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Posted (edited)

I’m on:
clozapine 200
paroxetine cr 37.5
clobazam 20mg

My benzo clobazam is sedating me too much. I can’t reduce its dose either. Well if i reduce my benzo my anxiety attacks come back. 

Is there something i can add to be wakeful without getting psychotic. My last option would be to reduce the dose

Edited by clinic

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Posted (edited)
27 minutes ago, clinic said:

Is there something i can add to be wakeful without getting psychotic.

Maybe Nuvigil, or Provigil?.......

Edited by CrazyRedhead
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Provigil or Nuvigil would be ideal for this. They make you be awake without stimulating things to the degree of an amphetamine or other strong stimulant. 

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7 hours ago, notloki said:

Provigil or Nuvigil would be ideal for this. They make you be awake without stimulating things to the degree of an amphetamine or other strong stimulant. 

I have tried both of them before, they make me psychotic.

I'm going to try sertraline 25mg for now. Sertraline 50mg makes me psychotic

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5 hours ago, clinic said:

I have tried both of them before, they make me psychotic.

I'm going to try sertraline 25mg for now. Sertraline 50mg makes me psychotic

that was always sedating and calming for me. to venture into stims but what about ritalin? adderall? I love vyvanse for its stim properties, no jitters, and mood boost. 

also what about strattera? non stimulant-stimulant

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39 minutes ago, looking for answers said:

that was always sedating and calming for me. to venture into stims but what about ritalin? adderall? I love vyvanse for its stim properties, no jitters, and mood boost. 

also what about strattera? non stimulant-stimulant

I have tried straterra before. It's just an NRI, r u sure that it takes away sleepiness and make u more alert

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6 minutes ago, clinic said:

I have tried straterra before. It's just an NRI, r u sure that it takes away sleepiness and make u more alert

I am not. Others are better with meds than me. I know it’s used for adhd. I also have seen some of my patients with brain injuries be given it to promote alertness. 

Was just another idea

 

@notloki @argh @mikl_pls @browri are the med guys

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39 minutes ago, looking for answers said:

I am not. Others are better with meds than me. I know it’s used for adhd. I also have seen some of my patients with brain injuries be given it to promote alertness. 

Was just another idea

 

@notloki @argh @mikl_pls @browri are the med guys

From what i can remember when i was on strattera for a while, i used to wake up very early like 5am plus it also gave me increased anxiety

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8 hours ago, clinic said:

I have tried straterra before. It's just an NRI, r u sure that it takes away sleepiness and make u more alert

Being a norepinephrine reuptake inhibitor makes it quite clinically relevant in this case. It ramps up the adrenergic system and increases alertness and vigilance as well as the fight or flight response in general. However, with time, this becomes desensitized and your energy and focus reset to a higher baseline level.

However, some pdocs may prescribe it with caution in cases where they are working with mania or psychosis as atomoxetine works much like an antidepressant in that it inhibits a transporter to increase a given neurotransmitter. This can precipitate mania in some people just the way an antidepressant would, perhaps even more so because of the norepinephrine-mania hypothesis and the cascade effect it implies.

What I can say is that pretty much all three of your medications are sedating. Clobazam is a benzodiazepine. Paroxetine is known to be one of the more sedating SSRIs, which are only further antagonized by its anticholinergic effects. And I think clozapine speaks for itself. 

Looking at your Dx, I see that we're treating for OCD/Panic and Psychosis NOS. So this tells me that the pdoc made a good choice with the paroxetine. I'd be curious to see if fluoxetine would be able to have a similar effect at a dose of like 20-40mg. It would also be stimulating unlike the paroxetine and may help to balance the clobazam+clozapine a bit more, as those two are the biggest likely culprits of your sedation. However, you may actually need up to 60mg. Have you ever tried fluoxetine (Prozac) before?

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besides wakefulness, are there any other symptoms you are treating?

If you are willing to try and switch out SSRIs, Prozac is said to be simulating vs sedating like paxil tends to be.

wellbutrin is stimulating, but i'll admit that it gives me insomnia/early awakening. It is reported to increase anxiety or panic, however if anything it reduced my anxiety.

wellbutrin is known to have the least likelihood of a manic switch out of all the ADs. Perhaps you can start with a small 150mg xl dose and go from there?

 

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I agree with everyone here, Prozac would be more stimulating than Paxil. Paxil is extremely sedating to me. I think you would be OK trying Wellbutrin too, since you are on an anticovulsant.

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Posted (edited)

I have tried fluoxetine before, it made me gain alot of weight. Plus fluoxetine has alot of drug interactions - it will increase blood levels of clozapine which I don't want.

After my sedation is fixed, I m going to start risperidone 0.5mg for my cognitive symptoms. Risperidone fixed benzo induced cognitive problems for me before but I stopped it due to intense sedation on risperidone 1mg. Now this time i will just take 0.5mg. My paroxetine increases risperidone blood levels, hence the sedation

No pdoc gave me paroxetine because there were no other options left. I had anxiety problem and i could not tolerate any psychiatric med at all. All SSRIs, beta blockers, made me cry. Pdoc couldnt understand why I'm crying on SSRI. But after we increased my benzo to 20mg, all crying went away. Now i can take any SSRI or any other meds possible apart from stimulants.

