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1 hour ago, clinic said:

13-14 hrs/day at night. And tiredness after waking up

Correct me if I'm wrong, but sedation can be a side-effect of nearly every med you're on. Perhaps it's an additive effect from all the meds? It sounds like (to me) extreme sedation or over-sleeping. Seroquel did the same thing to me. I could sleep 13-14h and I was so sedated the next day I ended up sleeping through multiple alarm clocks routinely. I ended up having to switch meds, despite trying to get up and function after 7-8h.

Abilify is known to be activating, perhaps useful as an adjunct? Wellbutrin can be activating too, but I'm not sure it's really indicated for your dx.

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On 5/17/2017 at 9:28 AM, dtac said:

Correct me if I'm wrong, but sedation can be a side-effect of nearly every med you're on. Perhaps it's an additive effect from all the meds? It sounds like (to me) extreme sedation or over-sleeping.

 

I was going to say the same thing... You are literally on one of the most synergistically sleep-inducing combinations I've ever seen.

I'm assuming that because you're on clozapine that you've tried pretty much every other antipsychotic, is that correct? I'm also assuming that because you've read Stahl's Essential Psychopharmacology, you know that aripiprazole (Abilify), ziprasidone (Geodon), Rexulti (brexpiprazole) (for most), and Vraylar (cariprazine) generally have much lower rates of sedation and for some may even be stimulating.

On 5/17/2017 at 9:28 AM, dtac said:

Abilify is known to be activating, perhaps useful as an adjunct?

 

I was going to suggest something like this too. Antipsychotic polypharmacy isn't recommended most of the time, but aripiprazole and clozapine have complimentary pharmacological profiles. Maybe you could ask your pdoc if it would be possible to gradually lower your clozapine dose while gradually adding some aripiprazole? That is of course if you can tolerate aripiprazole and you don't have a bad history with it.

Another possibility, if you haven't tried it yet, is to switch to loxapine (Loxitane). I've read many good things about it on this website and people seem to really like it. I've read it's really quite similar to clozapine but without the weight gain and metabolic side effects. I'm not sure about how it compares in regards to sedation, but perhaps it would be less sedating?

It is also possible to add a eugeroic like modafinil (Provigil) or armodafinil (Nuvigil), or, if your pdoc is comfortable with it, a stimulant (read from a source on controlling sedation in patients with psychosis. It does not that "amphetamine-type stimulants could worsen psychosis, so their use in patients with persistent sedation is controversial.")

Modafinil, 200 mg in the morning, has been reported to reduce total sleep time without adverse effects, but there was a case reported in which modafinil might have exacerbated psychosis in a patient with schizophrenia who was taking 200 mg qid (800 mg!!).

Wellbutrin can be activating too, but I'm not sure it's really indicated for your dx.

 

This is also indicated as an off-label use for managing sedation in those with psychosis. 75-100 mg instant release bupropion once in the morning or up to twice daily might help you feel more alert.

What is the valproic acid for? The reason I ask is so I might better make a recommendation for an alternative to bring up with your pdoc, but if you're attached to the valproic acid, then it's your cocktail. :) (For example, less sedating anticonvulsants might be lamotrigine (which is even stimulating for some), topiramate, oxcarbazepine, zonisamide...)

A benzo is a benzo, and part of a benzo being a benzo is that it will be sedating. So if you need the clobazam, you need it.

As far as the paroxetine goes, have you tried less sedating and even stimulating SSRIs or any of the SNRIs? Sertraline, fluoxetine, escitalopram, venlafaxine, desvenlafaxine, duloxetine?

Edited by mikl_pls
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9 hours ago, mikl_pls said:

I was going to say the same thing... You are literally on one of the most synergistically sleep-inducing combinations I've ever seen.

I'm assuming that because you're on clozapine that you've tried pretty much every other antipsychotic, is that correct? I'm also assuming that because you've read Stahl's Essential Psychopharmacology, you know that aripiprazole (Abilify), ziprasidone (Geodon), Rexulti (brexpiprazole) (for most), and Vraylar (cariprazine) generally have much lower rates of sedation and for some may even be stimulating.

