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Should I ask my pdoc to increase Vraylar to 6 mg?


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Hey everyone.

Since my pdoc increased my Vraylar to 4.5 mg, I've been feeling a lot stabler, but I still believe I am rapid cycling, experiencing depression on a regular basis that lasts about 2-3 weeks at a time with either euthymia or mixed episodes/hypomania in between for anywhere from 4 to 7 days at a time. My pdoc said I was rapid cycling when she increased my Vraylar from 3 mg to 4.5 mg, which is why she did that. She said the increased dose would not only help the cycling but also help my depression too.

Has anyone had experience with maxing out Vraylar to 6 mg? Any mood benefits to speak of (more than that when on 4.5 mg)—mainly with depression? Did you experience any EPS like akathisia or anything? Weight gain?

In case you can't see my signature, my cocktail is as follows:

  • dextroamphetamine (Dexedrine) 10 mg 2 PO tid (60 mg)
  • pindolol (Visken) 5 mg 1 PO q AM
  • protriptyline (Vivactil) 10 mg 1 PO tid (30 mg)
  • Viibryd (vilazodone) 40 mg 1 PO q AM
  • Vraylar (cariprazine) 4.5 mg 1 PO q AM
  • oxcarbazepine (Trileptal) 600 mg 1 PO bid (1,200 mg)
  • alprazolam (Xanax) 1 mg 1 PO tid prn
  • quetiapine (Seroquel) 100 mg 1 PO qhs prn
  • trazodone (Desyrel) 100 mg 1-2 PO qhs prn (100-200 mg)
  • L-methylfolate 15 mg 1 PO q AM
  • vitamin D3 50,000 IU 1 PO q wk

Are there any other med changes/increases/additions that might help?

I would rather not take Lamictal because it causes severe truncal and facial acne and it doesn't really help that much, but I wouldn't be opposed to trying it again.

I ran out of protriptyline so I haven't been taking it (might be responsible for my recent onset of depression), but I hope my pdoc will continue to prescribe it because I think it might be helping (although I still am cycling while on it).

Thanks for reading!

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2 minutes ago, mikl_pls said:

Hey everyone.

Since my pdoc increased my Vraylar to 4.5 mg, I've been feeling a lot stabler, but I still believe I am rapid cycling, experiencing depression on a regular basis that lasts about 2-3 weeks at a time with either euthymia or mixed episodes/hypomania in between for anywhere from 4 to 7 days at a time. My pdoc said I was rapid cycling when she increased my Vraylar from 3 mg to 4.5 mg, which is why she did that. She said the increased dose would not only help the cycling but also help my depression too.

Has anyone had experience with maxing out Vraylar to 6 mg? Any mood benefits to speak of (more than that when on 4.5 mg)—mainly with depression? Did you experience any EPS like akathisia or anything? Weight gain?

In case you can't see my signature, my cocktail is as follows:

  • dextroamphetamine (Dexedrine) 10 mg 2 PO tid (60 mg)
  • pindolol (Visken) 5 mg 1 PO q AM
  • protriptyline (Vivactil) 10 mg 1 PO tid (30 mg)
  • Viibryd (vilazodone) 40 mg 1 PO q AM
  • Vraylar (cariprazine) 4.5 mg 1 PO q AM
  • oxcarbazepine (Trileptal) 600 mg 1 PO bid (1,200 mg)
  • alprazolam (Xanax) 1 mg 1 PO tid prn
  • quetiapine (Seroquel) 100 mg 1 PO qhs prn
  • trazodone (Desyrel) 100 mg 1-2 PO qhs prn (100-200 mg)
  • L-methylfolate 15 mg 1 PO q AM
  • vitamin D3 50,000 IU 1 PO q wk

Are there any other med changes/increases/additions that might help?

I would rather not take Lamictal because it causes severe truncal and facial acne and it doesn't really help that much, but I wouldn't be opposed to trying it again.

I ran out of protriptyline so I haven't been taking it (might be responsible for my recent onset of depression), but I hope my pdoc will continue to prescribe it because I think it might be helping (although I still am cycling while on it).

Thanks for reading!

1) is it possible that vivactil plus viibryd plus Dexedrine is somehow conspiring to promote cycling?

