Counteracting Medications?

[Banana Smurf]

I feel like some medications in my cocktail counteract each other, like Klonopin and Ritalin.  I guess Ritalin is also counteracted by Latuda.  I was thinking about asking for a switch to clonidine or guanfacine to address my anxiety if he is willing.  I found them pretty calming when I was on them.  I guess I feel like I'm on too many drugs that do too many different things.  It really bothers me that I am scheduled to take a benzo rather than taking it prn and he complains at me when I don't take it 3 times a day.  

My cocktail is

Latuda 80mg          x1

Lithium ER 300mg x1

Topamax 75mg     x2

Klonopin .5mg       x3

Ritalin 10mg          x3        

 

 

[Iceberg]

6 minutes ago, Banana Smurf said:

I feel like some medications in my cocktail counteract each other, like Klonopin and Ritalin.  I guess Ritalin is also counteracted by Latuda.  I was thinking about asking for a switch to clonidine or guanfacine to address my anxiety if he is willing.  I found them pretty calming when I was on them.  I guess I feel like I'm on too many drugs that do too many different things.  It really bothers me that I am scheduled to take a benzo rather than taking it prn and he complains at me when I don't take it 3 times a day.  

My cocktail is

Latuda 80mg          x1

Lithium ER 300mg x1

Topamax 75mg     x2

Klonopin .5mg       x3

Ritalin 10mg          x3        

 

 

What Dx’s ars you treating? People do take benzo + stim, it’s maybe not ideal but also not unheard of 

[Banana Smurf]

I've been diagnosed with a lot of different things, so that I do not really not know anymore.  I haven't been told what I am being treated for now, except for gad, but I am pretty sure I am being treated for other disorders as well.  I was taking non-stimulant adhd medication for a while because of psychosis, but I am taking ritalin now because my psychotic symptoms were pretty mild and my sleep attacks during the day increased in severity to falling asleep while driving.  It has weirdly helped my hallucinations or something around that period did.  

[Iceberg]

2 minutes ago, Banana Smurf said:

I've been diagnosed with a lot of different things, so that I do not really not know anymore.  I haven't been told what I am being treated for now, except for gad, but I am pretty sure I am being treated for other disorders as well.  I was taking non-stimulant adhd medication for a while because of psychosis, but I am taking ritalin now because my psychotic symptoms were pretty mild and my sleep attacks during the day increased in severity to falling asleep while driving.  It has weirdly helped my hallucinations or something around that period did.  

Well first step might be to sit down with pdoc and figure out what issues are priority and then go from there to see which med approaches will target the right thngs 

[mikl_pls]

16 hours ago, Banana Smurf said:

my sleep attacks during the day increased in severity to falling asleep while driving.

So you have narcolepsy or a similar condition like idiopathic hypersomnia too?

[Banana Smurf]

The sleep doctor said it was probably narcolepsy but I couldn't be taken off my meds for a sleep test so the results were inconclusive except I fall asleep really fast.  He officially diagnosed me with hypersomnia nos.  

[Iceberg]

@Banana Smurf ever tried provigil or nuvigil? (Sorry in phone cant see sigs) might help the sleep attacks while being a little less ... assertive 

[Banana Smurf]

I haven't tried provigil or nuvigil, my sleep doctor put me straight onto ritalin.  I am not sure that it would help with the emotional issues that ritalin does, such as frustration tolerance and focus.

  I think that I should also ask my psychiatrist about the ritalin after resuming it because he is pretty enthusiastic about it even though it was prescribed by another doctor and the effects and side effects that are concerning me right now are mostly psychiatric.  He could probably just tell me if the flatness would go away, though.  

  I am also worried about telling my sleep doctor I lost it because I am not supposed to drive without it.  It seems kind of like my tolerance just went away and I need a starter dose again but it would probably get me into trouble to tell.  

[mikl_pls]

57 minutes ago, Banana Smurf said:

The sleep doctor said it was probably narcolepsy but I couldn't be taken off my meds for a sleep test so the results were inconclusive except I fall asleep really fast.  He officially diagnosed me with hypersomnia nos.  

