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14 minutes ago, mikl_pls said:

I can't help you any further. There is a trend for you asking for help and shooting down almost every response or idea.

I agree......

8 minutes ago, clinic said:

I'm not shooting down your idea. The meds u suggested have not worked for me. I've already tried them

It would be very helpful for others to know which previous meds you have tried and failed......You can add this information in your signature.

Edited by CrazyRedhead
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5 minutes ago, clinic said:

I will wait few days. Its not even been a week on reduced clobazam 15mg. Once 1 week is complete, I will start risperidone to see how it goes. If I start crying, I'll have to increase my benzo 

Shouldn’t your doctor be deciding this stuff? It sounds like your just playing doctor on yourself. 

16 minutes ago, mikl_pls said:

 

I can't help you any further. There is a trend for you asking for help and shooting down almost every response or idea.

Agreed. 

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3 minutes ago, DammitJanet said:

Shouldn’t your doctor be deciding this stuff? It sounds like your just playing doctor on yourself. 

Agreed. 

I have discussed this with my pdoc, he has agreed to every changes. Pdoc was one the one who told me to reduce my benzo and not actually add any med for sleepiness

Edited by clinic

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3 minutes ago, CrazyRedhead said:

I agree......

Perhaps it would be helpful for others to know which previous meds you have tried and failed......You can add this information in your signature.

seconded. seems like we're shooting in the dark when it comes to possibilities.

clozaphine is known to be ultra sedating. In terms of AAPs, perhaps start on the risperdal and then reevaluate where you are and possibly see if you can reduce the clozapine at a future, tbd date. As someone outlined earlier in the thread, you are on a super sedating combination. it might be more realistic to think along the lines of peeling back/substituting vs add on.

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2 minutes ago, clinic said:

I have discussed this with my pdoc, he has agreed to every changes. Pdoc was one the one who told me to reduce my benzo and not actually add any med for sleepiness

Are you supposed to be taking the risperadol or no?

3 minutes ago, clinic said:

I have discussed this with my pdoc, he has agreed to every changes. Pdoc was one the one who told me to reduce my benzo and not actually add any med for sleepiness

But if he told you to reduce your benzo, it confuses me, the thread you posted asking about taking two benzos. 

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3 minutes ago, DammitJanet said:

Are you supposed to be taking the risperadol or no?

Yes and I used to take 0.5mg before and it worked for a while but then i increased it to 1mg. Then things started going downhill, I was sleeping all day on 1mg. Plus my other meds reacted with risperidone and increased its plasma levels. So this time I will remain on just 0.5mg, 0.5 would prolly be increased to 1-2mg in my blood

13 minutes ago, CrazyRedhead said:

It would be very helpful for others to know which previous meds you have tried and failed......You can add this information in your signature.

I should have done this before. I'm sorry. I''ve updated my sig.

Edited by clinic

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2 minutes ago, clinic said:

Yes and I used to take 0.5mg before and it worked for a while but then i increased it to 1mg. Then things started going downhill, I was sleeping all day on 1mg. Plus my other meds reacted with risperidone and increased its plasma levels. So this I will remain on just 0.5mg, 0.5 would prolly be increased to 1-2mg in my blood

You said you’ll start your risperadone again to see how it goes. Shouldn’t your doctor be instructing you when to start or stop it?

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1 minute ago, DammitJanet said:

You said you’ll start your risperadone again to see how it goes. Shouldn’t your doctor be instructing you when to start or stop it?

I have prescription which says take 0.5mg at night then increase to 1mg after 1 week which I will not increase. Plus me and my pdoc are friends since 6 years, he knows me well.

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6 minutes ago, clinic said:

I have prescription which says take 0.5mg at night then increase to 1mg after 1 week which I will not increase. Plus me and my pdoc are friends since 6 years, he knows me well.

That doesn’t mean you start and stop your meds at will. I’ve been with my pdoc for years, but she definitely makes the decision when to start/stop meds or she’ll have no way to know what causes what!

ok well, it sounds like you and your pdoc need more frequent visits or an extended appointment to figure all this out. Cause with all these threads, nothing has been resolved, and it won’t....unless your doctor is calling the shots. He needs to know  and be in charge of every change, if he’s competent. 

