but it is just so hard. It looks like I am doctor shopping like crazy because every month I am filling from a new psychiatrist.  

About the adderall and the generic manufacturers, don't be afraid to ask the pharmacist if they can order a specific brand of generic manufacturer, sometimes they can and sometimes they can't but it won't hurt to ask. If pdoc started it because MDD and now thinks it is something else, I would let her know how helpful it has been in all aspects of your life. I would maybe suggest getting on something that is more consistent than Adderall XR, and I mean possibly Vyvanse, Dexedrine, Zenzedi, etc. The drugs that vary very little in effect with different generics or drugs that do not have a  generic formulation as of right now. It sucks  that we have to do these things to get the most out of our medications, but to me I believe that meds improve my life so much that I have a huge out of pocket personal budget I'm willing to spend on medications I know I need to function like Vraylar and Rexulti. So you could maybe  propose that route to pdoc. 40mg a day of adderall isn't too much in my opinion, I would say 60mg might be closer to the ceiling or possibly 90mg. You could always take an instant release "booster" dose in the afternoon when you aren't feeling the initial XR working anymore. It's frustrating when we ourselves know what medications and dosages work for us but our pdoc doesn't or isn't really on board so to say. Like for example, I know that 120mg of dextroamphetamine a day is what works for me, but not many pdocs are comfortable prescribing anywhere near that high of a dose. I don't like taking 2 or 3  different antipsychotics because the side effects scare the living crap out of me but it's what works to be  honest. 

Sometimes focusing on your dx isnt  really important but what is is focusing on your symptoms and how the meds are working for you. I guess you need to focus on your dx somewhat but don't let it discourage or confuse you if your dx is changing or not fixed yet. It will be. Sometimes it takes a longer time, like in my  aunt's case almost 30 years, or in my case where it only took 2 years. It  is sometimes very depressing thinking of our mental health when we are unstable because we often get to thinking that something is so wrong with us that we will never be able to fix it. 

That could be true, about the cymbalta  causing mood changes, mixed episodes, or hypomania. I initially had my first bipolar episode of mania from being on Paxil. Even though it's  a more sedating SSRI it threw me through the damn wringer. It's al;so very common for us to be unable to explain how we're feeling or what the meds are doing to us, especially when there is multiple changes in medications at once. How can anyone expect a person to unencrypt the science of psychopharmacology on themselves and report back to the psychiatrist? Like what... this is just one example of the problems that there are in psychiatry. My saving grace at the time was lithium. I was willing to try anything to stop my manic symptoms and get my ADHD under control. After I was stable on that I told the pdoc I wanted to look for a more ideal long-term solution besides lithium, due to the mandatory blood tests, side effects on kidneys, liver, and cognition, not to mention thyroid problems. This is when we began trying any and alll of the antipsychotics, higher doses than usual, combinations that were out of the ordinary. I mean I was definitely a "lab rat" in a way and my family even tells me that. My dad gets so concerned about  me and my medications because it's not like hie is 100% confident that I am stable on  my current cocktail so he still worries about me being symptomatic. I'd recommend this to anyone, but I strongly suggest becoming actively involved in your treatment plan and medication management. Take this switching pdocs as an opportunity to be more assertive and communicate with them in a way that shows you mean what you say and are serious about it. Tell them what works for you and what doesn't. Yes, they also have say in this of course, but don't let them take complete control and have you whacked out, because it happens pretty easily and quickly, right under your nose. 

I wish I could give more of a solid answer as well, but try to hang in there even with all the medication changes and switching providers!

Thank you so much for your reply. It was helpful & encouraging. Really appreciate it. 
I did ask my pharmacist for a special order but they said they can’t do that. I’ve recently found a pharmacy connected with our medical university that can provide the manufacturer my pdoc wanted. This was for the duloxetine which I am tapering off of. Won’t miss that RX! And I agree it’s likely causing the nasty symptoms. 
 

The adderall is another matter. It’s frustrating that some pdocs are so reluctant to play around with dosages. I came of age in the 60’s...I’ve long since gotten over the desire to alter my consciousness. I just want to feel whole. If their reluctance is due to fear of a bad outcome and even litigation then I feel they’re in the wrong business. Anyway, you mentioned zenzedi & vyvanse. I’m willing to spend more if it makes a difference. Sometimes I think my pdoc only focused on generics maybe due to cost. I asked her to consider any brand names if she felt they might be a good fit. So she did mention vyvanse. We checked the cost & it was over $300/month. Is that comparable to your cost? I’m not familiar with zenzedi but I like the name! Ha. I’ll look it up. Do you take both? 
 

It really is difficult to explain how I feel when they ask. I can’t even remember what I did yesterday so trying to describe complex feelings is impossible most of the time. I used a mood journal app for a couple of years but again the adjective list got so long it was basically meaningless. And it becomes depressing in itself to have to spend so much time thinking about how I’m feeling so I can report back to the doc. 
 

I have my first appointment with the new pdoc on Wednesday. It’ll be a phone appointment due to the virus thing. I’m not sure how that will feel since it’s our initial contact. But as you suggested I’m geared up to set a tone of mutual respect and trust. I’ll definitely want to explain my frustration with the diagnosis merry-go-round and med changes. I want to pin it down and work with her on a plan that makes sense. I look forward to a fresh start. Wish me luck. 
 

Thanks again for the great information & suggestions. It has really helped. 
 

