Iceberg Posted July 14, 2018 Share Posted July 14, 2018 So lithium is a mainstay of my cocktail, has been for many years. Unfortunately I've never been able to shake the stomach/digestive issues. I get nausea, heartburn, and really bad IBS-D symptoms. Currently I have to take three side effect meds on a pretty regular basis (Pepcid for reflux, Imodium for the diarrhea, and zofran for the nausea when I feel like I'm going to vomit or can't eat.). I have consulted docs about this including a clean endoscopy (no colonoscopy unless things get more severe). So it's Pepcid every night, zofran a couple mornings a week, and usually a few immodium a day especially before long trips. My doc is ok with this, and while it's not ideal it seems to not be causing me any problems. The obvious answer would be to reduce lith but I'm already down at a low blood level so that might cause it's own issues. I am currently on ER, the IR was hell things were ten times worse. We are considering a second opinion with another gastro but I can't really thing of anything they could do to address all three. (they've tried PPIs before but those can have depression as a side effect). Tried probiotics, hyoscyamine, high fiber etc. the only thing that has any impact is avoiding nuts/granola/fibrous granola or protein bars. So no one seems to have a great idea so far- any ideas? Link to comment Share on other sites More sharing options...
CeremonyNewOrder Posted July 14, 2018 Share Posted July 14, 2018 (edited) nevermind you said you tried probiotics Edited July 14, 2018 by CeremonyNewOrder Link to comment Share on other sites More sharing options...
looking for answers Posted July 14, 2018 Share Posted July 14, 2018 bentyl perhaps, its like hycosamine, but sometimes with GI issues one works when the other doesnt,,,,,,,,,,,i like hycosamine better Link to comment Share on other sites More sharing options...
Iceberg Posted July 14, 2018 Author Share Posted July 14, 2018 1 hour ago, looking for answers said: bentyl perhaps, its like hycosamine, but sometimes with GI issues one works when the other doesnt,,,,,,,,,,,i like hycosamine better Have to be careful tho cuz it lowers clozaril levels Link to comment Share on other sites More sharing options...
looking for answers Posted July 14, 2018 Share Posted July 14, 2018 53 minutes ago, Iceberg said: Have to be careful tho cuz it lowers clozaril levels honestly did not know that Link to comment Share on other sites More sharing options...
Iceberg Posted July 14, 2018 Author Share Posted July 14, 2018 Yeah medscape has 3 interactions listed Link to comment Share on other sites More sharing options...
mikl_pls Posted July 16, 2018 Share Posted July 16, 2018 Actually with IBS-D symptoms, I thought you needed to try a low fiber diet, not high fiber. Have you tried changing the scheduling of your lithium dosing? Like if you take it all at once, try taking it in divided doses? (bid, tid, etc.) Or vice versa? (Not a great idea I know, but it's an idea...) There's a few meds that are used for IBS-D... cholestyramine (many brands) (yuck!) Xifaxan (rifaximin) (Good luck getting insurance to pay for this! But man, this stuff can be very powerful! You might have to get a GI doc to prescribe this though...) alosetron (Lotronex) (restricted distribution...) Viberzi (eluxadoline) amitriptyline (Elavil) nortriptyline (Pamelor) doxepin (Sinequan) desipramine (Norpramin) (possibly pretty much any TCA...) Link to comment Share on other sites More sharing options...