Edited by DammitJanet
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1 minute ago, DammitJanet said:

That doesn’t mean you start and stop your meds at will. I’ve been with my pdoc for years, but she definitely makes the decision when to start/stop meds or she’ll have no way to know what causes what!

ok well, it sounds like you and your pdoc need more frequent visits or an extended appointment to figure all this out. Cause with all these threads, nothing has been resolved, and it won’t....unless your doctor is calling the shots. He needs to know every change, if he’s competent. 

I go once a month to meet him and we talk on whatsapp too. He even knows my meds by memory

Edited by clinic

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Just now, clinic said:

I go once a month to meet him and we talk on whatsapp too. He even knows my meds

Good luck with everything. 

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Looks like a case of wait and see what happens now that you have instructions to start the risperdal. Good luck

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On 6/3/2019 at 10:50 AM, clinic said:

Vortioxetine is not available in my country.

You see increasing dopmaine even a little bit is not a choice for me. See what happened with sertraline. Sertraline which is a SSRI increases dopamine little bit, I got highly paranoid on 50mg sertraline. I can't even drink coffee, i get so paranoid. I'm extremely sensitive to increased dopamine.

If I increase clobazam again to 20mg then I can only risk increasing norepinephrine(NRIs) instead of dopamine(DRIs) for wakefulness.  I can try strattera(atomoxetine) for that. If you know better NRI, let me know.

vortioxetine isn't available in your country, then I'm inclined to think you may have access to reboxetine which on its own is kind of useless but works well for some as an adjunct to serotonergic antidepressants. It's strictly an NRI.

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1 hour ago, browri said:

vortioxetine isn't available in your country, then I'm inclined to think you may have access to reboxetine which on its own is kind of useless but works well for some as an adjunct to serotonergic antidepressants. It's strictly an NRI.

Nah, we dont have reboxetine either. We have atomoxetine. You see, even NRIs are not truely NRI, they increase dopmaine as well.

Read the red lines [1]

NSsZnJC.png[1]

[1] https://www.amazon.com/Prescribers-Guide-Stahls-Essential-Psychopharmacology/dp/1316618137

 

Edited by clinic
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On 6/3/2019 at 9:50 AM, clinic said:

Vortioxetine is not available in my country.

You see increasing dopmaine even a little bit is not a choice for me. See what happened with sertraline. Sertraline which is a SSRI increases dopamine little bit, I got highly paranoid on 50mg sertraline. I can't even drink coffee, i get so paranoid. I'm extremely sensitive to increased dopamine.

If I increase clobazam again to 20mg then I can only risk increasing norepinephrine(NRIs) instead of dopamine(DRIs) for wakefulness.  I can try strattera(atomoxetine) for that. If you know better NRI, let me know.

If increasing dopamine anywhere in your brain truly makes you paranoid or psychotic, then clozapine would be doing just that despite being an antipsychotic.

It's not like the classical antipsychotics which antagonize D2 receptors diffusely throughout the brain. It, along with other AAPs, have 5-HT2A antagonism, which induces dopamine release. The reason they believe this does not induce psychosis is because the mesolimbic dopamine pathway (responsible for positive symptoms of psychosis) is denser in D2 receptors than 5-HT2A receptors, while in the mesocortical dopamine pathway (responsible for the negative symptoms of psychosis) is denser in 5-HT2A than D2 receptors, so the 5-HT2A antagonism overtakes the D2 antagonism in this pathway and the dopamine release is allowed to stimulate the D2 receptors in this pathway selectively and preferentially.

Things get a little more complicated when you add in the fact that it's a 5-HT1A partial agonist, which, posysynaptically, causes downstream dopamine release, and it's also a very potent 5-HT2C antagonist, which cuts the brake line for norepinephrine and dopamine release.

There are many more receptors to which clozapine and other AAPs bind to, which will cause dopamine release.

Clozapine's active metabolite, N-desmethylclozapine, is actually a D2 and D3 partial agonist with pretty high intrinsic activity.

So I posit that all this debunks your theory that increasing dopamine even a little is not a choice for you. It's just a matter of where the dopamine increase is happening.

I second @browri about reboxetine, which I think I mentioned earlier. It's actually classified as an antidepressant instead of ADHD medicine like atomoxetine, probably cheaper too. But being an NRI, it's going to increase dopamine in the prefrontal cortex too. There's also desipramine, but that's a TCA. About all it does, litterally, is NRI, and not much else.

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Honestly, it sounds like you could use an adjunct antipsychotic, preferably a typical antipsychotic, that is at least until your symptoms are under control and you have a more specific diagnosis for the reason of your psychosis (psychosis isn't a diagnosis, it's a symptom).  I know we have deviated from the original topic, but you're so sensitive to having psychosis induced, it's like you need ALL D2 receptors in your brain antagonized or blocked.

