OCD better after reducing clozapine

[clinic]

Hi @CrazyRedhead @Iceberg @mikl_pls @dancesintherain @Gearhead

I reduced my clozapine from 200mg to 175mg. I'm finally feeling like I'm able to control my compulsions through reasoning.

Earlier like i mentioned i washed my eyes 10 times in 1 hour, in this situation i knew my eyes were clean but i was still washing it like an idiot.

But I feel my ocd can be much better if i further reduce my clozapine to 150mg from 175mg. But on 150mg i feel like crying so i can't take it.

I'm searching for another augmentation antipsychotic which will control my positive symptoms so that i can further decrease clozapine. But i feel my options r limited

Following antipsychotics have failed:

Aripiprazole(worsening paranoia/anxiety), Blonanserin(sexual dysfunction), Flupentixol(still paranoid), olanzapine(cognitive decline), paliperidone(extreme EPS, crying spells), quetiapine(seizures), risperidone(massive panic attack/crying)

Edited March 3, 2020 by clinic

[mikl_pls]

23 hours ago, clinic said:

like an idiot.

First of all, please do not call yourself an idiot because of your mental illnesses/side effects of your medications. You are as you are, a human being, and while you have some issues to deal with, there is nothing wrong with having these issues except that they cause you suffering. You are not an idiot.

23 hours ago, clinic said:

But I feel my ocd can be much better if i further reduce my clozapine to 150mg from 175mg. But on 150mg i feel like crying so i can't take it.

I'm searching for another augmentation antipsychotic which will control my positive symptoms so that i can further decrease clozapine. But i feel my options r limited

I was just about to suggest further lowering your clozapine, but if you can't handle the lower dose, either you may need an adjunct antipsychotic, or maybe 175 mg is the best you may be able to do.

I feel so sorry for you that you are going through this. It must be excruciating.

23 hours ago, clinic said:

Following antipsychotics have failed:

Aripiprazole(worsening paranoia/anxiety), Blonanserin(sexual dysfunction), Flupentixol(still paranoid), olanzapine(cognitive decline), paliperidone(extreme EPS), quetiapine(seizures), risperidone(massive panic attack/crying)

What dose of aripiprazole did you take when you took it?

I'm not familiar with blonanserin, but it looks like it hits D2/D3 receptors pretty hard, but at the same time hits 5-HT2A pretty hard, which theoretically should counteract the sexual dysfunction induced by D2 antagonism. I don't know though, that's just theory. Clinical effects of the drug are far different from theoretical effects, especially from one individual to the other. I find it interesting that it and its metabolite have a pretty high affinity for the 5-HT6 receptor, which is known to prevent weight gain and help cognitive deficits in schizophrenia though. Just a scholarly interest I guess.

What dose of flupentixol were you on? If you were on a low dose, it would've potentiated dopamine neurotransmission via antagonism of the presynaptic dopamine D2 autoreceptors, which would explain your still being paranoid.

Olanzapine seems to go either way with people regarding cognition. I would think that the cognitive decline would be from the anticholinergic effects, but if that were the case, clozapine would do that to you even worse (however, clozapine is a muscarinic agonist as is its metabolite at a different muscarinic cholinergic site, hence the sialorrhea it induces in many people who take it).

I don't know much about paliperidone except that it's the metabolite of risperidone. Never taken either of them.

Quetiapine caused you to have seizures? That's interesting. Have you been diagnosed with a seizure disorder? You seem very prone to having seizures. Have you seen a neurologist and/or had an EEG?

 

Are the following antipsychotics available where you live?:

• Second generation (atypical)
  • Saphris (asenapine)
  • Rexulti (brexpiprazole)
  • Vraylar (cariprazine)
  • Fanapt (iloperidone)
  • Latuda (lurasidone)
  • ziprasidone (Geodon)
• First generation (Typical)
  • chlorpromazine (Thorazine)
  • fluphenazine (Prolixin)
  • haloperidol (Haldol)
  • loxapine (Loxitane)
  • molindone (Moban)
  • perphenazine (Trilafon)
  • pimozide (Orap)
  • prochlorperazine (Compazine)
  • thioridazine (Mellaril)
  • thiothixene (Navane)
  • trifluoperazine (Stelazine)

I don't know what would be good to either replace the clozapine with or add to the clozapine or what. But those are the rest of the antipsychotics I didn't see you list that are available in the US anyway (and their US brand names, which may or may not help you).