I was originally diagnosed with idiopathic hypersomnia by my first sleep doc, who was really just a GP/FP who could read and interpret sleep studies. He wasn't willing to prescribe Dexedrine above 15 mg/day, but did 30 mg/day what I was on with my pdoc at the time (when she would prescribe me stimulants) and said that would be the only Dex prescription he would write like that. He wrote me a Nuvigil 200 mg prescription, but didn't follow up with the prior authorization necessary for my insurance to let me have it. So I just gave up with him.

I saw a second sleep doc who was a total dick because he literally cussed me out and scorned me for being on so many meds at once, telling me I didn't need to be on most of my meds if I have a seizure disorder, which isn't set in stone as my neurologist has me down for PNES (psychogenic non-epileptic seizures) as my diagnosis. Despite me telling him that, he still was very gruff with me about my meds, saying I didn't need to be on most of them if I have seizures. In his defense, during my sleep study (which he did a sort of less complicated EEG montage than most EEGs), he captured what he interpreted as four seizures during my sleep. He couldn't tell me whether they were focal or generalized or anything, and said I needed to get a neurologist. My first neurologist was kind of a quack and finally quit her practice to do research on pediatric epilepsy, so I was without a neurologist for a while. I found my current neurologist, and even when showing him the rather fuzzy and almost unreadable sleep study report with printouts of the EEG montage of all four seizures, he said "those aren't seizures, that looks like myoclonus," which is either another type of epileptic seizure (which the way he described it sounded like he was actually referring to myoclonic epileptic seizures) or it refers to periodic limb movement disorder which I feel strongly I don't have and was not what he was referring to. My second sleep doctor refused to prescribe stimulants at all, saying "I just prefer to stick to my sleep medicines," and prescribed me iron for an iron deficiency I didn't have which eventually I couldn't take anymore because of rather a bitter, metallic taste in my mouth constantly as well as certain personal side effects I was having from it, a tiny dose of ropinirole (a dopamine agonist) for some supposed Parkinsonism that I had which severely exacerbated my already bad impulsiveness, and Belsomra for sleep. I stopped seeing him and stopped trying to see a sleep doc until recently. He also had me down as "hypersomnia unspecified."

My third sleep doc whom I saw earlier this month wanted me to get off ALL of my psych meds and have yet another sleep study. I told him that I could do that to an extent, but getting off my psych meds at that point in time (and still now) was not an option as I have been suicidal for the past month and a half. He said there was nothing he could prescribe me. He told me the Dexedrine I was on is worsening my bipolar (it's not), causing my seizures (it's not, I still had seizures, at time more often than now, when I was off stimulants, and amphetamine has documented anticonvulsant effects that have been long lost in the medical literature as amphetamines have been lumped in with methylphenidate as being pro-convulsant), and a third thing I can't remember, and that unless I had a note written from my psychiatrist and neurologist both, he would not prescribe any stimulant to me, and if he did, he would not exceed the max dose. He listed a whole bunch of meds, some of them that I had been on or was on at the time, and one my NP tried to prescribe me, Wakix, but said "oh you can't take this because you don't have narcolepsy." Then he just ended the appointment after like 5 minutes of talking to me. They asked me to schedule a followup appointment a month out, which I did at first, but I called after I left and said "forget the appointment, he didn't do anything for me and that appointment was a waste of money." I don't know why he wanted to follow up with me, I guess he assumed that I would try to get those letters of approval... He didn't ask me to, he just said those were the only circumstances under which he would prescribe anything.

I don't know what good this post is to you but that's my experience with sleep docs... 😕 

[Banana Smurf]

I am sorry you had such a crappy experience with sleep doctors.  It sounds like you've really been through the wringer with them.  I really lucked out with mine.  He is pretty knowledgeable about non-sleep apnea disorders.  He collaborates with my psychiatrist but is nice enough to do it by phone.  He switched practices but I followed him because I was pretty nervous about going to another sleep doc because I've heard they can be pretty hit and miss especially with neuro stuff.

[mikl_pls]

54 minutes ago, Banana Smurf said:

I am sorry you had such a crappy experience with sleep doctors.  It sounds like you've really been through the wringer with them.  I really lucked out with mine.  He is pretty knowledgeable about non-sleep apnea disorders.  He collaborates with my psychiatrist but is nice enough to do it by phone.  He switched practices but I followed him because I was pretty nervous about going to another sleep doc because I've heard they can be pretty hit and miss especially with neuro stuff.

Indeed they are very hit or miss.