 

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It's been a while, and I'm trying to actively stop from changing around too much as has been pointed out to me by many people on here as well as friends, family, and my pdoc. But this is what I believe I'm settling on for now. This is as few psych meds as I've been on in a while now!

Psych meds

  1. Caplyta (lumateperone) 42 mg 1 PO qam: brand new antipsychotic, gdoc prescribed as I just couldn't handle Latuda anymore... I lost a total of 31 lb on Latuda from not eating due to depression within a minimum of 3 weeks (can't remember exactly how long it was). I'm still losing weight on Caplyta but not as rapidly. Caplyta doesn't increase appetite, rather, it lowers it (at least in my case). I am my pdoc's first patient to be on Caplyta. She wasn't comfortable with letting me stay on it, but I begged her to let me stay on it because I have been doing so well on it in just the short time I've been on it!
  2. desipramine (Norpramin) 50 mg 1 PO qam
  3. sertraline (Zoloft) 100 mg 1 PO qam: lowered to 100 mg from 150 mg because Caplyta has some SSRI activity
  4. hydroxyzine pamoate (Vistaril) 50 mg 1 PO x1 prn

Nuero/psychiatric meds

  1. oxcarbazepine (Trileptal) 600 mg 1 PO bid
  2. Trokendi XR (topiramate XR) 50 mg 1 PO qam (actually is free with coupon compared to any other brand or generic topiramate! Less side effects than IR topiramate, and I actually seem to be getting a little appetite suppression!)
  3. propranolol LA (Inderal LA) 60 mg 1 PO qam

Psychiatric meds not prescribed by pdoc:

  1. dextroamphetamine (Dexedrine) 10 mg 2 PO tid (60 mg)

So 7 meds in total + 1 prn. There are more meds for other things, but this is just within the psych/neuropsych realm.

I'm pretty happy with this combination, actually. Not every day is a huge victory, but good lord am I so much better off than when I was on Latuda!!!

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20 hours ago, mikl_pls said:

It's been a while, and I'm trying to actively stop from changing around too much as has been pointed out to me by many people on here as well as friends, family, and my pdoc. But this is what I believe I'm settling on for now. This is as few psych meds as I've been on in a while now!

Psych meds

  1. Caplyta (lumateperone) 42 mg 1 PO qam: brand new antipsychotic, gdoc prescribed as I just couldn't handle Latuda anymore... I lost a total of 31 lb on Latuda from not eating due to depression within a minimum of 3 weeks (can't remember exactly how long it was). I'm still losing weight on Caplyta but not as rapidly. Caplyta doesn't increase appetite, rather, it lowers it (at least in my case). I am my pdoc's first patient to be on Caplyta. She wasn't comfortable with letting me stay on it, but I begged her to let me stay on it because I have been doing so well on it in just the short time I've been on it!
  2. desipramine (Norpramin) 50 mg 1 PO qam
  3. sertraline (Zoloft) 100 mg 1 PO qam: lowered to 100 mg from 150 mg because Caplyta has some SSRI activity
  4. hydroxyzine pamoate (Vistaril) 50 mg 1 PO x1 prn

Nuero/psychiatric meds

  1. oxcarbazepine (Trileptal) 600 mg 1 PO bid
  2. Trokendi XR (topiramate XR) 50 mg 1 PO qam (actually is free with coupon compared to any other brand or generic topiramate! Less side effects than IR topiramate, and I actually seem to be getting a little appetite suppression!)
  3. propranolol LA (Inderal LA) 60 mg 1 PO qam

Psychiatric meds not prescribed by pdoc:

  1. dextroamphetamine (Dexedrine) 10 mg 2 PO tid (60 mg)

So 7 meds in total + 1 prn. There are more meds for other things, but this is just within the psych/neuropsych realm.

I'm pretty happy with this combination, actually. Not every day is a huge victory, but good lord am I so much better off than when I was on Latuda!!!

Glad to hear from you and glad you are doing better than you were when you were on latuda!

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A lot has happened recently in my life. I lost my mom due to a sudden illness a few weeks ago. I suffer from both bipolar I and C-PTSD and am going through a complicated grief process. I am currently on medical leave from work and will be participating in a trauma-focused PHP program. Posting the current cocktail up for reference but things will likely be adjusted over the course of the next few weeks, although I'm sure the focus will be on good quality therapy. 

Psych meds

  1. Latuda (lurasidone) 90 mg 1 PO qhs: has been a mainstay of my therapy but I feel that it may not be packing enough of a punch for me lately; I am concerned about metabolic side effects as my fasting blood sugar is elevated so I am hesitant about increasing the dose - but this has been a staple for the last 2.5 years 
  2. zonisamide (Zonegran) 100 mg 3 PO qhs: has also been a staple; seems to be the only anticonvulsant that has had noticeable mood-stabilizing properties for me; I also take this for migraine prophylaxis; it does not seem to give me as much appetite suppression and I would like and I experience fewer cognitive side effects on this compared to topiramate
  3. prazosin (Minipress) 1 mg 2 PO qhs: for C-PTSD nightmares
  4. lorazepam (Ativan) 2 mg 1 PO qhs and PRN (up to 6 mg daily): mainly for insomnia and occasional breakthrough anxiety and panic

I'd like to replace the Ativan with something else for sleep. I am wary about adding an antidepressant although there is good reason to believe this could help with the PTSD symptoms. I would be interested in potentiation my cocktail with a more evidence-based mood stabilizer like Lamictal - I feel my team has never been patient enough with it to see if it could help me and I think it could be a nice compliment to the Latuda which I am way too scared to change. I may not be in a great place right now but things could really be so much worse - I do feel that Latuda raises the floor for me significantly. 