 I2) I was at Vraylar 6 for awhile w/ no bad side effects but we were using it as a temporary add on with clozaril to reduce mania without a clozaril increase 

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Just now, Iceberg said:

1) is it possible that vivactil plus viibryd plus Dexedrine is somehow conspiring to promote cycling?

 I2) I was at Vraylar 6 for awhile w/ no bad side effects but we were using it as a temporary add on with clozaril to reduce mania without a clozaril increase 

1) It's very possible, that's something I've considered too. The cycling has been going on since before the Vivactil though. I was on Norpramin before but decided to go off of it in an effort to reduce the amount of medication I'm taking. That was also when I switched to Viibryd. I haven't been taking Vivactil for about a week or so and I've been very depressed since running out of it. Dexedrine, however, to my knowledge, has never contributed to mood switched in me. If I don't take it (try to go on holidays from it), I lay in bed and sleep 15+ hours per day and get extremely depressed.

2) That's good to know. I remember the last time I was on even 4.5 mg (about three years ago), I had horrible akathisia and extreme dysphoria. That's not the case this time around for whatever reason. I've never been up to 6 mg though. I'll ask my pdoc about it and see what she says.

Thanks for your response! :)

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13 minutes ago, argh said:

Is there anything that isn't an actual AD that gives you an AD effect? Seroquel increase perhaps? I know you dislike that one, but it is indicated as an all in an AD and AP which could help with the cycling mixed episodes.

Worse case scenario, can you drop the Vivactil and bump your other ADs up? TCAs are known to have the greatest risk of switching.

Well, Lamictal helps a little, I think. I have gone on and off of it several times over the years. I had to go up to 400 mg the first time I took it though because it sort of lost its effectiveness; that was several years ago though. I was on 300 mg a few years back and it didn't really seem to do much except cause side effects. At the end of last August and beginning of September, I had a very bad hypo/manic episode after which I crashed into a very severe depression, and when my pdoc wanted to add Latuda to the Abilify I was taking at the time, I suggested Lamictal instead since I didn't want to take two AAPs together (on a daily basis). It seemed to help, but she wouldn't go past 100 mg for some reason.

Other than Vivactil, Viibryd is the only antidepressant I'm on, and I'm at the "max" dose; however, my pdoc did say some people need as much as 80 mg for it to be completely effective for them. I have no idea how I'd do that though since my insurance doesn't pay for more then 30 pills per month (quantity limit). I guess I could supplement the 40 mg with samples of 20 mg.

Dexedrine I think is the crux of my cocktail as it does the most for me, including benefiting depression (it is the most profoundly "enabling" medication for me with the least side effects), but unfortunately I'm at the "max" dose of it too, and my prescribing doctor won't consider going above 60 mg like some people are able to do. I thought about asking my doc if he would augment it with Nuvigil or something, which I've taken before with great benefits, but had to quit due to cost (didn't know about copay coupons back then... lol).

Desipramine (Norpramin) never had any switching effect on me, even when I was up to 200 mg of it, but I also don't really think it was super effective to begin with. The first time I took it, it was a miracle pill, but not so much the second time around. It worked well with Zoloft though while I was on that (and it still worked).

As for Seroquel, if I go any higher than my current dose (which I take for sleep), it makes me depressed. It actually seems to contribute to depression at little even at just 100 mg. I have been up to 300 mg, but it was the IR version, so maybe if I tried the XR version it might be better? I'll ask my pdoc about this too, but I'd prefer not to take more than one AAP on a daily basis.

Thanks for your response! :) 

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1 minute ago, argh said:

Are your seizures under control?

maybe get some bupropion ir in the mix if the are. Its SAD time right now. That might give you a temporary bump. Maybe even synergize with the vralyar

And probably less chance of cycling than the TCAs

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15 hours ago, argh said:

Are your seizures under control?

maybe get some bupropion ir in the mix if the are. Its SAD time right now. That might give you a temporary bump. Maybe even synergize with the vralyar

My seizures seem to be under control at the moment. Nevertheless, regardless of how well controlled my seizures are, any time I take bupropion, I get very severe myoclonic jerks, including hypnogogic jerks that wake me up several times per night, with an occasional tonic-clonic seizure. It could be worth revisiting. I think @notloki said that the IR form of bupropion is more susceptible to causing seizures IIRC. Also, I believe he takes bupropion and I know he has a seizure disorder. Perhaps my anticonvulsant regimen isn't controlling my seizures as well as it could be.