I was going to suggest something like this too. Antipsychotic polypharmacy isn't recommended most of the time, but aripiprazole and clozapine have complimentary pharmacological profiles. Maybe you could ask your pdoc if it would be possible to gradually lower your clozapine dose while gradually adding some aripiprazole? That is of course if you can tolerate aripiprazole and you don't have a bad history with it.

Another possibility, if you haven't tried it yet, is to switch to loxapine (Loxitane). I've read many good things about it on this website and people seem to really like it. I've read it's really quite similar to clozapine but without the weight gain and metabolic side effects. I'm not sure about how it compares in regards to sedation, but perhaps it would be less sedating?

It is also possible to add a eugeroic like modafinil (Provigil) or armodafinil (Nuvigil), or, if your pdoc is comfortable with it, a stimulant (read from a source on controlling sedation in patients with psychosis. It does not that "amphetamine-type stimulants could worsen psychosis, so their use in patients with persistent sedation is controversial.")

Modafinil, 200 mg in the morning, has been reported to reduce total sleep time without adverse effects, but there was a case reported in which modafinil might have exacerbated psychosis in a patient with schizophrenia who was taking 200 mg qid (800 mg!!).

This is also indicated as an off-label use for managing sedation in those with psychosis. 75-100 mg instant release bupropion once in the morning or up to twice daily might help you feel more alert.

What is the valproic acid for? The reason I ask is so I might better make a recommendation for an alternative to bring up with your pdoc, but if you're attached to the valproic acid, then it's your cocktail. :) (For example, less sedating anticonvulsants might be lamotrigine (which is even stimulating for some), topiramate, oxcarbazepine, zonisamide...)

A benzo is a benzo, and part of a benzo being a benzo is that it will be sedating. So if you need the clobazam, you need it.

As far as the paroxetine goes, have you tried less sedating and even stimulating SSRIs or any of the SNRIs? Sertraline, fluoxetine, escitalopram, venlafaxine, desvenlafaxine, duloxetine?

My pdoc is slowly going to stop valproic acid. I was once on 800mg and now I'm down to 200mg. Im taking it for clozapine induced seizures. Valproic acid causes too much Word salad. Yes clozapine causes sedation, but we can't do anything about it. It's very effective for my paranoia. I'm talking about sedation caused by meds other than clozapine. Clobazam(benzo) is also very sedating but it's effective for seizures caused by clozapine. I'm going to ask my pdoc for seizure meds other than clobazam. Paroxetine is sedating but I don't know how much. We r going to increase it to 37.5mg cuz I still have anxiety. I can only tolerate prozac and paroxetine, other SSRIs worsen psychosis. I cant take more than 25mg paroxetine at one time or else I feel like crying. Only divided dose works 25mg in morning and evening. Also I can't take more than 20mg prozac for same reasons.

For energy we can add prozac low dose 10-20mg. Another med is low dose aripiprazole - 2.5-5mg cuz paroxetine/prozac will increase aripiprazole blood levels. Maybe 2.5mg aripiprazole will work but I have not tried it. I have once tried 5mg aripiprazole and It made me very energetic and my cognition became faster too. But it can make me psychotic too cuz of it's activating effects. My pdoc said don't be scared and try low dose modafinil/armodafinil. But the last time I tried those meds, it made me psychotic and I started crying.

Edited by clinic
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Getting a right cocktail which works for u takes too much time. Months and sometimes years go by trying different meds. I don't have much time now. I think i just have to accept the meds which r good enough and live with the side effects.

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5 hours ago, clinic said:

Getting a right cocktail which works for u takes too much time. Months and sometimes years go by trying different meds. I don't have much time now. I think i just have to accept the meds which r good enough and live with the side effects.