Neuro meds 

  1. Wakix (pitolisant) 17.8 mg 1 PO qam: recently approved non-stimulant wakefulness promoting agent for narcolepsy; switched to this from Xyrem when Xyrem started giving me severe side effects; was taking the full 35.6 dose but it was making my migraines/clusters worse so we are trying to see I still get a benefit at a lower dose
  2. dextroamphetamine (Dexedrine) 10 mg 1 PO qam: booster for the Wakix and serves more of a psych purpose as pdoc believes I have a touch of ADHD; also hoping this helps with appetite suppression as they has become an issue lately out of nowhere
  3. Ubrelvy (ubrogepant) 50 mg 1 PO + 1 w/in 2h if no effect: new oral CGRP inhibitor abortive I am trying out as an alternative to my triptan
  4. rizatriptan (Maxalt) 10 mg 1 PO + 1 w/in 2 h if no effect: migraine abortive
  5. methylprednisolone (Depo-Medrol taper pack) 4 mg x 21, tapered over 6 days: just completed a steroid treatment to try to break a cluster cycle 
  6. baclofen (Lioresal) 20 mg 1 PO PRN: for tension migraine

Recently discontinued taking verapamil as a cluster headache prophylactic because I feared it was responsible for a rapid weight gain and some associated gastric issues. I'm no longer convinced it's necessarily responsible and it might be back on the table. 

Other health conditions and medication side effect management

  1. Levoxyl (levothyroxine) 112 mcg 1 PO qam: post-surgical hypothyroidism
  2. liothyronine (Cytomel) 5 mcg 2 PO qam: post-surgical hypothyroidism and the extra T3 has also conferred some antidepressant action for me
  3. ergocalciferol (vit D2) 50k IU 1 PO 1x week: vitamin D deficiency - which apparently can also be contributed to by being on anticonvulsant therapy; seems to support mood
  4. metformin ER (Glucophage) 500 mg 2 PO qpm with food: I developed insulin resistance while on clozapine and never fully recovered - I am also predisposed to this and sensitive to the metabolic side effects of antipsychotics possibly due to underlying PCOS
  5. spironolactone (Aldactone) 100 mg 1 PO qpm: for PCOS
  6. omeprazole (Prilosec) 20 mg 1 PO qam: was experiencing some dyspepsia with occasional nausea and vomiting and had a workup done by my PCP - we couldn't figure out why I was experiencing my symptoms but adding this med has helped tremendously; my neuro suspects that frequent use of NSAIDs like naproxen for my chronic migraines may have created some stomach damage

I also take a probiotic, digestive enzyme, and a raw food multivitamin but I'll spare you those details. I meet with the program pdoc at some point early this week and then with my personal pdoc on Saturday. 

On 4/25/2020 at 6:00 PM, mikl_pls said:

Caplyta (lumateperone) 42 mg 1 PO qam: brand new antipsychotic, gdoc prescribed as I just couldn't handle Latuda anymore... I lost a total of 31 lb on Latuda from not eating due to depression within a minimum of 3 weeks (can't remember exactly how long it was). I'm still losing weight on Caplyta but not as rapidly. Caplyta doesn't increase appetite, rather, it lowers it (at least in my case). I am my pdoc's first patient to be on Caplyta. She wasn't comfortable with letting me stay on it, but I begged her to let me stay on it because I have been doing so well on it in just the short time I've been on it!

@mikl_pls, I'm sad to hear the Latuda wasn't working out for you. The Caplyta sounds intriguing and I'm glad you're seeing progress. Do you have any specific info on how its receptor binding profile compares to other AAPs on the market? Especially the -dones?

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On ‎4‎/‎25‎/‎2020 at 4:00 PM, mikl_pls said:

Caplyta (lumateperone) 42 mg 1 PO qam: brand new antipsychotic, gdoc prescribed as I just couldn't handle Latuda anymore... I lost a total of 31 lb on Latuda from not eating due to depression within a minimum of 3 weeks (can't remember exactly how long it was). I'm still losing weight on Caplyta but not as rapidly. Caplyta doesn't increase appetite, rather, it lowers it (at least in my case). I am my pdoc's first patient to be on Caplyta. She wasn't comfortable with letting me stay on it, but I begged her to let me stay on it because I have been doing so well on it in just the short time I've been on it!

I'm thinking about asking my pdoc about this.  How has it been on your mood?  Any help with anxiety?

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On 4/26/2020 at 9:16 PM, ByePolarCoordinates said:

A lot has happened recently in my life. I lost my mom due to a sudden illness a few weeks ago. I suffer from both bipolar I and C-PTSD and am going through a complicated grief process.

I'm so very sorry for your loss. 😢 My heart goes out to you and your family. ❤️ 

On 4/26/2020 at 9:16 PM, ByePolarCoordinates said:

@mikl_pls, I'm sad to hear the Latuda wasn't working out for you. The Caplyta sounds intriguing and I'm glad you're seeing progress. Do you have any specific info on how its receptor binding profile compares to other AAPs on the market? Especially the -dones?