I have heard of Rexulti, Vraylar, and trifluoperazine being combined with clozapine. If trifluoperazine is used, you may need to lower your clozapine dose since trifluoperazine is metabolized by CYP1A2. I personally love trifluoperazine. To me, lower doses have a mood-brightening effect for me without going too high. It helps with anxiety a lot for me, as well as tics (I have Tourette's syndrome), and even OCD (not being able to make decisions especially). I've actually thought about seeing if I can go back on it but my pdoc hates prescribing it for some reason.

I hope you find a better solution for your clozapine-induced OCD.  Keep us posted.

[clinic]

7 hours ago, mikl_pls said:

Quetiapine caused you to have seizures? That's interesting. Have you been diagnosed with a seizure disorder? You seem very prone to having seizures. Have you seen a neurologist and/or had an EEG?

Are the following antipsychotics available where you live?:

• Second generation (atypical)
  • Saphris (asenapine)
  • Rexulti (brexpiprazole)
  • Vraylar (cariprazine)
  • Fanapt (iloperidone)
  • Latuda (lurasidone)
  • ziprasidone (Geodon)
• First generation (Typical)
  • chlorpromazine (Thorazine)
  • fluphenazine (Prolixin)
  • haloperidol (Haldol)
  • loxapine (Loxitane)
  • molindone (Moban)
  • perphenazine (Trilafon)
  • pimozide (Orap)
  • prochlorperazine (Compazine)
  • thioridazine (Mellaril)
  • thiothixene (Navane)
  • trifluoperazine (Stelazine)

Quetiapine worsened myoclonic jerks and my benzo clobazam was not able to control them. I also had myoclonic jerks on clozapine , but my benzo clobazam controls clozapine induced myoclonic jerks very well. Yes i have history of seizures. I had my first partial seizure at age 9. Took tegretol for 3 years.

Apart from the antipsychotics which i posted in first post. We have the following antipsychotics here. Could be more, tell me the antipsychotic, i will check if its available here or not

Asenapine
iloperidone
lurasidone
ziprasidone 
Amisulpride
ziprasidone 
Zotepine
Chlorpromazine
fluphenazine injection
haloperidol
loxapine(hard to find)
pimozide 
prochlorperazine(hard to find)
thioridazine 
trifluoperazine (hard to find)

Edit: I just noticed when i increased my clozapine from 150 to 175, my ocd symptoms are again worse. Ocd was better when i went down from 200 to 175mg, but when going up from 150mg to 175mg, ocd is again bad. I took 150mg for just 1 day. Maybe it will take some days to develop tolerance ? WIll increasing clozapine again to 200 for a week, then going down to 175 again solve the ocd ?

Edited March 2, 2020 by clinic

[clinic]

I can try amisulpride but im worried about high prolactin. I had to quit it last time due to high prolactin, it was 3 times higher than normal levels 53 ng/ml (2-17). And i dont want gynecomastia and osteoporosis due to high prolactin.

Edit: Or maybe try olanzapine again along with clozapine. I think cognitive decline might go away if i increase the dose.

Edited March 2, 2020 by clinic

[mikl_pls]

7 hours ago, clinic said:

Asenapine
iloperidone
lurasidone
ziprasidone 
Amisulpride
ziprasidone 
Zotepine
Chlorpromazine
fluphenazine injection
haloperidol
loxapine(hard to find)
pimozide 
prochlorperazine(hard to find)
thioridazine 
trifluoperazine (hard to find)

Zotepine is likely to induce hyperprolactinemia which you don't want, as well as EPS and weight gain. I think I read somewhere that it can cause a fatal cardiovascular side effect, don't remember specifically what. It definitely wouldn't be a good companion to clozapine.

Iloperidone I've read is one of the least effective antipsychotics, and its potent α1 adrenergic antagonism would not pair well with clozapine's potent α1 adrenergic antagonism (too much of a bad thing) if you wanted to pair the two.