Not as a point of discouragement, but it took me about 5 years to find the right cocktail. You can see in my sig how many meds I've been through. If the side-effects are heavily affecting your quality of life, in my opinion it's worth trying out something else. I had a pdoc that (years ago) told me "well, you're about out of options, I'm not sure what else I can do to help you." He was flat out wrong, and I'm glad I switched doctors. I don't expect perfection, but I believe there is a workable balance that can be achieved with psych meds and their side effects.

If psychosis is your primary dx, there's also Seroquel IR/XR. The XR is supposed to be far less sedating, and at 400mg+ is usually effective for psychosis. 

Edited by dtac
than -> can
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On 5/19/2017 at 3:17 AM, clinic said:

My pdoc is slowly going to stop valproic acid. I was once on 800mg and now I'm down to 200mg. Im taking it for clozapine induced seizures. Valproic acid causes too much Word salad. Yes clozapine causes sedation, but we can't do anything about it. It's very effective for my paranoia. I'm talking about sedation caused by meds other than clozapine. Clobazam(benzo) is also very sedating but it's effective for seizures caused by clozapine. I'm going to ask my pdoc for seizure meds other than clobazam. Paroxetine is sedating but I don't know how much. We r going to increase it to 37.5mg cuz I still have anxiety. I can only tolerate prozac and paroxetine, other SSRIs worsen psychosis. I cant take more than 25mg paroxetine at one time or else I feel like crying. Only divided dose works 25mg in morning and evening. Also I can't take more than 20mg prozac for same reasons.

For energy we can add prozac low dose 10-20mg. Another med is low dose aripiprazole - 2.5-5mg cuz paroxetine/prozac will increase aripiprazole blood levels. Maybe 2.5mg aripiprazole will work but I have not tried it. I have once tried 5mg aripiprazole and It made me very energetic and my cognition became faster too. But it can make me psychotic too cuz of it's activating effects. My pdoc said don't be scared and try low dose modafinil/armodafinil. But the last time I tried those meds, it made me psychotic and I started crying.

Depending on what type of seizures you're having from the clozapine (absence, focal/simple, generalized, etc.) depends on which anticonvulsant to use, but one that would work well for focal seizures, I think especially in the temporal lobe, is oxcarbazepine, and it wouldn't cause much in the way of psychiatric side effects—if anything would probably help you. Carbamazepine is another good one, but it has a more serious side effect profile and is a stronger CYP inducer than oxcarbazepine. I take levetiracetam for complex-partial seizures and like it a lot, it doesn't have any interactions with my meds and doesn't have any side effects to speak of like sedation or depression (though depression is listed as a possible side effect). You may have tried lamotrigine before, but it's a good one, and is activating too, so may be good for your fatigue. Topiramate is also good, can be activating or sedating depending on the individual, but has a possibility of inducing agitation in some people. Zonisamide, one of, if not my favorite anticonvulsants, is fantastic. It's said to have a heavy side effect profile, but I have never experienced side effects from it personally.

I honestly have no idea what to say about the SSRIs. The only thing I can think of is have you ever tried nefazodone? It can help some people who don't respond favorably to first line agents like SSRIs, but may not be potent enough to help with your anxiety.

What dose of modafinil/armodafinil did you try? You could try half of a 100 mg modafinil tablet, or half to a whole 50 mg armodafinil tablet to start with to assess your tolerance, perhaps. What about a tiny dose of bupropion? Like half of a 75 mg instant release twice daily (37.5 mg + 37.5 mg)? The aripiprazole 2.5 mg idea sounds like it might work too, but if it will make you psychotic, then it's probably best not to do that. Are 2 mg tablets available where you live? If so, you could split a 2 mg tablet for 1 mg, perhaps.

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On 5/19/2017 at 5:12 AM, clinic said:

Other antipsychotics i can try is amisulpride(available in my country) and risperidone and then add aripiprazole to the mix to reduce prolactin..

Is sertindole available in your country? I think it's pretty similar to amisulpride but has less of a chance of inducing hyperprolactinemia.

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