Well, oddly enough, Caplyta is related to Haldol (it's a butyrophenone derivative, but still an atyipcal...) of all things... It has a very, very specific pharmacological profile. It has the highest affinity for the 5-HT2A receptor as an antagonist (Ki = 0.54 nM), and everything after that is a good bit less potent. It acts as a partial agonist presynaptically and an antagonist (according to the prescribing information, Wikipedia now, as of quite recently, actually, says "partial antagonist") postsynaptically at D2 (Ki = 32 nM), an antagonist at D1 (Ki = 41 nM), and an inhibitor of the SERT (Ki = 33 nM) (so it has built-in SSRI properties roughly equal to its effects at the D2 receptor). It does have "non-specific" affinity for the D4 receptor as well as the α1A- and α1B-adrenergic receptors (don't know whether it is an antagonist or what, and don't know the affinities), and has negligible affinity for H1 and mACh receptors. That's pretty much it! Not even any 5-HT1A partial agonism or anything like that that we know of (yet). According to Wikipedia, "through the mTOR pathway, lumateperone augments both NMDA and AMPA activity."

Compared to other AAPs, especially to the -done AAPs...

According to Stahl... 

"The 'pines' (clozapine, olanzapine, quetiapine, asenapine) all bind much more potently to the 5-HT2A receptor than they do to the D2 receptor. The 'dones' (risperidone, paliperidone, ziprasidone, iloperidone, lurasidone) also bind more potently to the 5-HT2A receptor than to the D2 receptor, or show similar potency at both receptors. Aripiprazole and cariprazine both bind more potently to the D2 receptor than to the 5-HT2A receptor, while brexpiprazole has similar potency at both receptors."

Since it has no binding to the 5-HT1A, 5-HT1B/1D, 5-HT2C, 5-HT6/7 receptors (that we know of yet), I won't really go into what he says about those antipsychotics and those receptors.

I guess if you had to compare, though, just based on 5-HT2A-to-D2 receptor affinity ratios, it probably more closely resembles a -pine, but the potency of both affinities more closely resembles a -done, I think. It has insignificant to no activity on H1 and mACh receptors, so it's more like a -done in that respect, I believe, or even the "two pips and a rip," as he calls the dopamine partial agonist, which, I guess you could say it resembles those too insofar as it is "partially" a partial agonist at the D2 receptor at least. (I think what Wikipedia is saying by it being a "partial antagonist" postsynaptically is that it is still a partial agonist but with low intrinsic activity and thus is a functional antagonist... maybe?)

Plus there's the added bonus of being an SSRI, so it resembles ziprasidone and aripiprazole a bit in those regards (without the NRI activity associated with ziprasidone and stronger SRI activity than aripiprazole), and the SSRI activity of lumateperone is much more clinically significant (being almost equipotent to that of its effects at D2) than those of the other two AAPs with monoamine reuptake inhibition. (Oh, I forgot about norquetiapine's NRI activity, but... I mean... that's NRI and not SRI...)

The fact that it is a butyrophenone (like haloperidol) seems like a coincidence to me, because it doesn't (to me) resemble the pharmacological profile of haloperidol. It's far cleaner/more specific, and... not an emotional sledgehammer like haloperidol is...

5 hours ago, Arj72 said:

I'm thinking about asking my pdoc about this.  How has it been on your mood?  Any help with anxiety?

I would highly, highly recommend it, even insist upon it if your pdoc is uncomfortable because "it's new" or whatever excuse they may give... Put your big-pdoc pants on and learn to prescribe it! How else are you going to learn? My pdoc didn't want to keep me on it (I got my gdoc to prescribe it for me after I tried my damnedest to stay on Latuda and just couldn't hack it any longer... The worsened depression was just getting too much, and my emotional volatility/lability was also getting to be too much for my family to handle...). She was admittedly very uncomfortable with it, didn't like that I had switched meds yet again in such a short amount of time, and that she'd rather me have stayed on Latuda, to which I responded promptly, "that simply was not an option... It was literally killing me..." (Like, I lost 31 lb in 3 weeks because I wasn't eating due to the significantly worsened depression Latuda caused me, and this was my 3rd time on it--each time I took it was worse than the last...) I had to kind of plead with her to let me stay on Caplyta, and she did agree (didn't take much pleading...) She said of all her patients, she would trust me the most to take such a brand new medication. So she congratulated me on being her first Caplyta patient... lol.

I will tell you that the effects on my mood were like night and day. Within like the first 3-5 days of taking it (can't remember quite exactly... but it was definitely within the first week...), my dad actually noted to me that the difference in me after starting it was "like night and day," for the better of course. After he noted that (in front of my mom), she also confirmed that. I was capable of handling a conversation for extended periods of time, whereas before I was only capable of just short exchanges (like 3-word sentences at the most... and as brief as possible...) just enough to get by... and then I'd lay back down and go to sleep because I was always invariably in my bed sleeping all day and night before. My mood has mostly continued to improve. I still have "down days," but they are nowhere as bad as even the best of days before (I had been spiraling downward since November, and Latuda just about finished me off quite literally). I'm still not quite as motivated or bathing as often as I'd like to, but I think that's actually mostly bad grooming habits that I developed from depression as well as isolation due to COVID-19, as well as my ADHD not being well controlled (despite being on the max dose of Dexedrine, 60 mg/day). My room is still a disastrous mess... It always gets that way no matter what.