I personally like asenapine. It's very calming and relaxing. I found a case study about augmentation with asenapine of two patients (who are likely much more severe than you), one of whom was on clozapine among other medicines. It was kind of an interesting read. It seemed to help them. Perhaps asenapine would be something to discuss with your pdoc about augmenting with a lower dose of clozapine? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4212489/

Lurasidone I haven't really heard much success with in people who are treatment-resistant. I would recommend either skipping this one or discussing it with your pdoc if you really want to try it (it's very weight-friendly and can be rather stimulating in low doses for depressive symptoms, but can trigger anxiety in some people in these doses, and relaxing in high doses but prone to causing EPS). It must be consumed with 350 calories in order to be properly absorbed.

Amisulpride is tried and true for you, but it raises your prolactin levels. You could probably take a low dose of a dopamine agonist like bromocriptine or cabergoline (assuming those are available in India, or other dopamine agonists that are used for that indication in India that we may not have in the US), but that runs the risk of you having more severe psychosis. I think if the dose were kept low enough though it might be forgiving for you, but please don't take my word as the word of a professional because I am certainly not. Please discuss this option with your pdoc.

Ziprasidone I have heard mostly bad results about from people on here. I personally haven't had bad results, but I think it just has to do with the fact the you have to consume 500 calories with each dose (two doses per day) and people rarely adhere to that, which lowers their absorption of ziprasidone and causes them to go manic or psychotic. However, lower doses can be so stimulating that it can actually induce mania/psychosis even when consumed with the right amount of food. That being said, it needs to be started at the target dose (higher dose for mania/psychosis, lower dose for depression, etc.)

Chlorpromazine would definitely not be a good combo with clozapine, but that's just my opinion. Two low-potency, highly sedating antipsychotics... Nah. Chlorpromazine might be a good replacement for clozapine but its efficacy is probably nowhere near as much as clozapine, and its side effects are pretty brutal.

Is the fluphenazine injection a depot (long-acting) injection? Personally, fluphenazine never did much for me...

Haloperidol is a heavy-hitter. It's kind of like a sledgehammer of the antipsychotics, kinda like olanzapine and clozapine. It's weight-neutral for the most part (but can cause weight gain in way higher doses so I've read). It could possibly be a good adjunct to clozapine at least temporarily, maybe? Haloperidol has the worst reputation for causing tardive dyskinesia, just so you know. Here's a link to a study of aripiprazole vs haloperidole in combination of clozapine. I don't really understand what it's saying in conclusion though. Sorry I can't be of help in summarizing it for you. https://www.ncbi.nlm.nih.gov/pubmed/21508849 It seems they're both similarly efficacious in reducing symptoms of schizophrenia treatment-resistant to clozapine but aripiprazole had less side effects I think? (which doesn't surprise me)

Loxapine I think would be a good substitute for clozapine actually. It's structurally related to clozapine and has similar receptor affinities. It does produce the antidepressant amoxapine as a metabolite, which also has atypical antipsychotic properties 'built in." It's primarily a norepinephrine reuptake inhibitor with little effect on serotonin and no effect on dopamine. Loxapine is sometimes considered an atypical antipsychotic rather than a typical antipsychotic because it has such a high affinity to 5-HT2A. It would be worth a try IMO if you're feeling brave. The atypical-ness is only in low doses (<25 mg), above that it becomes more like a typical (D2 > 5-HT2A) so I've read, and can raise prolactin just like any typical antipsychotic can. It could possibly be a good adjunct to clozapine in a low dose and allow you to lower your clozapine dose. This would definitely be one I would discuss with your pdoc even though it's hard to find. It'd be well worth the search IMO.

Pimozide is a dangerous medicine and used for last-resort situations kinda like clozapine. It is very prone to causing heart problems and sudden cardiac death. I would stay away from it if you can.

Prochlorperazine isn't all that effective IMO. I took it for nausea and then found out it could be used for anxiety, so asked for a higher dose, and found no benefit for anxiety. I have also taken it for acute psychotic breaks and found no relief from it. I don't have much good to say about it, but if you wanted to try it, be my guest, lol.

