PRN anxiety med (no benzo), help?

[OliverB]

Pregabalin and trazodone are controlling diarly anxiety

Trazodone as PRN would make me sleep during the day and then disturb my sleeping patterns.

With my diarly pregabalin used as PRN would happen something similar, even a small increase causes me severe memory issues to the point I leave a book on my bed, I turn arround and I don't remember anymore where I left it. I am not functional while this and cannot they care of myself. So an extra PRN is a no no.

I need a benzo dosis higer than the maximum per dosis to get any relief, I have a high natural tolerance to them, and have tried almost all at the maximum dosage and with some like clorazepate dipotassium I didn't feel anything. The one that better works is klonopin, but I need 4-6mg during a crisis. My pdoc wants to find another alternative.

For crisis I was thinking on hydroxycine, but I don't know anything else I can use.

[mikl_pls]

 

 

 

I'm in a similar boat as you, I am extremely benzo resistant... I have to take extremely high doses of benzos just to get a barely noticeable effect. The only benzos that work for me are alprazolam (the ODT version) and oxazepam. I've tried all others except triazolam (insurance won't cover it), Doral (quazepam) (copay is too expensive and there isn't a copay coupon), midazolam (pdoc won't prescribe it), and Onfi (clobazam).

Hydroxyzine pamoate (Vistaril) was more effective than hydroxyzine hydrochloride (Atarax), but Vistaril was only minimally effective at best, and that was when I doubled or quadrupled up on my dose (50 mg). My best friend though took 25 mg of Vistaril and slept all day from it though. Go figure...

I'm just curious... In the US, pregabalin is most commonly dosed twice daily (actually I've only seen it dosed that way but I haven't been exposed to the medicine much). Rather than taking 75 mg 4x/day, do you think it would improve your daytime sedation to take 150 mg twice a day? Just throwing that out there as a what-if possibility.

As for the trazodone, an alternative would be nefazodone, which also has anti-anxiety effects (but has the big black box warning of liver damage, so many prescribers won't prescribe it, but there are other meds with similar or greater rates of liver damage/failure that don't get the same stigma attached to it for some reason). It's nowhere near as sedating as trazodone. It's taken twice daily. It should be relatively inexpensive, but in the US, for some reason, it's charged like a brand-name only medicine for all doses except the 50 mg and 250 mg tablets, which are charged like generics. Stupid...

Here are some things I recall from reading and from my experiences and some stuff I dug up from the internet:

 

 

 

• I have read that the anticonvulsants oxcarbazepine and levetiracetam can have beneficial effects on anxiety, although you have to be careful with levetiracetam because it can cause depression or dysphoric hypo/mania (anger, rage, etc.).
  • I have taken oxcarbazepine but didn't really feel anything, albeit I took it at a very low dose (150 mg/day) so it was most likely far too low to feel any benefit. One thing you have to watch out for with oxcarbazepine (mostly in high doses) is low salt levels which can cause seizures.
  • I currently take levetiracetam for essential tremor, and a neat benefit I've noticed is that it helps with my OCD (an anxiety disorder, so may help with other anxiety states in other people), but I'm also on a relatively low dose of it too (750 mg/day).
• Carbamazepine (closely related to oxcarbazepine but carries a riskier side effect profile) has been shown to improve anxiety and sleep in some people taking it; I've taken it before but a very low dose, only 200 mg at bedtime, which did produce a minor antidepressant, anti-anxiety, and mild sedative effect. One side effect of carbamazepine that really irked me that I couldn't seem to get over was that it caused everything I heard to sound one semitone flat (in other words, a middle C, C4, would sound like a B below middle C, B3).
• I've read of sodium valproate/divalproex sodium/valproic acid/whatever you want to call it helping with anxiety and panic, but it comes with some potentially serious side effects. I've never taken it and plan on never taking it.
• Topiramate is said to have benefit for anxiety, and while I experienced moderate, short-lived mood stabilization and relief from depression the first time I took it, I didn't really notice any benefits an anxiety personally.
• Zonisamide has been studied for treatment-resistant anxiety, and this is one of my mainstay mood stabilizers that I have been taking for two years now (I think). Originally I started it for its purported benefits for essential tremor and appetite suppression, which I had minor benefits for the former and no benefits for the latter (despite many people having profound appetite suppression from it), but I noticed a marked brightening in my mood that even lamotrigine never caused (don't get me wrong, lamotrigine was a life saver!). Zonisamide enabled me to lower my lamotrigine dose and eventually come off it (now I'm back on it though because of severe depression), but zonisamide improved depression, mood stability, cognition, stopped my "staring spells" (which my psychiatrist and neurologist believe may be petit mal seizures but could never catch them on an EEG), and I guess I did experience some benefit in my anxiety, though nothing spectacular.
• Gabatril is another anticonvulsant that is used for anxiety, more specifically, panic attacks I believe, and for those for whom it works, it supposedly works wonders, but it's certainly not for everybody; I've never taken this so I can't give my subjective experience of it.
• Phenobarbital and primidone can be used for anxiety too, how well they work I don't know though; I've not taken the former, but have taken the latter for essential tremor, but not for long because it caused depression and nightmares.
• Sabril (vigabatrin) has been shown in animal models to have anti-anxiety effects, but it carries some majorly risky side effects like vision loss, so its use is limited.

 

• Have you ever tried buspirone? It's a very hit or miss medication, but it is specifically indicated for anxiety (but is also used as an adjunct for antidepressants). Personally, I had a paradoxical response from it with increased anxiety and eventually anger and rage outbursts and finally a terrible dysphoric hypomanic mixed episode. I just can't tolerate buspirone. Even 5 mg/day will eventually turn me into a monster.