As for anxiety, I mean, it does have built-in SSRI properties, for which I actually lowered my Zoloft dose from 150 mg to 100 mg. I am not feeling like I'm missing anything by doing that. I think it was the right thing to do, a perfect exchange. I'm actually considering further lowering the Zoloft and maybe even discontinuing it and letting the Caplyta take over the SSRI effects (or at least trying it like that for a while...). I haven't noticed as marked of an effect on my anxiety as I have on my mood, but I suppose it does have an effect on anxiety. I don't think it will likely have as pronounced of an effect on anxiety as an AAP with strong 5-HT1A partial agonism (with high intrinsic activity--theoretically, like Abilify, which we know can worsen anxiety, usually depending on the dose; Rexulti; Seroquel; or Geodon, which can also worsen anxiety depending on dose usually). Potent 5-HT2A antagonism also plays a part, which is definitely a department in which Caplyta excels! Other AAPs which have both high affinity, high-intrinsic activity 5-HT1A partial agonism and high affinity 5-HT2A antagonism are Abilify (kinda... it's actually a 5-HT2A partial agonist, but the intrinsic activity is so, so low that it is really a functional antagonist), Saphris (maybe? not sure about 5-HT1A intrinsic activity), Rexulti (theoretically should definitely be very anxiolytic), Seroquel (kinda, but mostly due to antihistamine actions likely), and Geodon (also is a "mini-SNRI"). Latuda would cut it, but its affinity for 5-HT1A as well as intrinsic activity are kinda low... Vraylar's affinities for 5-HT1A and 5-HT2A are pretty low relative to its affinity for D2/D3, and its intrinsic activity for 5-HT1A is roughly that of Latuda's.

If you compare...

5-HT1A (IA %) / 5-HT2A (IA %) / D2 (IA %) / H1 / SERT / NET
Abilify: 1.7-5.6 nM (68%) / 3.4-35.0 nM (12.7%) / D2(L) 0.34-0.74 nM (75%) / 27.9-61.0 nM / ~98 nM / 2090 nM
Saphris: 2.5 nM (? %) / 0.06 nM / 1.3 nM / 1 nM / - / -
Rexulti: 0.12 nM (60%) / 0.47 nM / 0.3 nM (43%) / 19 nM / "65% @ 10 mcM" / "0% @ 10 mcM"
(Vraylar: 2.6 nM (38.6%) / 18.8 nM / D2(S) 0.69 nM (? %), D2(L) 0.49 nM (60%) / 23.2 nM / - / - )
Caplyta: - / 0.54 nM / 32 nM (? %) / - / 33 nM / -
(Latuda: 6.75 nM (33%) / 2.03 nM / 1.68 nM / > 1000 nM / > 1000 nM / > 1000 nM)
Seroquel: 
320-432 nM (81-97%) / 96-101 nM / 245 nM / 2.2-11 nM / - / -
*Norquetiapine: 45 nM (82-98%) / 48 nM / 196 nM / 3.5 nM / 927 nM / 58 nM (Seroquel's active metabolite...)
Geodon: 2.5-76.0 nM (71-75%) / 0.08-1.40 nM / 4.8 nM / 15-130 nM / 112 nM / 44 nM

(Left out Clozaril (due to being a drug of last resort), as well as Fanapt, Zyprexa, Invega, and Risperdal due to not being 5-HT1A partial agonists...)

I hope that "table" is legible... lol. The only 5-HT2A "partial agonist" is Abilify. The only D2/D3 partial agonists are Abilify, Rexulti, Vraylar, and kinda Caplyta. The only AAPs with any monoamine reuptake inhibition of any kind are Abilify, Caplyta, Seroquel (through its active metabolite), and Geodon. Maybe Rexulti? (I don't know how to interpret that notation...)

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Current medications: 

AM:

fluoxetine 40mg

Lorazepam 2mg

Haldol 2.5mg

Esomeprazole 40mg

PM:

lorazepam 2mg

Nocte:

Sodium Valproate Chrono 2000mg

Quetiapine 800mg 

Lorazepam 2mg

Lamotrigine 75mg

Haloperidol 7.5mg 

Flurazepam 30mg

 

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psych:

  • mixed amphetamine salts (Adderall) 20 mg QID
  • Fetzima (levomilnacipran) 120 mg QD
  • paroxetine (Paxil) 5 mg BID
  • diazepam (Valium) 2.5–5 mg BID PRN
  • temazepam (Restoril) 30 mg QHS PRN

GD/GID:

  • estradiol transdermal (twice-weekly, i.e. Vivelle-Dot) 0.1mg/24h — 2 patches (0.2mg/24h) three times a week
  • bicalutamide (Casodex) 25–50 mg QD (technically 50 mg QD, taken as 25 mg QD, was told to also consider trying 50 mg every other day again)

general:

  • pantoprazole (Protonix/Pantoloc) 40 mg QD
  • sumatriptan 50 mg PRN (usually with 200–400 mg OTC ibuprofen)

Feel like I'm missing a med or two here... hmm.

New pdoc up here in Chicago is fucking amazing, he manages meds and does therapy – and not like 5 minutes of it, but a good 30–45 minutes or so. Since the COVID lockdown he's been doing telepsych.

For hormones/GP I'm seeing a provider at Howard Brown, which is a bit odd tbh as they apparently have very few people on transdermal E2 and almost nobody on bicalutamide. Not quite what I expected from such a prestigious place. They only barely agreed to RX the bicalutamide after quite a bit of internal discussion and only with the caveat that they want to pull blood tests every 3 months due to concerns over potential liver damage, which I was fine with. Since COVID though they've basically closed up shop temporarily outside of a few edge cases and some limited telehealth, I never did get a callback from my provider to tell me what she wanted to do about the appointment that got cancelled due to that or the blood tests she was wanting to draw, and the general instructions from when this started were to wait until at least May or June if not later before calling about rescheduling...
 