Neurologists are too. My mother had one who, I'm not going to get into it at all because he was such an ass to her and so mean to her when she had her TBI and concussion that I almost beat the shit out of him and strangled him to death. It still makes me violently angry to think about to this day, and I can't let go of it. The triage nurse who was in full army uniform was also very harsh. He yelled at my mom because her instructions for her Xanax said to take half to a whole tablet as needed, and he kept asking "which is it?" and my mother and I kept saying "it's both, it just depends on how much she needs," and he was visibly getting very angry and finally his whole body's muscles all flexed, his nostrils flared, and his eye brows went down as he practically yelled "WHICH ONE?!" to us, which was very alarming as I thought if we said it again he would've assaulted us. That whole office was full of bad vibes... God almighty... Dr. Mulpur in Huntsville, AL. I will never forget that name. I avoid it like the plague, but if I am ever confronted with him and he pulls that shit with me, he'll never forget why not to do that with his patients.

[notloki]

Mixing Ritalin and benzos.....they work on totally different pathways so you can't do a "so this one is an upper and this one a downer" comparison. That is too simplistic.

[mikl_pls]

Also I thought I'd mention that there is no shame in taking several psych meds. The only time the quantity becomes a concern is if the combination is either not helping or making one worse, the individual can't afford that many meds with or without insurance, and/or the presence of several drug-drug interactions that could result in toxicity.

[mikl_pls]

1 minute ago, notloki said:

Mixing Ritalin and benzos.....they work on totally different pathways so you can't do a "so this one is an upper and this one a downer" comparison. That is too simplistic.

According to my pdoc, mixing stimulants particularly in high doses and benzos particularly in high doses can be dangerous to the heart. The doses must complement each other: if one is high, the other must be low, and vice versa. I don't know how much truth that holds, but that's how she used to prescribe both agents to me when she used to prescribed stimulants and now when she used to prescribe benzos to me. I pissed her off one day by calling her out on her inconsistent rules on stimulant prescribing concerning dosage, and she jumped down my throat pulling the "I'm the doctor here" card, citing several medical non sequiturs that had nothing to do with stimulants and their dosing, and has not prescribed a stimulant to me since. I haven't asked either. Benzos are off-limits indefinitely because of my recent suicide attempts.

[notloki]

The thing is I have adult onset epilepsy which is the most common and idiopathic. Children tend to be more likely to have triggers but they also outgrow their epilepsy generally. We don't know why people have seizures (idiopathic) a few lucky have a specific trigger. They could not elicit seizure like activity during my EEG but my temporal lobe was already sending out epileptic activity, sharp spikes and slow waves ALL THE TIME. This is not the norm for adult epilepsy, Epileptic like activity is usually only seen around the seizure and between seizures it goes away. I sometimes feel like a pair of dice, the activity is there it is just when my number is up that I have a seizure. Random chance. The right AED lowers the odds. The odds are I will have at least another seizure in my life.

Edited February 20, 2020 by notloki
add facts

[Iceberg]

33 minutes ago, mikl_pls said:

According to my pdoc, mixing stimulants particularly in high doses and benzos particularly in high doses can be dangerous to the heart. The doses must complement each other: if one is high, the other must be low, and vice versa. I don't know how much truth that holds, but that's how she used to prescribe both agents to me when she used to prescribed stimulants and now when she used to prescribe benzos to me. I pissed her off one day by calling her out on her inconsistent rules on stimulant prescribing concerning dosage, and she jumped down my throat pulling the "I'm the doctor here" card, citing several medical non sequiturs that had nothing to do with stimulants and their dosing, and has not prescribed a stimulant to me since. I haven't asked either. Benzos are off-limits indefinitely because of my recent suicide attempts.

My pdoc has been fine with simultaneous high dosing, but also makes attempts to ensure that it doesn’t become a permanent measure 

[browri]

On 2/18/2020 at 10:42 PM, Banana Smurf said:

I feel like some medications in my cocktail counteract each other, like Klonopin and Ritalin.  I guess Ritalin is also counteracted by Latuda.  I was thinking about asking for a switch to clonidine or guanfacine to address my anxiety if he is willing.  I found them pretty calming when I was on them.  I guess I feel like I'm on too many drugs that do too many different things.  It really bothers me that I am scheduled to take a benzo rather than taking it prn and he complains at me when I don't take it 3 times a day.  