 

• Sedating antipsychotics are used for anxiety, most commonly olanzapine and quetiapine.
  • Personally, I had horrible effects from them, but I had great but short-lived benefits from Saphris (asenapine).
  • Latuda (lurasidone) at 40 mg was decent, but 60-80 mg seemed to be somewhat anxiolytic.
• Also, the first generation antipsychotics, which are no longer prescribed as commonly because of their side effect profile, have been very successful for me.
  • Haloperidol 0.5-1 mg as needed up to 3 times per day helped me with anxiety and agitation especially in the context of hypomania.
  • Fluphenazine 1 mg up to 3 times a day wasn't quite as helpful but still offered subtle results.
  • But the biggest help I have ever received from any medication for my anxiety was from trifluoperazine (Stelazine) (I'm a huge Stelazine fanboy!).
    • I started with 1 mg twice daily, moved up to 1 mg 3 times daily, then 2 mg 3 times daily, and each time my dose would increase, I felt more confident, was able to leave the house more (prior to starting, I was unable to leave the house for even simple errands like, say, picking up prescriptions from the pharmacy or even things I desperately wanted to do like hang out with friends), found that I was able to make decisions more quickly and confidently instead of debating for 45 minutes in the store about which flavor of ice cream to get or which notebook has the best quality paper or whether or not to get that $99 2 TB external USB 3.0 hard drive when I already have 2 at home I'm not using because it's on sale). In fact, Stelazine is one of the only antipsychotics in the US that has a specific indication for anxiety, the others being prochlorperazine (Compazine) and perphenazine (Trilafon) I believe (all of which are first-gen antipsychotics, go figure!).

 

• Beta-blockers are commonly used for the physical symptoms of anxiety, but some benefit psychologically from them too.
  • Personally, I've tried atenolol, propranolol, and am now on nadolol. I've tried them for various reasons—atenolol because of poor circulation and propranolol and nadolol both for essential tremor.
  • I must say that I felt no anxiolytic effects from neither atenolol nor propranolol (even though I got up to a decent dose of propranolol), but even on as low as 10-20 mg of nadolol, I have noticed a major improvement in certain aspects of my anxiety (an extremely embarrassing one being that it has remarkably improved my shy bladder syndrome when I thought nothing would help it). The nadolol even helps my tremor better than propranolol ever did at any dose. I started it at 20 mg but saw on my Fitbit heart rate records that my heartrate was dropping down to 40 BPM in my sleep which scared me, so I started halving them for 10 mg and still get just as much benefit.

 

I hope this is of some help, that your pdoc will consider one or more of these options to help you get some relief, and that you get relief as soon as possible. Take care and keep us updated.

[mcjimjam]

Beta blockers are an option. I sometimes take propranalol. It helps with physical symptoms like shakiness, rapid heart rate and sweating more than the mental symptoms of anxiety but I found taking 40mg all at once to help my anxiety overall.

[Iceberg]

I wish propranolol worked for me seeing as I need it regardless. I would try to avoid antipsychotics as a first line...id look at buspar first and hydroxyzine too...or maybe use them to help "boost" a lower dose of benzo (theoretically I guess). I kno people have luck with stelazine but some doc's won't go near it. Idk that id go for haldol just for anxiety but it can be helpful when anxiety is comorbid. Seroquel can work too...either PRN or added as a night dose...especially the XR if it doesn't make you sleep all day

[thunder]

I was prescribed hydroxycine (Vistaril) at one point for anxiety and as a possible sleep aid. It didn't really do shit for me. But then again, none of the antihistamine family things make me tired (I can take Benadryl for allergic reactions and then carry on with my day). One of my friends took it for nighttime anxiety with good results, but it made them sleepy, which is why they only took it at night. My current psych is okay with prescribing me a low dose of Ativan, which is the only PRN that has really worked for me, so I'm no help there. 

 

[browri]

tailing on what @mikl_pls suggested, I find that oxcarbazepine at 1200mg does a lot for my anxiety along with loxapine. However, I don't think that oxcarbazepine on its own would be enough. Combining it with an antidepressant that's good for anxiety or a low dose antipsychotic would be more effective. It definitely feels to me like it's meant to be an adjunct, not something that you take on its own. But hey you know what they say: YMMV.

There's also a trend of loxapine being prescribed PRN in 5mg and 10mg doses for racing thoughts or anxiety. With 25mg and 50mg being reserved for maintenance treatment.

[Alien Navel Cord]

On 5/7/2017 at 5:00 PM, OliverB said:

Pregabalin and trazodone are controlling diarly anxiety

Trazodone as PRN would make me sleep during the day and then disturb my sleeping patterns.

With my diarly pregabalin used as PRN would happen something similar, even a small increase causes me severe memory issues to the point I leave a book on my bed, I turn arround and I don't remember anymore where I left it. I am not functional while this and cannot they care of myself. So an extra PRN is a no no.

I need a benzo dosis higer than the maximum per dosis to get any relief, I have a high natural tolerance to them, and have tried almost all at the maximum dosage and with some like clorazepate dipotassium I didn't feel anything. The one that better works is klonopin, but I need 4-6mg during a crisis. My pdoc wants to find another alternative.

For crisis I was thinking on hydroxycine, but I don't know anything else I can use.

I'm on hydroxyzine now myself. I just started last night. I don't know how it is going to work, but I hope it helps because my anxiety has been awful lately...