Outside of the COVID-related woes things have been going pretty well. The psych meds seem to finally be stable, as is life (well, mostly). Work kinda sucks and I'm paid utter shit (insultingly low compared to market rates), but at least I still have a job, and once the economy unfucks itself a bit I'm going to start applying to positions up here. Not fond of the prospect of a long commute or having to go into an office again (although I may get lucky and find a place that allows partial WFH), but decent benefits (which will become critical in a little over a year when I can no longer get coverage through my parents' insurance) and doubling (or more) my pay seems like fair compensation.

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Saw both my pdoc and neurologist on Wednesday last week.

Psych meds:

  • desipramine (Norpramin) 50 mg 1 PO qam (officially taken off script... turned against me after starting Caplyta...)
  • Caplyta (lumateperone) 42 mg 1 PO qam cc (still taking and doing well on)
  • ↓ sertraline (Zoloft) 50 mg 1-1½ PO qam (50-75 mg) (lowered from 100 mg)
  • hydroxyzine pamoate (Vistaril) 50 mg 1 PO x1 prn (simply wasn't taking anymore because it wasn't effective...)
  • + Belsomra (suvorexant) 20 mg 1 PO qhs prn (a little too effective this time around for some reason—causes extremely vivid nightmares, hallucinations, etc., next day hypersomnia... I asked for lower dose samples and all they had were 15 mg... If I stick with this one, I may need to go down to 10 mg or even 5 mg...)
  • + Doral (quazepam) 15 mg 1 PO qhs prn (awaiting a pharmaceutical rep for some sort of cash discount? May just try to fill it and deal with the PA difficulties with my pdoc...)
  • + doxepin (Sinequan) 50 mg 1 PO qhs prn
  • + Rozerem (ramelteon) 8 mg 1 PO qhs prn (awaiting PA, probably won't bother with it because it will be expensive and doesn't have a coupon...)
  • dextroamphetamine (Dexedrine) 10 mg 2 PO tid (60 mg)

Neuro meds:

  • oxcarbazepine (Trileptal) 600 mg 1 PO bid (1,200 mg) (Officially taken of script... just stopped taking out of laziness and never filled again, didn't seem to need it and stopping it seemed to enhance the effectiveness of Trokendi XR anyway...)
  • Trokendi XR (topiramate ER) 50 mg 1 PO qam (now may only anticonvulsant and mood stabilizer)
  • ↓ propranolol (Inderal) 20 mg 1 PO bid (40 mg) (lowered from Inderall LA 60 mg, which was causing bradycardia and orthostatic hypotension... It seems the lower dose of propranolol isn't doing any better for the bradycardia, but orthostasis is a little better...)
  • zolmitriptan ODT (Zomig-ZMIT) 2.5 mg 1 PO x1 prn, may repeat x1 in 2h prn, max: 2x/24h

(Other meds:)

I have discontinued quite a lot of my other daily meds as well, mostly out of laziness, but finding that I actually don't really need them anymore after not taking them for a while.

  • montelukast (Singulair) 10 mg 1 PO qhs
  • omeprazole (Singulair) 20 mg 1 PO qam
  • losartan (Cozaar) 25 mg 1 PO qhs
  • tamsulosin (Flomax) 0.4 mg 1 PO qpm 30min pc
  • levothyroxine (Synthroid) 150 mcg 1 PO qam 1h ac
  • Ozempic (semaglutide) 2 mg/1.5 mL pen 1 mg SC qwk (Mon)
  • Breo Ellipta (fluticasone furoate/vilanterol) 100 mcg/25 mcg/act DPI 1 puff qd
  • doxycycline monohydrate (Monodox) 100 mg 1 PO bid (200 mg) (switched from minocycline)
  • ↓ glycopyrrolate (Robinul Forte) 2 mg 1 PO qam-bid (2-4 mg) (down from 8 mg/day)
  • baclofen (Lioresal) 20 mg 1 PO tid prn
  • trifluoperazine (Stelazinie) 5 mg 1 PO bid prn
  • ProAir RespiClick (albuterol inhaled) 90 mcg/act DPI 2 puffs q4-6h prn
  • levalbuterol (Xopenex) inhalation solution 1.25 mg/3 mL (0.042% neb 1.25 mg NEB q6h prn

Supplements:

  • MethylFolate® L-Methylfolate 15 mg 1 PO qam
  • Vitamin D3 50,000 IU 1 PO qwk (Sun)

 

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Paxil 20 mg

Vraylar 3.5 mg 

Vyvanse 20 mg

Seroquel 100 mg

Seroquel 25 mg as needed...never need it but it's on hand... 

 

Thoughts?

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Hi, it's been a while, I decided to change pdoc and been better nowadays. So actually here it goes:

1. Paroxetine 60 mg (one in the morning and two at night) 

2. Olanzapine 20 mg (two at night) 

3. Clonazepam 4 mg (one in the morning and one at night) 

4. Vyvanse 70 mg (one, AM) 

I feel something is missing and is my Ritalin so I decided to self medicate PRN but i'm gonna tell him the truth and lets see in the next appointment what to do. Same with risperidone 2mg PRN since it helps a lot for my ocd. Cheers! 