15 hours ago, Iceberg said:

And probably less chance of cycling than the TCAs

I have to agree. It has never caused me to switch that I know of, even when I was on as much as 500 mg/day.

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2 minutes ago, argh said:

Yeah that is true. The XL version has the least seizure risk. Through I gotta say. The IR almost feels like a different drug than the xl

That it does! I agree completely. For me, for some reason, the SR is the least effective form, no idea why...

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On 10/15/2019 at 8:06 PM, mikl_pls said:

Has anyone had experience with maxing out Vraylar to 6 mg?

I had a very atypical experience, I'm not sure any of it is generally applicable. 

My atypical experience: After months on 1.5mg, went 3 -> 4.5 -> 6 within a two week period, then went right back down in the next two week period.  I was experiencing severe restlessness as a side effect, thus the aborted flight.  I had reported significant (for me) depression which is what triggered the boost up.  I'm not sure I agree with my PDoc's choice to ramp up so fast on a drug that has an explicit warning to wait a couple weeks before judging side effects.  My depression receded, but unknown if that's the result of the trip to 6 or if it naturally receded.

I don't know whether the 1.5mg that I'm still on has an anti-depressant effect or not.  I stay on it anyway because it very effectively neuters any urges to drink.

To put it in context, my current cocktail is 1200mg Lithium, 200mg Lamictal, 1.5mg Vraylar, and 20mg BuSpar.

It may be worth noting that the PI sheet lists 3mg as the max dose for bipolar depression and 6mg as the max for bipolar mania, so the mfgr doesn't think you'll see help with the depression up there.

 

On 10/15/2019 at 8:45 PM, mikl_pls said:

Well, Lamictal helps a little, I think..... I had to go up to 400 mg the first time I took it though because it sort of lost its effectiveness; that was several years ago though. I was on 300 mg a few years back and it didn't really seem to do much except cause side effects..... I suggested Lamictal instead since I didn't want to take two AAPs together (on a daily basis). It seemed to help, but she wouldn't go past 100 mg for some reason.

I've read that Lamictal has anti-depressant effects in the 100-150 range, and that the 200-400 range may stabilize but not be anti-depressant.  So as your experience seems to agree, "more" isn't "better" with Lamictal.

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4 hours ago, Fruitful.Entropy said:

My atypical experience: After months on 1.5mg, went 3 -> 4.5 -> 6 within a two week period, then went right back down in the next two week period.  I was experiencing severe restlessness as a side effect, thus the aborted flight.  I had reported significant (for me) depression which is what triggered the boost up.  I'm not sure I agree with my PDoc's choice to ramp up so fast on a drug that has an explicit warning to wait a couple weeks before judging side effects.  My depression receded, but unknown if that's the result of the trip to 6 or if it naturally receded.

Yeah, the first time I took Vraylar (three years ago), I had a somewhat similar experience, except I was on 3 mg for several months before my pdoc decided to go up to 4.5 mg. She said it would help my depression, but I got extremely depressed immediately after starting the 4.5 mg dose and developed severe akathisia that made me want to claw my skin off. I also already had developed RLS-like symptoms from 3 mg, which got worse on 4.5 mg. I had to stop Vraylar after that.

This time around, 4.5 mg seems a lot more helpful for depression and isn't causing much in the way of EPS like akathisia and whatnot. I'm actually surprised because I have gone up on Vraylar way quicker than the first time I took it.

4 hours ago, Fruitful.Entropy said:

I don't know whether the 1.5mg that I'm still on has an anti-depressant effect or not.  I stay on it anyway because it very effectively neuters any urges to drink.

1.5 mg is supposedly the dose for bipolar depression, which can be increased up to 3 mg. That's great that it helps you with curbing alcohol cravings. I think @browri mentioned something about Vraylar doing that.

4 hours ago, Fruitful.Entropy said:

It may be worth noting that the PI sheet lists 3mg as the max dose for bipolar depression and 6mg as the max for bipolar mania, so the mfgr doesn't think you'll see help with the depression up there.

This is true. I need something to help control the cycling, and currently I believe I'm either in a mixed state or I'm ultra-rapid cycling. Most people tend to like their mania but it scares the hell out of me when I get like this.

