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Beth45

Sleep issues after gastric bypass surgery

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Hi,

I had gastric bypass surgery on January 8th and ever since I have had a hard time sleeping.  I can fall asleep ok but then I wake up a few hours later and my heart is pounding in my chest and I toss and turn the rest of the night.   My NP prescribed Remeron 30mgs and Ambien 10mgs (not at the same time) and they both do not work.  I have also tried melatonin with no good results.   I have to have the pills crushed, chewable or liquid because of my surgery.  I also take fluoxetine 40mgs and Klonopin 1mg.  I have MDD, anxiety disorder and PTSD.   Any advice would greatly be appreciated.   Thank you!

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I cannot remember if you've ever taken prazosin (Minipress), but it is a hallmark medicine for PTSD, and can maybe help with some of the symptoms you're having. Beta-blockers are sometimes used but aren't nearly as effective, but in your case might be something to try (usually they're taken in the morning because they suppress melatonin production at night).

The Klonopin should be helping, but it sounds like you could be having trouble either with full absorption of your medicine and subsequently not getting enough of it. Perhaps you need some of your dose(s) increased of some of your medicine(s)? Like maybe Klonopin 2 mg? Ambien has a quantity limit on it so you can't go over 10 mg, but with a prior auth, you can, but it's not generally advised for female patients to even exceed 5 mg (but your case is an exception). Remeron is more sedating in lower doses, but there again, you're an exception. 

The Prozac could be triggering some panic/overstimulation for you at that dose (even though I said you might not be absorbing your meds fully). Perhaps going down very gradually (with your pdoc's/NP's permission) in increments of 5 mg (since you have the liquid form) until you experience relief both from depression/anxiety/PTSD and the night-time arousals. Otherwise, Prozac might not be a good match for you. Have you tried Zoloft, Paxil, Lexapro, or Celexa? Just brainstorming here... Zoloft I know comes in a concentrate/liquid form, and I think Lexapro does too, but I'm not sure about the others. Paxil is generally regarded as the most calming of the SSRIs, but has the most weight gain side effects and a terrible withdrawal syndrome should you ever switch or discontinue it. Lexapro is more potent than Celexa; Celexa is a little more sedating than Lexapro.

Perhaps your NP should allow you to take the Remeron and Ambien together, that might help. I'd speak to them about that if you can.

Those are just some ideas/things that stick out to me.

Some herbal ideas might be combining melatonin (lower doses are better, but yet again, you are an exception; also try an extended release melatonin at bedtime with the instant release a couple of hours before bedtime) with lemon balm, gotu kola, ashwagandha, and/or oleamide. Some you might have to order online (like oleamide), others you can find in supplement stores, pharmacies, or stores like Walmart/Target/etc. They generally come in capsule form, so my assumption would be that you could just empty the capsule's contents and take it like that?? (Very uncertain about that, you may wish to contact your NP before consuming any herbal supplements like that. Melatonin very often comes in a sublingual tablet. The sustained-release melatonin actually come most often in tablet form, and crushing them would prevent them from being sustained-release, so maybe that's not a good idea in hind sight).

Let me know what you think, and contact your NP about your symptoms too. Keep us posted.

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Thank you Mike for your input.  I was going to take the Remeron 1/2 of a 30mg with one 3mg. Melatonin tonight to see if that will help.   The Ambien makes me sweat so I don't really care for it.  I see my NP on Thursday and I will talk to him about the prozac and see what he says. 

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1 minute ago, Beth45 said:

Thank you Mike for your input.  I was going to take the Remeron 1/2 of a 30mg with one 3mg. Melatonin tonight to see if that will help.   The Ambien makes me sweat so I don't really care for it.  I see my NP on Thursday and I will talk to him about the prozac and see what he says. 

That's interesting about the Ambien. There are several other GABAergic sedatives that you could try, but if that is the machanism of action that is causing you to sweat, perhaps you need to avoid those. Remeron is sedative mainly be means of being an extremely potent antihistamine. Another option to try or combine with it might be Belsomra, but I don't know of those tablets can be crushed or not. It works by a completely different mechanism of action than any sedative on the market thus far.

I hope you get some quality sleep, and these symptoms go away. Careful not to make too many changes at once.

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Do you think I should try 7.5 of the Remeron instead of the 15?  I am desperate for sleep and I don't know what to do. 

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15 mg probably given that your absorption would be reduced, but please contact your NP before you make any changes to your meds or decide to take any herbal supplements. Melatonin should be benign and isn't likely to interact with anything, but it can cause nightmares in some people, especially those who are susceptible, and having PTSD definitely puts you at a predisposition for very terrifying nightmares.