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Posted (edited)

I started getting Zoloft withdrawal symptoms and increased anxiety when I tried to go down on the Zoloft (as instructed), so I went all the way back up to 100 mg Zoloft and I felt fine today for the most part.

I finally got my Doral (sleeping med), and I think it's basically generic quazepam but a preferred generic brand of it since the tablets still say "DORAL" on them. It's... not as cracked up to be what I thought it would be... I'm sitting here almost 3:00 AM on here. Taking it with Belsomra 20 mg doesn't seem to touch anything. If I overdo the sleep combo thing, I sleep all day next day though, which is why I don't touch doxepin anymore... lol. Even though the Rozerem is generic now, my insurance still wants a prior authorization. T_T So screw that.

My ADHD got pretty bad lately so I had protriptyline (Vivactil) added. It's an NRI TCA (secondary amine). I've taken it before with success, but the anticholinergic effects can get to me if I'm not careful.

Psych meds:

  • Caplyta (lumateperone) 42 mg 1 PO qam cc (still taking and doing well on)
  • sertraline (Zoloft) 100 mg 1 PO qam
  • Belsomra (suvorexant) 20 mg 1 PO qhs prn
  • doxepin (Sinequan) 50 mg 1 PO qhs prn
  • quazepam (Doral) 15 mg 1 PO qhs prn
  • dextroamphetamine (Dexedrine) 10 mg 2 PO tid (60 mg)
  • trifluoperazine (Stelazine) 5 mg 1 PO bid prn
  • protriptyline (Vivactil) 10 mg 1 PO tid (30 mg)

Neuro meds:

  • Trokendi XR (topiramate ER) 50 mg 1 PO qam
  • propranolol (Inderal) 20 mg 1 PO bid (40 mg) 
  • zolmitriptan ODT (Zomig-ZMIT) 2.5 mg 1 PO x1 prn, may repeat x1 in 2h prn, max: 2x/24h
Edited by mikl_pls

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13 hours ago, mikl_pls said:

I started getting Zoloft withdrawal symptoms and increased anxiety when I tried to go down on the Zoloft (as instructed), so I went all the way back up to 100 mg Zoloft and I felt fine today for the most part.

I finally got my Doral (sleeping med), and I think it's basically generic quazepam but a preferred generic brand of it since the tablets still say "DORAL" on them. It's... not as cracked up to be what I thought it would be... I'm sitting here almost 3:00 AM on here. Taking it with Belsomra 20 mg doesn't seem to touch anything. If I overdo the sleep combo thing, I sleep all day next day though, which is why I don't touch doxepin anymore... lol. Even though the Rozerem is generic now, my insurance still wants a prior authorization. T_T So screw that.

My ADHD got pretty bad lately so I had protriptyline (Vivactil) added. It's an NRI TCA (secondary amine). I've taken it before with success, but the anticholinergic effects can get to me if I'm not careful.

Psych meds:

  • Caplyta (lumateperone) 42 mg 1 PO qam cc (still taking and doing well on)
  • sertraline (Zoloft) 100 mg 1 PO qam
  • Belsomra (suvorexant) 20 mg 1 PO qhs prn
  • doxepin (Sinequan) 50 mg 1 PO qhs prn
  • quazepam (Doral) 15 mg 1 PO qhs prn
  • dextroamphetamine (Dexedrine) 10 mg 2 PO tid (60 mg)
  • trifluoperazine (Stelazine) 5 mg 1 PO bid prn
  • protriptyline (Vivactil) 10 mg 1 PO tid (30 mg)

Neuro meds:

  • Trokendi XR (topiramate ER) 50 mg 1 PO qam
  • propranolol (Inderal) 20 mg 1 PO bid (40 mg) 
  • zolmitriptan ODT (Zomig-ZMIT) 2.5 mg 1 PO x1 prn, may repeat x1 in 2h prn, max: 2x/24h

Do you think the Doral is even worth taking? or do you think it has something to do with the brand and not necessarily the med. 

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17 hours ago, mikl_pls said:

 

  • trifluoperazine (Stelazine) 5 mg 1 PO bid prn

Stelazine is great! I've been on it like 2 years ago at 5 mg also and was a very good mood stabilazer, but then pdoc decided to change it to aripiprazole and then to olanzapine, which i'm still on it cause the good results on me, and eventually forgot my Stelazine. I think i'm gonna ask it again to this new doctor and let's see what he thinks about it, maybe like a PRN too. So wish me luck hehe. Cheers bro. 

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4 hours ago, Equilibrium022x said:

Stelazine is great! I've been on it like 2 years ago at 5 mg also and was a very good mood stabilazer, but then pdoc decided to change it to aripiprazole and then to olanzapine, which i'm still on it cause the good results on me, and eventually forgot my Stelazine. I think i'm gonna ask it again to this new doctor and let's see what he thinks about it, maybe like a PRN too. So wish me luck hehe. Cheers bro. 

It really is a fantastic medicine. It holds my brain together when things are getting a bit too weird for me.

Only do so if you think it could benefit you. No need to fix what isn't broken, you know?

Best of luck to you!

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AM Meds - 
Adderall ER (60mg)
Galantamine (8mg)
Deplin (15mg)

PM Meds - 
Abilify (10mg)
Wellbutrin (300mg)
Lamictal (100mg)

Someone tell me why the fuck I am so tired all the goddamn time.  I could sleep the day away.  I have no gumption.  I have no verve or willpower.  My house is a mess.  Please send help.