Thioridazine is another dangerous one as far as cardiovascular symptoms. My pdoc has many patients who are still on it back from the olden days who absolutely love it and refuse to get on a newer agent she says, so it must be good, but it does have a lot of dangerous side effects and serious drug-drug interactions. It's somewhat similar to chlorpromazine I think at least in potency mg-per-mg, but differs vastly in clinical effects. It supposedly has far less of a chance of inducing dystonic episodes. Other than that, I don't know much else about it. I think it is also a treatment-resistant schizophrenia drug like clozapine. Definitely would have to be a replacement for clozapine if you took it.

Trifluoperazine I cannot say enough good things about. I won't preach about it, but I will just say it's wonderful for anxiety in particular. It's admittedly probably not the absolute best of all the antipsychotics for psychosis, but it'll knock it out pretty quickly if it's not too terribly bad. Trifluoperazine is commonly prescribed (to my understanding) with clozapine. Like I said, you'd need to lower the dose of clozapine to take trifluoperazine with it as it is metabolized by CYP1A2. It's another one that would be well worth the search to get IMO. @Simba Cub I believe is on this combination and can tell you more about it.

These are my two cents worth. I would bring the list of antipsychotics you made with you to your pdoc appointment and ask your pdoc "what can we augment to clozapine or replace clozapine with out of this list?" or something to that effect. Because you definitely need relief. Be sure to be using artificial tears to keep your eyes moisturized after all that washing.

[mikl_pls]

7 hours ago, clinic said:

I can try amisulpride but im worried about high prolactin. I had to quit it last time due to high prolactin, it was 3 times higher than normal levels 53 ng/ml (2-17). And i dont want gynecomastia and osteoporosis due to high prolactin.

See my comment above about combining amisuplride and clozapine with a dopamine agonist.

7 hours ago, clinic said:

Edit: Or maybe try olanzapine again along with clozapine. I think cognitive decline might go away if i increase the dose.

This is a formula for diabetes. You would definitely need to get on metformin if you're not already on it if you got on this combo.

Wishing you all the best!

[Iceberg]

12 hours ago, clinic said:

I can try amisulpride but im worried about high prolactin. I had to quit it last time due to high prolactin, it was 3 times higher than normal levels 53 ng/ml (2-17). And i dont want gynecomastia and osteoporosis due to high prolactin.

Edit: Or maybe try olanzapine again along with clozapine. I think cognitive decline might go away if i increase the dose.

Yeah but the improvement in cognition might very well be masked by severe sedation 

[clinic]

I just noticed when i increased my clozapine from 150 to 175, my ocd symptoms are again worse. Ocd was better when i went down from 200 to 175mg, but when going up from 150mg to 175mg, ocd is again bad. I took 150mg for just 1 day. Maybe it will take some days to develop tolerance ? WIll increasing clozapine again to 200 for a week, then going down to 175 again solve the ocd ?

[clinic]

I wish i could tolerate low dose risperidone. But it gives me massive panic attack and crying so loud. 

It only works if i raise my benzo to 20mg but that gives me massive sleepiness and sleeping all day. I can only tolerate my benzo(clobazam) max 10mg.

There has to be something which can control my positive symptoms without high adverse effects.

[mikl_pls]

3 hours ago, clinic said:

I just noticed when i increased my clozapine from 150 to 175, my ocd symptoms are again worse. Ocd was better when i went down from 200 to 175mg, but when going up from 150mg to 175mg, ocd is again bad. I took 150mg for just 1 day. Maybe it will take some days to develop tolerance ? WIll increasing clozapine again to 200 for a week, then going down to 175 again solve the ocd ?

This should probably be something discussed with your pdoc.

41 minutes ago, clinic said:

I wish i could tolerate low dose risperidone. But it gives me massive panic attack and crying so loud. 

It only works if i raise my benzo to 20mg but that gives me massive sleepiness and sleeping all day. I can only tolerate my benzo(clobazam) max 10mg.

There has to be something which can control my positive symptoms without high adverse effects.

What about trifluoperazine + clozapine? Or asenapine + clozapine?