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2 hours ago, Beth45 said:

 I am desperate for sleep and I don't know what to do. 

Another option that I don't think has been mentioned is Trazodone......It is technically an antidepressant, but is commonly prescribed for insomnia....Perhaps you could ask your NP about it....

Edited by CrazyRedhead

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15 hours ago, mikl_pls said:

15 mg probably given that your absorption would be reduced, but please contact your NP before you make any changes to your meds or decide to take any herbal supplements. Melatonin should be benign and isn't likely to interact with anything, but it can cause nightmares in some people, especially those who are susceptible, and having PTSD definitely puts you at a predisposition for very terrifying nightmares.

So I took the 15 mg of Remeron. 1mg of klonopin, put on my headphones and put on some deep sleep music and I fell asleep around 9:30pm and didn't wake up until 5am!  I actually slept!!  I feel a bit groggy this morning and hungry but I am SO happy that I finally was able to sleep.   Thank you for your support!!  

13 hours ago, CrazyRedhead said:

Another option that I don't think has been mentioned is Trazodone......It is technically an antidepressant, but is commonly prescribed for insomnia....Perhaps you could ask your NP about it....

Hi,

They gave me trazadone in the hospital 3 years ago and it didn't help me sleep.  It gave me nightmares and my blood pressure shot up.  I appreciate your advice,  thank you!!

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2 hours ago, Beth45 said:

So I took the 15 mg of Remeron. 1mg of klonopin, put on my headphones and put on some deep sleep music and I fell asleep around 9:30pm and didn't wake up until 5am!  I actually slept!!  I feel a bit groggy this morning and hungry but I am SO happy that I finally was able to sleep.   Thank you for your support!!

I'm very happy for you! I just don't want to tell you how to take your medicine because I'm not a doctor. It's great that this worked, but be sure that next time you see your NP that you tell them what you are doing and make sure it's okay. Remeron has more antidepressant properties at 30 mg and above, but more sedative and appetite stimulant properties at 15 mg and below. Don't know about 22.5 mg (half a 45 mg pill)... it must be somewhere in between.

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On 2/17/2020 at 10:05 AM, mikl_pls said:

I'm very happy for you! I just don't want to tell you how to take your medicine because I'm not a doctor. It's great that this worked, but be sure that next time you see your NP that you tell them what you are doing and make sure it's okay. Remeron has more antidepressant properties at 30 mg and above, but more sedative and appetite stimulant properties at 15 mg and below. Don't know about 22.5 mg (half a 45 mg pill)... it must be somewhere in between.

I appreciate your input and I am going to talk to my prescriber on Thursday.  I didn't take the Remeron last night because I had a headache all day yesterday and I was hungry.  Its difficult because I can only eat certain foods and amounts because of the gastric bypass surgery and only being 6 weeks out.  I feel like I need a medication to help me sleep for a while but not one that will increase my appetite because that will defeat the purpose of my surgery.   Does the Belsomra give you the munchies?  I'm wondering what else I can try that won't make me hungry. 

Thank you.

PS:  I know you are not "telling " me how to take my medications, you are offering me your advice.  :)

Edited by Beth45
Forgot to add something

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What about an orally desintgrating pill? Would that bypass some of the absorption issues? Ambien has a sublingual version 

I’ve also had luck (recently) with alprazolam ODT 

So does remeron, In 15, 30, 45

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8 hours ago, Beth45 said:

Does the Belsomra give you the munchies?  I'm wondering what else I can try that won't make me hungry.

If anything, it would inhibit appetite, but I never experienced that. One side effect of Belsomra to be aware of especially is that it can cause sleep paralysis with hallucinations which can be pretty terrifying. I never had that (have experienced it many times before though!), but that's just me.

7 minutes ago, Iceberg said:

Ambien has a sublingual version 

Edluar and Intermezzo (Intermezzo is for middle of the night waking and comes in much smaller doses than Ambien/Edluar).

Also, Ambien has an oral mist version, Zolpimist. It tastes horrible, but I'm sure that's an abuse deterrent.