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On 7/4/2020 at 7:17 AM, Bad Haiku said:

AM Meds - 
Adderall ER (60mg)
Galantamine (8mg)
Deplin (15mg)

PM Meds - 
Abilify (10mg)
Wellbutrin (300mg)
Lamictal (100mg)

Someone tell me why the fuck I am so tired all the goddamn time.  I could sleep the day away.  I have no gumption.  I have no verve or willpower.  My house is a mess.  Please send help.

You're on a rather stimulating cocktail (or what should be stimulating).

My suggestions would be:

  • Regarding your Adderall XR...
    • If your pdoc/doc approves, increasing the Adderall XR in 15-30 mg increments past the 60 mg maximum until you get more benefit.
      • This can be done by adding more Adderall XR or by adding Adderall IR tablets to supplement the Adderall XR.
      • IME, Adderall IR tablets are more stimulating anyway.
    • Try switching to Adderall IR tablets with your total dose divided into 3 doses daily (20 mg every 3x/day ~3-4 hours)
    • Try the new amphetamine salts product, Mydayis, perhaps?
      • It's brand-name, so the quality of amphetamine may be higher.
      • Max dose is 50 mg/day and it lasts 16 hours.
      • Could add Adderall IR/XR to supplement the dose as needed.
    • Try switching to Dexedrine tablets or Dexedrine Spansules (extended release capsules).
      • More potent stimulant mg-per-mg than Adderall
      • More wakefulness promotion, IME...
      • Dexedrine 60 mg = Adderall ~80 mg, or if you do the conversion by accounting for molecular weights of the two stimulants, more like ~92.715 mg
  • Regarding the Wellbutrin...
    • You could try going to 400 mg/day by doing either Wellbutrin IR 100 mg x2 2x/day (2 bid) or SR 200 mg 2x/day (bid), or doing 450 mg/day by doing 300 mg XL + 150 mg XL or 300 mg XL + 150 mg SR or 300 mg XL + 75 mg IR 2x/day (bid).
    • Instant release may act more like a stimulant and confer more stimulation, but also increases risk of seizures.
    • They make a 450 mg tablet called Forfivo XL and a bupropion hydrobromide version called Aplenzin at 522 mg (equivalent to 450 mg hydrochloride). They're both brand-name only so you may run into insurance problems with coverage.
    • When I tried Forfivo XL with just 40 mg Adderall, it made me violently nauseated... Never got sick though, just extremely nauseous. I didn't experience this with the generic XL 300 mg + SR 150 mg or even when I was on 500 mg/day of Wellbutrin by doing 300 mg XL + 100 mg IR 2x/day (bid)

Definitely keep the Deplin at 15 mg.

Galantamine I believe is a stimulating medicine. The acetylcholinesterase inhibitors, especially Aricept (donepezil), tend to actually cause sleep problems like insomnia in dementia patients and is dose dependent.

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Saw my pdoc on the 22nd of July. These are the changes she made (in bold).

  • Caplyta 42 mg 1 PO qam
  • Cymbalta 60 mg 1 PO bid (120 mg)
  • Vivactil 10 mg 1 PO tid (30 mg)
  • Doxepin 10 mg 1 PO qhs prn
  • Belsomra 20 mg 1 PO qhs prn
  • Zofran ODT 4 mg 1 PO bid prn

On the Caplyta, I told her I felt like maybe it wasn't stabilizing me enough because I've been having to patch myself up occasionally with Stelazine, and she said sometimes with brand new antipsychotics, it can take up to 9 months for them to really start working, so she wanted me to give it the full 9 months trial before we consider starting something new.

Zoloft pooped out rapidly and started causing withdrawal symptoms even while taking up to 150 mg (I was prescribed 50-75 mg down from that dose over a long period of time). Brain zaps, anxiety, impending doom/death feeling, panic attacks, dark ominous cloud hanging over my head, you name it. So I switched to the next strongest thing I had in my meds (bad patient, I know), Cymbalta, and took 60 mg + 20 mg for 80 mg, and eventually bumped it up to 120 mg just before I saw her. It helped immensely. Only problem is my manly parts don't want to work anymore. I guess it's a fair trade off.... Also sorry if TMI.

Doxepin was just too damn strong at 50 mg. It made me sleep all day the next day, so she lowered it to 10 mg at my request.

Zofran ODT is just a safety blanket since I'm an emetophobe and I've been having some nasty migraines lately where I almost got sick. She wrote it for x60 but apparently my insurance only cleared x21, because they cut up the blister packs in put them in a Ziplock baggie... lol.

She took off the prescription for Doral because it wasn't doing anything.

___________

Then today (29th of July) I saw my sleep doctor.

He kinda just claimed the prescriptions of Belsomra and doxepin, so now my pdoc has even less to prescribe me, and added temazepam (Restoril). He also replaced the Dexedrine 30 mg with Adderall 20 mg (why he lowered the dose I don't know...?). I started to get him to give me Evekeo but I told him it would need a PA because insurance won't cover it, etc., so he said "let's do Adderall first."

So from him, here is what I have:

  • Belsomra 20 mg 1 PO qhs prn
  • Doxepin 10 mg 1 PO qhs prn
  • Restoril 30 mg 1 PO qhs prn
  • Adderall 20 mg ½ PO bid (20 mg)

I do plan on telling my pdoc about all these changes, including the Adderall.

 

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