Clozapine goes very well with aripiprazole, but also with typicals too, my favorite of course being trifluoperazine. Adding an adjunct may allow for your pdoc to lower your clozapine dose, and especially if you use trifluoperazine, you might feel a little more energized. I would definitely not recommend chlorpromazine or thioridazine because of sedation and QTc interval prolongation.

E.g., there are case reports of people who are clozapine-resistant or who have partial responses but can't continue with dose increases because of side effects wherein they had aripiprazole added, in one person, up to 90 mg/day, which allowed them to lower their clozapine doses and remained symptom free long enough to start a career, etc.

E.g., this is just an idea, but if you added 2 mg tid of trifluoperazine (or even 5 mg bid), you could eventually lower your clozapine dose by 12.5 mg increments until you find your new happy spot wherein your symptoms are under control and you're not as sedated or not sedated at all.

I'm aware there would be a drug interaction between clozapine and trifluoperazine, being that they both inhibit CYP1A2, but in some instances, prescribers use those interactions to their advantage. In such a case, you'd need less clozapine and less TFP, likely having less side effects. Then you might not need something to take away the sleepiness.

TFP is also good for anxiety (excellent actually), so it may allow you to reduce your paroxetine CR and clobazam doses...

Just a suggestion, or an idea, but it probably won't be to your favor.

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5 hours ago, clinic said:

Nah, we dont have reboxetine either. We have atomoxetine. You see, even NRIs are not truely NRI, they increase dopmaine as well.

Read the red lines [1]

NSsZnJC.png[1]

[1] https://www.amazon.com/Prescribers-Guide-Stahls-Essential-Psychopharmacology/dp/1316618137

 

Almost anything that increases norepinephrine alone will have the downstream effect of increasing dopamine. They're both catecholamines unlike serotonin and there's evidence that the brain actively converts norepinephrine and dopamine back and forth between each other through normal metabolic processes.

If you truly want lower dopamine activity you have to basically take super high doses of SSRIs (which after receptor desensitization actually dramatically reduces dopamine signaling) and then cap that off with a first generation typical antipsychotic like haloperidol or chlorpromazine which block dopamine receptors almost exclusively. Good luck actually being able to feel after that though. Seems to me like a one-way trip to anhedonia.

Additionally at doses of risperidone like 0.25mg and 0.5mg it is preferential to PRE-synaptic receptors which are auto-receptors, meaning if you block them you increase dopamine release. Without blocking POST-synaptic dopamine receptors you would actually have a net INCREASE in dopamine signaling. Not a decrease. And clozapine is regarded as having some of the strongest hold on the 5HT2A receptors, which as @mikl_pls said will actually INCREASE dopamine activity.

EDIT: Important to read the fourth bullet COMPLETELY. "Since dopamine is inactivated by norepinephrine reuptake in the frontal cortex..." This means that when the norepinephrine transporter reuptakes norepinephrine back into the cell, dopamine signaling is also indirectly reduced. By inhibiting norepinephrine reuptake (NRI) you actually indirectly increase dopamine signaling. This is not because atomoxetine is a dopamine reuptake inhibitor, this is because norepinephrine isn't ALWAYS norepinephrine and dopamine isn't ALWAYS dopamine.

Edited by browri
auto-cowreck fails
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On 6/3/2019 at 10:50 PM, argh said:

Looks like a case of wait and see what happens now that you have instructions to start the risperdal. Good luck

Update: Bad news. Risperidone 0.5mg + clobazam 15mg couldnt be tolerated. I took risperidone at bedtime last night and today I'm feeling like crying too much but i controlled myself. Risperidone can only be tolerated if my benzo is increased to 20mg like before but that makes me sleepy throughout the day. 

I have stopped risperidone for now. I'm not even sure if my improved memory and overall improved cognition was caused by risperidone or escitalopram cuz I took both of them at the same time before.

I'm thinking maybe we can add another benzo like clonazepam

Edited by clinic

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Update 2: I just got text from pdoc he said i can add clonazepam 0.5 to clobazam. So basically i can take 2 benzos :)Max 2mg divided dose

Edited by clinic

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forgive me for not sorting through three pages...but your initial question is about what would reduce sleepiness....did it change between the original post and now?

(it's perfectly fine if it did...I just don't see how klonopin would fix sleepiness issues)

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