Edited by clinic

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I like the fluoxetine (Prozac) idea. I have another idea that might help too. Sertraline is good because it works at the sigma-1 receptor as an antagonist, but nowhere near as potent as fluvoxamine (Luvox) works as an agonist at this site.

So I would venture so far as to say to try fluvoxamine. Fluvoxamine, while slightly sedating (albeit far less so than paroxetine), is a potent inhibitor of CYP1A2. Clozapine is also metabolized by CYP1A2 extensively (so much so that if one smokes, which induces CYP1A2, the dose must be increased). So I speculate that if you take a very low dose of fluvoxamine, say, 12.5-25 mg, you could possibly lower your clozapine slowly by 12.5-25 mg increments, then cross-titrate until you find a happy medium (e.g., 50 mg fluvoxamine, 100-150 mg clozapine). Fluvoxamine is also a sigma-1 receptor agonist, which has been implicated in helping anxiety and psychosis, so fluvoxamine may assist the clozapine with helping treat your psychosis, while helping OCD and panic disorder. In the US, Luvox is only indicated for OCD (instant release) and social anxiety disorder (Luvox CR). Fluvoxamine is the only SSRI required to be taken twice daily (unless the doses are small enough to take it all at night), and is the only SSRI to be dosed at night (preferrably).

As for your benzo, clobazam, it could be that it's working excessively at the GABA-A α1 subreceptor, which is responsible for sedation. You could switch to a benzo that works less on it and more on the α2 and α3 sites like alprazolam (Xanax, Xanax XR, Niravam), clonazepam (Klonopin), diazepam (Valium), etc.

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4 minutes ago, mikl_pls said:

I like the fluoxetine (Prozac) idea. I have another idea that might help too. Sertraline is good because it works at the sigma-1 receptor as an antagonist, but nowhere near as potent as fluvoxamine (Luvox) works as an agonist at this site.

So I would venture so far as to say to try fluvoxamine. Fluvoxamine, while slightly sedating (albeit far less so than paroxetine), is a potent inhibitor of CYP1A2. Clozapine is also metabolized by CYP1A2 extensively (so much so that if one smokes, which induces CYP1A2, the dose must be increased). So I speculate that if you take a very low dose of fluvoxamine, say, 12.5-25 mg, you could possibly lower your clozapine slowly by 12.5-25 mg increments, then cross-titrate until you find a happy medium (e.g., 50 mg fluvoxamine, 100-150 mg clozapine). Fluvoxamine is also a sigma-1 receptor agonist, which has been implicated in helping anxiety and psychosis, so fluvoxamine may assist the clozapine with helping treat your psychosis, while helping OCD and panic disorder. In the US, Luvox is only indicated for OCD (instant release) and social anxiety disorder (Luvox CR). Fluvoxamine is the only SSRI required to be taken twice daily (unless the doses are small enough to take it all at night), and is the only SSRI to be dosed at night (preferrably).

As for your benzo, clobazam, it could be that it's working excessively at the GABA-A α1 subreceptor, which is responsible for sedation. You could switch to a benzo that works less on it and more on the α2 and α3 sites like alprazolam (Xanax, Xanax XR, Niravam), clonazepam (Klonopin), diazepam (Valium), etc.

fluvoxamine gives me intense sedation. Plus it increases the blood levels of clozapine which i dont want. fluvoxamine does not gives me energy or fixes fatigue

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Posted (edited)
8 hours ago, clinic said:

fluvoxamine gives me intense sedation. Plus it increases the blood levels of clozapine which i dont want. fluvoxamine does not gives me energy or fixes fatigue

What about switching your benzo to alprazolam, clonazepam, or diazepam, like @mikl_pls suggested?

8 hours ago, mikl_pls said:

  As for your benzo, clobazam, it could be that it's working excessively at the GABA-A α1 subreceptor, which is responsible for sedation. You could switch to a benzo that works less on it and more on the α2 and α3 sites like alprazolam (Xanax, Xanax XR, Niravam), clonazepam (Klonopin), diazepam (Valium), etc.

 

Edited by CrazyRedhead
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Posted (edited)
22 hours ago, CrazyRedhead said:

What about switching your benzo to alprazolam, clonazepam, or diazepam, like @mikl_pls suggested?

 

Yea thats a possibility.

 

Edited by clinic

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7 minutes ago, clinic said:

Yea thats a possibility.

Great...!! ....Let us know if it works....

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11 hours ago, clinic said:

I have tried fluoxetine before, it made me gain alot of weight. Plus fluoxetine has alot of drug interactions - it will increase blood levels of clozapine which I don't want.

So you've gained LESS weight on paroxetine than you did on fluoxetine? You'd probably be a first.