8 minutes ago, Iceberg said:

I’ve also had luck (recently) with alprazolam ODT

Yes, I will say that Niravam is the best benzo in the world. My pharmacy can't get it unfortunately for some reason. When I was still going to CVS they would have to order it every time. That and sometimes they'd just put it in a ziplock baggie as they come in blister packs. That looks totally legit... lol

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One other option would be to try restoril instead of PM klonipin. Restoril is meant for sleep, specifically sleep maintaince if your waking up too soon. That’s probably a toss up though, and idk how it’d fit in with the surgery 

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13 hours ago, Iceberg said:

What about an orally desintgrating pill? Would that bypass some of the absorption issues? Ambien has a sublingual version 

I’ve also had luck (recently) with alprazolam ODT 

So does remeron, In 15, 30, 45

I have never heard of Restoril?  Is that a benzodiazepine?  I have the disintegrating Remeron in 30mg and I take 1/2 of it but it makes me incredibly hungry!  Plus it tastes like crap!  I don't want to take it if it makes me hungry, defeats the purpose of my surgery.  

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27 minutes ago, Beth45 said:

I have never heard of Restoril?  Is that a benzodiazepine?  I have the disintegrating Remeron in 30mg and I take 1/2 of it but it makes me incredibly hungry!  Plus it tastes like crap!  I don't want to take it if it makes me hungry, defeats the purpose of my surgery.  

Yes, Restoril (temazepam) is a benzodiazepine, usually prescribed for insomnia.

Unfortunately, Remeron, especially in lower doses, can cause increase in appetite..

Edited by CrazyRedhead

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5 hours ago, Beth45 said:

I have never heard of Restoril?  Is that a benzodiazepine?  I have the disintegrating Remeron in 30mg and I take 1/2 of it but it makes me incredibly hungry!  Plus it tastes like crap!  I don't want to take it if it makes me hungry, defeats the purpose of my surgery.  

Lower doses of Remeron make you sleepier and hungrier than higher doses do. You may try taking the full 30 mg again and see how your sleep vs appetite is on that dosage. If I recall, you weren't sleeping well on that dose though.

Restoril (temazepam) is a benzo, but in the US comes in a capsule. I suppose you could empty the contents of the capsule and take it like that? That would be something your NP would have to address, possibly the bariatric doctor who performed your surgery or who is following up with you. Unfortunately, being a benzo, your NP wouldn't be able to prescribe it and would have to go to the pdoc who presides over them. It's only schedule IV and isn't renowned for abuse or anything like Xanax is (I believe mistakenly) so often.

The "sedative/hypnotic" benzos are as follows:

  • Short acting: triazolam (Halcion), oxazepam (Serax)
  • Intermediate acting: esatazolam (ProSom), lorazepam (Ativan)
  • Long-acting: quazepam (Doral), flurazepam (Dalmane)

As has been mentioned already, alprazolam ODT (Niravam), basically orally disintegrating Xanax, is extremely effective (to me far more effective than the original tablet form), and helps immensely with insomnia for me (at 2 mg, but I'm extremely benzo-resistant).

You definitely need something to help you sleep that won't increase your appetite though. Most meds that act on the H1 histamine receptor will increase appetite.

Rozerem (ramelteon) is a brand-name only med that works on melatonin receptors, but it has been debated as to whether this is any more effective than taking melatonin supplements.

Doxepin (Sinequan), in capsule form as low as 10 mg, or Silenor, in micro-dose tablet form as low as 3 mg, is a TCA that really is predominantly a very potent antihistamine. If taken in low doses (10 mg and below), it is actually more effective than higher doses, especially the micro-dose form Silenor. It is said not to increase appetite or cause weight gain at these low doses. I've taken a range of doses of the Sinequan form from 10 mg to 75 mg for insomnia, and there is definitely a dose-dependent hangover effect... Keeping the dose as low as possible while keeping effectiveness is I think crucial for this medicine to work well.

Hydroxyzine hydrochloride (Atarax) or pamoate (Vistaril) is an antihistamine with a few more mechanisms of action like 5-HT2A antagonism which is said to help with anxiety. It can be used as a sedative or anxiolytic. It may put weight on you, but if you keep the dose low (like 10 mg Atarax or 25 mg Vistaril/Atarax), it might not do that. For some people, even low doses will knock them out silly.

Doxylamine succinate (Unisom?), an OTC sleep aid which can be a little pricey, is said to be as or more sedating than some barbiturates. I've personally never had luck with it, but that's just me. It has much less side effects than diphenhydramine (Benadryl, Zzzquil, some forms of Unisom so be sure to look at the label on the back).

There appears to be a brand new medicine as of December 2019, Dayvigo (lemborexant) which my guess is a similarly acting medicine on orexin receptors as Belsomra (suvorexant) is just by its "generic" name. It will of course be brand-name only when it comes out, and likely Schedule IV just as its apparent cousin medicine Belsomra is.