4 hours ago, Fruitful.Entropy said:

I've read that Lamictal has anti-depressant effects in the 100-150 range, and that the 200-400 range may stabilize but not be anti-depressant.  So as your experience seems to agree, "more" isn't "better" with Lamictal.

That's interesting and definitely seems to correlate with my experience with Lamictal. When I was on 400 mg, I was actually just numb and couldn't feel anything at all--no emotions, no ups or downs (even normal ups and downs), I was just flat as hell.

I read that Lamictal can exacerbate myoclonic jerks, which I tend to have quite often, especially when sleeping and if I take bupropion, so I might want to go a different route or if I do take it, stay in the lower dose range (maybe?).

Thanks for your response! :) 

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However- there are aap type mood stabilizers that are used above typical antidepressant doses that sometimes help to manage depression ... like maybe abilify or zyprexa when combined with other meds - it’s not common but I might file it under “never say never” if nothing else is helpful ... especially with mixed features

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6 hours ago, Iceberg said:

However- there are aap type mood stabilizers that are used above typical antidepressant doses that sometimes help to manage depression ... like maybe abilify or zyprexa when combined with other meds - it’s not common but I might file it under “never say never” if nothing else is helpful ... especially with mixed features

Thanks! You are talking about doses above those indicated for depression, not supratherapeutic doses, right?

I was on as much as 30 mg Abilify before I stopped it. I believe Abilify either caused or "jumpstarted" an impulse control disorder (very bad impulse buying/spending). Someone—who, I can't remember for the life of me—suggested that it might not have entirely been the Abilify, which is what I meant by "jumpstarted," as I am off Abilify and the impulse spending came back recently after it had receded almost 100% after stopping Abilify. I made a blog post about it. I feel so bad that I can't remember so many things... I must say though that Vraylar has really helped me a lot in the realms of cognitive and social functioning. I'm still not 100% where I'd like to be, but I'd at least like to be able to recall my boyfriend's sisters' names and other biographical details like that he has told me before. He remembers so much about me and I recall so little about anything or anyone that it bums me out when I can't remember whom I've told what, or who has told me what, etc. I miss my functioning memory... lol. I've gone off topic though.

Anyway, Zyprexa is definitely something I want to avoid if possible (taking regularly anyway). I have a stockpile of it somewhere, don't know where anymore, that I am to take if I become manic/mixed, start cycling, and to attempt to help with depression. 

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20 hours ago, mikl_pls said:

1.5 mg is supposedly the dose for bipolar depression, which can be increased up to 3 mg.

Yep. For bipolar depression the starting dose is 1.5mg. It's also the recommended dose, and the max dose in bipolar depression is 3mg. However, if you look at the clinical data regarding Vraylar's treatment of bipolar depression, only a small portion of those patients who don't find complete relief at 1.5mg will see an improvement by increasing to 3mg. And while that increase actually doubles the dose, the increase in response isn't linear like you would expect it to be. Meaning where doubling the dose would make you think you get 100% more or, said another way, twice as efficacious, 3mg may only increase efficacy by like 20-40% just to throw out a random number to give perspective. Allergan and Gedeon-Richter had to do multiple bipolar depression studies because at least one of those studies actually said that 1.5mg was effective for bipolar depression but that 3mg didn't even separate from placebo. That COULD have been a clinical trial design flaw but it also legitimately could mean that in the depressive phase of bipolar disorder, you want to stay as low as you can on Vraylar and increase back to 3mg and higher for control of manic/mixed episodes and maintenance.

20 hours ago, mikl_pls said:

That's great that it helps you with curbing alcohol cravings. I think @browri mentioned something about Vraylar doing that.

They actually currently have Vraylar in post-marketing trials to see if they can add efficacy data to the prescribing information that would indicate that Vraylar can reduce cravings for substances in patients with schizophrenia and bipolar disorder who also have a comorbid substance abuse issue. The initial data for specifically alcohol and cocaine is VERY promising. Not sure about others though. Taking nicotine for example, when I was on Vraylar, I felt the need to smoke cigarettes more often, but when I did, I really didn't get much of a nicotine buzz. So it was almost like a perverted form of Chantix essentially dangling your nicotine addiction in front of you by not suppressing cravings but not letting you actually reach it by blunting the nicotine buzz. Was definitely kinda weird.

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