[clinic]

Edit: Sorry had to edit this post .Was thinking about paliperidone. But I just checked my online diary it says that i also cried on paliperidone. So i cant take it

Edited March 3, 2020 by clinic

[clinic]

I always look at this chart when im looking for antipsychotic options

[Iceberg]

Low dose add on of an old-time one? Prolixin? Stelazine (as suggested above) ? Perphenazine? I know you thought you tried that, but I know it was a bit of a muddy attempt

[mikl_pls]

9 hours ago, clinic said:

I always look at this chart when im looking for antipsychotic options

You're obsessing with your treatment options to the point where it's interfering with your own treatment itself. For instance, you're obsessed with this chart. You view it as the end all be all reference of efficacy of antipsychotics. These are an average of statistics. Individual clinical outcomes vary widely from individual to individual. I understand it's difficult, I have the same tendencies which is why I feel I can call you out on this, but please quit looking at this chart and open your mind to more treatment options. You are asking the same questions repeatedly albeit worded slightly differently every time, you get suggestions (oftentimes the same suggestions), and then you either turn the suggestions down or you just don't even respond to or acknowledge many of the suggestions. Like, you have yet to even so much as acknowledge any of my responses that I have put a lot of effort into. I'm not looking for admiration or praise or anything, but I admit it's really frustrating to put so much effort into something in hopes that my contribution will help someone else only to be ignored and overlooked, like my contribution was nothing to them. It's almost like no one is telling you what you want to hear or something. We can only put so much creativity and thought into our suggestions before we are repeating ourselves with the same things over and over. We are all trying our best to think outside the box for you and think of unconventional treatment options to bring up to your pdoc. Please try to open your mind to more treatment options you normally wouldn't consider, because as it is now, you are going to have to work with your pdoc to likely try rather unique treatment regimens, as you are clearly a very complicated patient to treat with unusual symptoms and side effects to medications.

If it's a matter of not understanding something, please don't hesitate to ask for clarification. We will be happy to do our best to clarify what we said in a more easily understandable fashion. There's no shame in that whatsoever. We're all human, and we all learn from each other. We build each other up (ideally).

As for trifluoperazine being hard to find, I have checked Indian pharmacy websites and found it readily available. I don't know how local pharmacies work in India, but I imagine if you could get it online with a prescription, then you could get it from your local pharmacy.

Best wishes! Please keep us updated and posted. And please give some of our suggestions some consideration and give us some feedback, rather than making your thread a monologue with yourself.

[MiaB]

20 hours ago, mikl_pls said:

This should probably be something discussed with your pdoc.

 

ALL of this should be discussed with your pdoc, clinic.  How much of what you're reporting here is just you messing around with your meds on your own?  Mikl is correct when he says that you don't always seem to take on board or acknowledge any responses or suggestions you receive, and that it gets repetitive.  But to me the bottom line is, talk to your doctor. I'm very concerned that you do not seem to be doing this.  CrazyBoards is not and should not be a substitute for professional care.

Edited March 4, 2020 by MiaB

[clinic]

ok, sorry guys.

[mikl_pls]

5 hours ago, clinic said:

ok, sorry guys.

I would love to hear how you're doing and what your pdoc decides to do. Please keep us updated on your condition and what med changes your pdoc decides to do.  We care a lot about you, @clinic! ❤️ 

[Simba Cub]

On 3/2/2020 at 6:59 PM, mikl_pls said:

Zotepine is likely to induce hyperprolactinemia which you don't want, as well as EPS and weight gain. I think I read somewhere that it can cause a fatal cardiovascular side effect, don't remember specifically what. It definitely wouldn't be a good companion to clozapine.

Iloperidone I've read is one of the least effective antipsychotics, and its potent α1 adrenergic antagonism would not pair well with clozapine's potent α1 adrenergic antagonism (too much of a bad thing) if you wanted to pair the two.

I personally like asenapine. It's very calming and relaxing. I found a case study about augmentation with asenapine of two patients (who are likely much more severe than you), one of whom was on clozapine among other medicines. It was kind of an interesting read. It seemed to help them. Perhaps asenapine would be something to discuss with your pdoc about augmenting with a lower dose of clozapine? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4212489/

Lurasidone I haven't really heard much success with in people who are treatment-resistant. I would recommend either skipping this one or discussing it with your pdoc if you really want to try it (it's very weight-friendly and can be rather stimulating in low doses for depressive symptoms, but can trigger anxiety in some people in these doses, and relaxing in high doses but prone to causing EPS). It must be consumed with 350 calories in order to be properly absorbed.