My cocktail is

Latuda 80mg          x1

Lithium ER 300mg x1

Topamax 75mg     x2

Klonopin .5mg       x3

Ritalin 10mg          x3        

None of your medications really directly counteract each other actually. Ritalin is a norepinephrine and dopamine reuptake inhibitor and releasing agent. Sure, taking Latuda will block dopamine receptors and "tone it down" a bit, but it isn't a direct counteraction. A direct counteraction would be like combining Mirapex (pramipexole) a dopamine receptor agonist with a dopamine receptor antagonist like Latuda.

It's important to read between the lines though with some medications. Latuda may be a dopamine antagonist, but it has an intermediate dissociation profile at the post-synaptic receptors while continuing to bind tightly to pre-synaptic receptors. This means that with Ritalin and Latuda together, you could theoretically have a net INCREASE in dopamine signaling, because pre-synaptic dopamine receptors are auto-receptors whose blockade causes dopamine release.

Klonopin may be a positive allosteric modulator of the benzodiazepine site on the GABA-A receptor, and this may generally calm or "depress" the CNS. However, an increase in GABA signaling can lead to a downstream increase in dopamine signaling. This is part of the chemical reinforcement in alcoholism.

Lithium has been shown to increase serotonin signaling in various brain pathways. When increased serotonin signaling is paired with receptor blockade such as that produced by Latuda, net signaling is increased and other neurotransmitter systems become optimized as a result. So while their actions may SEEM counterproductive, the brain is RARELY that intuitive.

[Blahblah]

@browri Related to the above: How does the combo of a Stimulant + SNRI or SSRI work together?   Can you have too much Serotonin floating around, and that can reduce Dopamine? I just wonder, because it seems since I added Effexor (to Lamictal & Ritalin) Ritalin's effect is diminishing and I'm having symptoms of low dopamine (apathy, lack of motivation, pleasure, interest)

I'm only on 75mg Effexor, so I'm thinking of lowering it, and if it doesn't help I'll need to find an antidepressant that does not cause this level of apathy & emotional numbing. They all seem to do this 😞 but if I go off a Serotogenic med, I am prone to dysphoria, sadness & crying spells (low serotonin) I can't win!!!  I am very also sensitive to side effects, so I prefer low-dose of anything....

Edited February 28, 2020 by Blahblah

[browri]

3 hours ago, Blahblah said:

@browri Related to the above: How does the combo of a Stimulant + SNRI or SSRI work together?

Well you're probably hitting desensitization. serotonin reuptake inhibitors elicit their effect via central 5HT1 receptor activation. This causes downstream dopamine release. However, in the long term, 5HT1 receptors are desensitized and downstream dopamine release is reduced. In fact it's been shown that chronic antidepressant treatment results in a reduction in baseline dopamine signaling. This might explain SSRI-induced apathy, hence adding a stimulant or bupropion to bring norepinephrine and dopamine back to pre-SSRI levels because they induce release of these catecholamines and inhibit their reuptake. SNRIs understandably seem to have less of an apathy problem than SSRIs because increases in norepinephrine signaling will indirectly result in increased dopamine signaling as well. In certain areas of the brain that lack the dopamine transporter, the brain relies upon the norepinephrine transporter to remove dopamine from the synapse, So inhibiting NET results in some DAT increases.

Remind me how high you've gone on Effexor? Also, can you confirm (based on your sig) that you haven't tried Viibryd (vilazodone)? Can you tolerate any more of the Ritalin?

Edited February 28, 2020 by browri

[Banana Smurf]

4 hours ago, browri said:

None of your medications really directly counteract each other actually. Ritalin is a norepinephrine and dopamine reuptake inhibitor and releasing agent. Sure, taking Latuda will block dopamine receptors and "tone it down" a bit, but it isn't a direct counteraction. A direct counteraction would be like combining Mirapex (pramipexole) a dopamine receptor agonist with a dopamine receptor antagonist like Latuda.

It's important to read between the lines though with some medications. Latuda may be a dopamine antagonist, but it has an intermediate dissociation profile at the post-synaptic receptors while continuing to bind tightly to pre-synaptic receptors. This means that with Ritalin and Latuda together, you could theoretically have a net INCREASE in dopamine signaling, because pre-synaptic dopamine receptors are auto-receptors whose blockade causes dopamine release.