Iceberg Posted July 16, 2018 Author Share Posted July 16, 2018 Yeah they weren't so hot on xifaxan I forget why, and my insurance will fight me all the way on viberzi even with a PA. Right now I use immodium (a lot) and since there similar modes of action why pay the 500+ a month. Could the TCAs increase cycling? Also I already get a ton of anticholenergic side effects from clozaril Link to comment Share on other sites More sharing options...
mikl_pls Posted July 16, 2018 Share Posted July 16, 2018 2 hours ago, Iceberg said: Yeah they weren't so hot on xifaxan I forget why, and my insurance will fight me all the way on viberzi even with a PA. Right now I use immodium (a lot) and since there similar modes of action why pay the 500+ a month. Could the TCAs increase cycling? Also I already get a ton of anticholenergic side effects from clozaril Xifaxan is an antibiotic, so it has a different mode of action than Viberzi and Immodium. Not sure why they would be against it... It's taken acutely for x14 days I believe. If I were in your position, I would at least try badgering them to give that a try, couldn't hurt, ya know? It could be that you have an overgrowth of bad bacteria in your GI tract, and the Xifaxan could help offset this with the help of concurrent administration of probiotics (to help encouragement of good bacteria regrowth). That's what my dad's GI doc did for him when he was having issues with mysteriously extremely severe diarrhea after he got out of the hospital once a few years ago. Granted, his insurance absolutely refused to pay for it, so he had to get by with samples, and ultimately just wound up being prescribed doxycycline... which was kind of a joke compared to the Xifaxan. Xifaxan was the only thing that helped him, and the probiotics also definitely helped too. I see what you're saying about Viberzi having the same mechanism of action as Immodium (sort of). I imagine it would be much stronger, though. I don't know why your insurance would fight you so much about it, though! You must have Blue Cross though, I imagine... TCAs, as with any antidepressants, can, indeed, increase cycling, but I believe their use in IBS-D typically is in a much lower dose range than used for depression, and if it helps you with your digestive health and you luck out with it, I think it would be worth the risk. These medicines you're using for these GI symptoms can interfere with the absorption of your psych medicines as it is, and anything that can help you decrease the intake of said meds would be of great help, I think. The TCAs and actually also the SSRIs are used for IBS-D. The idea is that they may alter pain perception by a central modulation of visceral afferents, treat comorbid psychiatric symptoms, and alter GI transit. The different classes of antidepressants likely act by different combinations of mechanisms. Here's a link with some info about their use: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2669938/ Different doses and dosing schedules outlined in studies from link: Amitriptyline: 10 mg; 25 mg x1wk, 50 mg thereafter; 25 mg x1wk, 50 mg x1wk, 75 mg thereafter Imipramine: 25 x2wk, 50 mg thereafter Doxepin 75 mg (depending on your insurance provider, this particular dosage, for some reason, is charged as a Tier 4 brand-name drug...) Desipramine 50 mg x1wk, 100 mg x1wk, 150 mg thereafter (this is within the dose range for depression) Trimipramine 30 mg (not typically dosed this way in US) Quote Generally, management of IBS requires lower doses of TCAs compared to doses used to treat depression; reflecting the fact that that modulation of the brain-gut axis rather than treating concomitant depression is the target in IBS patients. Quote TCAs exhibit clinically and statistically significant control of IBS symptoms; however, given their abundant side effects they should be reserved for moderate to severe cases. Subjects should be started on subtherapeutic doses for depression and choice of drug should be tailored for each individual. We suggest using TCAs with the least anticholinergic effects (i.e. doxepin and desipramine) for elderly patients or constipation-predominant IBS and imipramine or amitriptyline for diarrhea-predominant IBS and patients with insomnia. Metronidazole (Flagyl), an antibiotic and antiprotozoal, is also apparently another medication used in IBS, and may be worth looking into. Some people claim it cured their IBS. Link to comment Share on other sites More sharing options...
Iceberg Posted July 16, 2018 Author Share Posted July 16, 2018 Navitus-they seem to have a vendetta against many brand names relevant to me, including Vraylar. I had blue cross previously and they were actually great. I think I'd feel uneasy about the TCAs and my doc definetly would because the bad reactions I've had to ADs have always been at the low starting dose. The fact of the matter is I need another opinion about the Xifaxan, the theory was that the IBS was mostly from lithium use and not naturally occurring. Link to comment Share on other sites More sharing options...
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