Amisulpride is tried and true for you, but it raises your prolactin levels. You could probably take a low dose of a dopamine agonist like bromocriptine or cabergoline (assuming those are available in India, or other dopamine agonists that are used for that indication in India that we may not have in the US), but that runs the risk of you having more severe psychosis. I think if the dose were kept low enough though it might be forgiving for you, but please don't take my word as the word of a professional because I am certainly not. Please discuss this option with your pdoc.

Ziprasidone I have heard mostly bad results about from people on here. I personally haven't had bad results, but I think it just has to do with the fact the you have to consume 500 calories with each dose (two doses per day) and people rarely adhere to that, which lowers their absorption of ziprasidone and causes them to go manic or psychotic. However, lower doses can be so stimulating that it can actually induce mania/psychosis even when consumed with the right amount of food. That being said, it needs to be started at the target dose (higher dose for mania/psychosis, lower dose for depression, etc.)

Chlorpromazine would definitely not be a good combo with clozapine, but that's just my opinion. Two low-potency, highly sedating antipsychotics... Nah. Chlorpromazine might be a good replacement for clozapine but its efficacy is probably nowhere near as much as clozapine, and its side effects are pretty brutal.

Is the fluphenazine injection a depot (long-acting) injection? Personally, fluphenazine never did much for me...

Haloperidol is a heavy-hitter. It's kind of like a sledgehammer of the antipsychotics, kinda like olanzapine and clozapine. It's weight-neutral for the most part (but can cause weight gain in way higher doses so I've read). It could possibly be a good adjunct to clozapine at least temporarily, maybe? Haloperidol has the worst reputation for causing tardive dyskinesia, just so you know. Here's a link to a study of aripiprazole vs haloperidole in combination of clozapine. I don't really understand what it's saying in conclusion though. Sorry I can't be of help in summarizing it for you. https://www.ncbi.nlm.nih.gov/pubmed/21508849 It seems they're both similarly efficacious in reducing symptoms of schizophrenia treatment-resistant to clozapine but aripiprazole had less side effects I think? (which doesn't surprise me)

Loxapine I think would be a good substitute for clozapine actually. It's structurally related to clozapine and has similar receptor affinities. It does produce the antidepressant amoxapine as a metabolite, which also has atypical antipsychotic properties 'built in." It's primarily a norepinephrine reuptake inhibitor with little effect on serotonin and no effect on dopamine. Loxapine is sometimes considered an atypical antipsychotic rather than a typical antipsychotic because it has such a high affinity to 5-HT2A. It would be worth a try IMO if you're feeling brave. The atypical-ness is only in low doses (<25 mg), above that it becomes more like a typical (D2 > 5-HT2A) so I've read, and can raise prolactin just like any typical antipsychotic can. It could possibly be a good adjunct to clozapine in a low dose and allow you to lower your clozapine dose. This would definitely be one I would discuss with your pdoc even though it's hard to find. It'd be well worth the search IMO.

Pimozide is a dangerous medicine and used for last-resort situations kinda like clozapine. It is very prone to causing heart problems and sudden cardiac death. I would stay away from it if you can.

Prochlorperazine isn't all that effective IMO. I took it for nausea and then found out it could be used for anxiety, so asked for a higher dose, and found no benefit for anxiety. I have also taken it for acute psychotic breaks and found no relief from it. I don't have much good to say about it, but if you wanted to try it, be my guest, lol.

Thioridazine is another dangerous one as far as cardiovascular symptoms. My pdoc has many patients who are still on it back from the olden days who absolutely love it and refuse to get on a newer agent she says, so it must be good, but it does have a lot of dangerous side effects and serious drug-drug interactions. It's somewhat similar to chlorpromazine I think at least in potency mg-per-mg, but differs vastly in clinical effects. It supposedly has far less of a chance of inducing dystonic episodes. Other than that, I don't know much else about it. I think it is also a treatment-resistant schizophrenia drug like clozapine. Definitely would have to be a replacement for clozapine if you took it.