Klonopin may be a positive allosteric modulator of the benzodiazepine site on the GABA-A receptor, and this may generally calm or "depress" the CNS. However, an increase in GABA signaling can lead to a downstream increase in dopamine signaling. This is part of the chemical reinforcement in alcoholism.

Lithium has been shown to increase serotonin signaling in various brain pathways. When increased serotonin signaling is paired with receptor blockade such as that produced by Latuda, net signaling is increased and other neurotransmitter systems become optimized as a result. So while their actions may SEEM counterproductive, the brain is RARELY that intuitive.

Wow, that is really descriptive and explains a lot of its effects.  Thanks for going into that.

[browri]

28 minutes ago, Banana Smurf said:

Wow, that is really descriptive and explains a lot of its effects.  Thanks for going into that.

No problem. Always glad to make it apparent just how confusing and counter-intuitive the brain can be sometimes.  

[Blahblah]

13 hours ago, browri said:

Well you're probably hitting desensitization. serotonin reuptake inhibitors elicit their effect via central 5HT1 receptor activation. This causes downstream dopamine release. However, in the long term, 5HT1 receptors are desensitized and downstream dopamine release is reduced. In fact it's been shown that chronic antidepressant treatment results in a reduction in baseline dopamine signaling. This might explain SSRI-induced apathy, hence adding a stimulant or bupropion to bring norepinephrine and dopamine back to pre-SSRI levels because they induce release of these catecholamines and inhibit their reuptake.

SNRIs understandably seem to have less of an apathy problem than SSRIs because increases in norepinephrine signaling will indirectly result in increased dopamine signaling as well. In certain areas of the brain that lack the dopamine transporter, the brain relies upon the norepinephrine transporter to remove dopamine from the synapse, So inhibiting NET results in some DAT increases.

Remind me how high you've gone on Effexor? Also, can you confirm (based on your sig) that you haven't tried Viibryd (vilazodone)? Can you tolerate any more of the Ritalin?

Thanks @browri this is very interesting, I've had the intuition that this was happening. I've been on Effexor 10 months. Went up to only 150mg, this side effect seemed worse. (I'm concerned about painful withdrawal if I ever need to come off Effexor or switch). I think I'd prefer being on a low dose of something else, but dunno what..?

I'm going to mention Viibryd to my pdoc, never tried. not sure if it's available in europe? Ritalin I've increased recently, I just feel hyperfocused, but nothing else.....Wellbutrin had no effect on my in the past (up to 300mg).

What are the best options, do you think (other than increasing Effexor to like 300mg?)

[browri]

3 hours ago, Blahblah said:

Thanks @browri this is very interesting, I've had the intuition that this was happening. I've been on Effexor 10 months. Went up to only 150mg, this side effect seemed worse. (I'm concerned about painful withdrawal if I ever need to come off Effexor or switch). I think I'd prefer being on a low dose of something else, but dunno what..?

I'm going to mention Viibryd to my pdoc, never tried. not sure if it's available in europe? Ritalin I've increased recently, I just feel hyperfocused, but nothing else.....Wellbutrin had no effect on my in the past (up to 300mg).

What are the best options, do you think (other than increasing Effexor to like 300mg?)

Well these would be my suggestions:

1. Try pushing Effexor to 150mg and adding Remeron (mirtazapine). This should pull out the brake lines on norepinephrine and dopamine and perhaps even serotonin to a degree. Remeron is known to be a good augmenting agent but it's also known to be particular good with Effexor. And you would have to get up to 15mg or so on the Remeron most likely, but each person is different.

2. Switch the Effexor for Viibryd (vilazodone). This kind of cuts the brake lines on serotonin a bit with the partial agonist actions at 5HT1A. I found Viibryd to be quite stimulating. And I don't recall anhedonia or anything. Only real problems were diarrhea and some insomnia. But again, each person is different.

3. Maybe swap the Ritalin for Focalin XR (dexmethylphenidate) capsules at 20mg (equivalent to 40mg methylphenidate roughly). Then it will allow you to adjust in 5mg increments up or down. Might be a bit more potent, but you were saying right now at 40mg of Ritalin you just feel hyper-focused. I felt similar on 20mg of Focalin XR. So maybe it's not worth increasing that any more.