Certain antipsychotics are used for insomnia, but they can have effects not only on appetite and subsequently weight, but metabolism too, inducing type 2 diabetes over time. Low-dose, instant release quetiapine (Seroquel) (25-100 mg) is said to be more sedating and cause less weight gain than higher doses of both instant- and extended-release quetiapine (Seroquel and Seroquel XR). Low-dose olanzapine (Zyprexa) (2.5-5 mg) will knock you out, but it is one of the most infamous for weight gain and diabetes (just below clozapine (Clozaril)). In my experience, my pdoc has prescribed Saphris (asenapine), and despite being heavy on blockade of H1 and 5-HT2C receptors, it never really caused any or minimal weight gain at 5 mg sublingually at night (it tastes horrible though). It worked fast and kept me asleep (sometimes for too long especially at first), but for me the sedative effect wears off very quickly if I take it every night for too long, like a week or two is for as long as I can use it at once. Otherwise it does benefit anxiety and depression; however, with me, if I take it for too long at a time (several weeks to at least a month), it starts making me feel extremely dysphoric and "weepy." It's brand-name but not for much longer as its patent is expiring, so generic asenapine will soon be available. Latuda (lurasidone), while not typically used as a sedative, has sedating properties especially in high doses (low doses can be even stimulating and cause insomnia). 60-120 mg doses ranged from moderately to extremely sedating depending on how high the dose was. It must be taken with food in the evening (350 calories is the minimum requirement). I take my Latuda at 4 PM, so I take it with a small snack before eating a smaller portioned supper. It's not a "knock you out" kind of sedation (at least below 120 mg), but rather a pleasant, relaxing, "let you sleep" type sedation. It may be worth a try if the above aren't options or don't work. It's very weight friendly and metabolically friendly, probably one of the most friendly of all atypicals. It has no affinity at all for the H1 receptor, so its sedation may be primarily through its antagonism of 5-HT2A receptors, similar to trazodone (except without the stimulating metabolite mCPP with trazodone...).

If all else fails (literally everything):

Short-acting barbiturates that were used once for insomnia have either been taken off the market, made prohibitively expensive, or pharmacies have decided to quit carrying and ordering them. The only barbiturate on the market that you can get I think is phenobarbital (Luminal) which is a long-acting barb, and isn't necessarily indicated for insomnia, but has an indication for "sedation." I think this is likely for presurgery sedation or something. But I don't see why it wouldn't be able to be used for insomnia in severe, intractable cases where nothing else has worked. It would very likely cause next-day hangover and cognitive/brain fog.

There used to be a medicine called chloral hydrate but I don't think it's manufactured anymore. There is a migraine medicine that is a combination of meds, one of which metabolizes into chloral hydrate. Whether it's enough for insomnia I don't know, but it may actually be stimulating due to the noradrenergic effects of one of the other meds in it. Meprobamate (Miltown) is another med that used to be used for anxiety and sometimes insomnia, but it is very, very rarely prescribed. Carisoprodol (Soma), a scheduled muscle relaxant that is being prohibited from being prescribed to new patients left and right due to its addictive nature and narrow therapeutic window, much like barbiturates and barbiturate-like substances, metabolizes into meprobamate, which itself acts very similarly to barbiturates. 

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@mikl_pls many states give NPs full perscriptive authority even on scheduled drugs so it may not be A problem. In some states, (psych) NPs can end up not even needing MD oversight at all, although they usually have to work up to this 

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1 hour ago, Iceberg said:

@mikl_pls many states give NPs full perscriptive authority even on scheduled drugs so it may not be A problem. In some states, (psych) NPs can end up not even needing MD oversight at all, although they usually have to work up to this 

I had no idea! Such is likely not the case in Alabama where I live though. A bunch of tight-ass bible thumpers... I can't stand living here but it's where all my family is and it's all I've known. Anyway...

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3 minutes ago, mikl_pls said:

I had no idea! Such is likely not the case in Alabama where I live though. A bunch of tight-ass bible thumpers... I can't stand living here but it's where all my family is and it's all I've known. Anyway...

 

 https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/specialty group/arc/ama-chart-np-prescriptive-authority.pdf

one is up to date I believe from the American Medical Assn. 

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However, there is a wide range in the leeway in those Dr/nP contracts. Where I live NPs having clients that are minimally supervised is quite common. I think partially that’s because they are so much more affordable. A family member goes to one and she’s been Rx alprazolam TID for months. I also have a family member who actually is a psych NP and sees people in a. College setting, and often writes for PRN Ativan. Even some inpatient places around here hire NPs as attendings. I think it’s all slowly moving that way because allowing NPs  to do their own thing (ish) both fights wait times and psychiatrist shortages and is more cost effective when no one takes insurance 

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