That being said, your current cocktail of paroxetine/clobazam/clozapine is actually littered with interactions. Paroxetine inhibits CYP1A2 and CYP2D6 which will increase levels of clozapine. Additionally, paroxetine itself is metabolized by CYP2D6. So it inhibits not only clozapine's metabolism but its own as well. Furthermore, clobazam is known to inhibit CYP2D6, which would only have a downstream effect of increasing paroxetine levels and therefore clozapine levels even further, and by inhibiting CYP2D6, it would also directly inhibit clozapine as well. So when it comes to drug-drug interactions, trading fluoxetine for paroxetine would be trading apples for apples. Except one of your meds would be stimulating instead of all three being sedating.

That being said, the combination you are on now will interact with the vast majority of any other medication you could possibly add. So a few probing questions:

Were you on clozapine and clobazam first and then added paroxetine? Or how did your current combination transpire? If this is the case, it's possible that the sleepiness was introduced when you added the paroxetine and it dramatically changed the way the other two medications affected you. It's possible that adding the paroxetine meant you needed to actually DECREASE one of the other two meds (either clozapine, clobazam, or both) to compensate for the changes in drug metabolism.

11 hours ago, clinic said:

After my sedation is fixed, I m going to start risperidone 0.5mg for my cognitive symptoms. Risperidone fixed benzo induced cognitive problems for me before but I stopped it due to intense sedation on risperidone 1mg. Now this time i will just take 0.5mg. My paroxetine increases risperidone blood levels, hence the sedation

Did you take the risperidone at night? You are correct that paroxetine would make the risperidone persist in your system and increase plasma levels. So perhaps the 0.5mg dose is sufficient and again may allow you to come down on the clozapine which may reduce sedation.

11 hours ago, clinic said:

No pdoc gave me paroxetine because there were no other options left. I had anxiety problem and i could not tolerate any psychiatric med at all. All SSRIs, beta blockers, made me cry. Pdoc couldnt understand why I'm crying on SSRI. But after we increased my benzo to 20mg, all crying went away. Now i can take any SSRI or any other meds possible apart from stimulants.

Then perhaps what you need to do is go back and try some of those meds again, specifically the ones you can recall were the MOST tolerable as it seems like none of them were, but there was likely a degree of intolerance for each that only you would be able to determine. So the real question would be, is paroxetine your magic pill or did it just happen to be what you tried after you stabilized yourself with clobazam?

I would second @argh's suggestion and augment the paroxetine with a small dose of bupropion. However, I personally wouldn't recommend starting on the generic 150mg XL (24-hour extended release) because I find that they really aren't great quality. I would recommend starting with 100mg of the SR formulation (12-hour sustained release) in the morning and you can step it up to 100mg twice a day but I think you'll find with the paroxetine on-board that it will inhibit the metabolism of bupropion. Thus, lower doses may be more tolerable and will "go further" than they would for most people who aren't taking medications with impact on metabolism.

If you do find that you're getting tired at the end of the day, then that's when you would move to twice daily dosing with the SR formulation. However, if you wanted to switch to the 24-hour, you could try the 150mg XL at this point or you can switch to Aplenzin which is a different bupropion salt and has a better extended release mechanism in my experience that doesn't make you as jittery. Much smoother release of the drug throughout the day. The 150mg Wellbutrin XL dose would be equivalent to 174mg of Aplenzin.

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Posted (edited)
1 hour ago, browri said:

Were you on clozapine and clobazam first and then added paroxetine? Or how did your current combination transpire? If this is the case, it's possible that the sleepiness was introduced when you added the paroxetine and it dramatically changed the way the other two medications affected you. It's possible that adding the paroxetine meant you needed to actually DECREASE one of the other two meds (either clozapine, clobazam, or both) to compensate for the changes in drug metabolism.

I have clozapine induced anxiety. I was first on clozapine 200mg. All SSRIs, beta blockers made me cry but paroxetine did not. So pdoc added paroxetine. But i still had anxiety even on 37.5mg. Then we added clobazam for myoclonus jerks 5mg. But later found out it controls my anxiety as well, so we increased it to 20mg. I have taken clobazam 20mg before for months and never had this sedation problem. My sedation started suddenly few weeks ago.

fluoxetine and clozapine together were worsening my weight maybe cuz prozac increases clozapine blood levels.

1 hour ago, browri said:

Did you take the risperidone at night? You are correct that paroxetine would make the risperidone persist in your system and increase plasma levels. So perhaps the 0.5mg dose is sufficient and again may allow you to come down on the clozapine which may reduce sedation.

Yea at night, it improved my cognition alot.

1 hour ago, browri said:

 So the real question would be, is paroxetine your magic pill or did it just happen to be what you tried after you stabilized yourself with clobazam?

Nah paroxetine does nothing for anxiety. It's all clobazam. Paroxetine is good for mood though.

I have reduced my clobazam to 15mg now from 20mg. Let's see if the sedation improves. If it does not then maybe clozapine is to blame. I cant try bupropion cuz history of seizures plus it increases dopamine as well. I tried sertraline 50mg and it took away all my sleepiness but it made me paranoid, so i tried 25mg which did nothing. My sedation is intense i dont think prozac will help. Should i try prozac ?

Edited by clinic

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