Trifluoperazine I cannot say enough good things about. I won't preach about it, but I will just say it's wonderful for anxiety in particular. It's admittedly probably not the absolute best of all the antipsychotics for psychosis, but it'll knock it out pretty quickly if it's not too terribly bad. Trifluoperazine is commonly prescribed (to my understanding) with clozapine. Like I said, you'd need to lower the dose of clozapine to take trifluoperazine with it as it is metabolized by CYP1A2. It's another one that would be well worth the search to get IMO. @Simba Cub I believe is on this combination and can tell you more about it.

These are my two cents worth. I would bring the list of antipsychotics you made with you to your pdoc appointment and ask your pdoc "what can we augment to clozapine or replace clozapine with out of this list?" or something to that effect. Because you definitely need relief. Be sure to be using artificial tears to keep your eyes moisturized after all that washing.

I am on Clozapine and Trifluoperazine and by and large it has worked... with one major problem. The Trifluoperazine has potentiated the concentration of Clozapine in my blood stream to THREE TIMES the toxic dose. At the height of the side effects, people around me thought I was having a stroke! I have lowered the Clozapine to see if I can cope with the reduction and am considering either upping the Trifluoperazine to offset the Clozapie or introducing Amisulperide to balance things out.

It is worth noting that there is VERY LITTLE research into the interactions of Clozapine and Trifluoperazine.

Edited March 4, 2020 by Simba Cub

[mikl_pls]

1 hour ago, Simba Cub said:

I am on Clozapine and Trifluoperazine and by and large it has worked... with one major problem. The Trifluoperazine has potentiated the concentration of Clozapine in my blood stream to THREE TIMES the toxic dose. At the height of the side effects, people around me thought I was having a stroke! I have lowered the Clozapine to see if I can cope with the reduction and am considering either upping the Trifluoperazine to offset the Clozapie or introducing Amisulperide to balance things out.

It is worth noting that there is VERY LITTLE research into the interactions of Clozapine and Trifluoperazine.

Ooh, I didn't know that about your combination, @Simba Cub... Sorry to hear about that! I remember you were on a combination before that was increasing your clozapine levels (or seem to remember anyway) to toxic levels, and that the switch to trifluoperazine was an attempt to mitigate that issue. (Correct me if I'm wrong, I may be getting mixed up with someone else... 😕)

Definitely duly noted, and @clinic, definitely take note of this, please.

[Simba Cub]

27 minutes ago, mikl_pls said:

Ooh, I didn't know that about your combination, @Simba Cub... Sorry to hear about that! I remember you were on a combination before that was increasing your clozapine levels (or seem to remember anyway) to toxic levels, and that the switch to trifluoperazine was an attempt to mitigate that issue. (Correct me if I'm wrong, I may be getting mixed up with someone else... 😕)

Definitely duly noted, and @clinic, definitely take note of this, please.

@mikl_pls, thank you for your kind words! As I said, I am down to 400mg Clozapine from 450mg starting two days ago and so far no biggie. Will report back later on!

[clinic]

On 3/3/2020 at 12:29 AM, mikl_pls said:

Be sure to be using artificial tears to keep your eyes moisturized after all that washing.

Does too much artifical tears cause blurry vision ?

Met with another pdoc. He agrees and says i have clozapine induced ocd. He said i have tried most of the popular meds and said I should give CBT more time cuz I had only 3 sessions. He told me to keep myself busy. I told him my compulsions are very extreme and trying to reason it out is not working.

On the med side, we discussed and decided we should try amisulpride 50mg again and slowly decrease clozapine.

Edited March 7, 2020 by clinic

[mikl_pls]

1 hour ago, clinic said:

Does too much artifical tears cause blurry vision ?

It may temporarily right after applying them, but as you blink the excess fluid out of your eyes and your eyes adjust to it being there, it should normalize and your eyes should feel very refreshed and "moisturized," especially if you're very prone to having dry eyes like I am. I wear contact lenses too, so my eyes dry out very badly several times a day, so I have to use special eye drops for contact lenses, then while my contacts are out at night, I use artificial tears to help restore moisture that was lost during the day while wearing the contacts. I'm not as diligent about doing it as I should be, so my contacts aren't as comfortable as they could be to wear and I get headaches.

If you're getting blurry vision still, it could be a medication side effect, but I don't know why, because you haven't really changed much of your meds. You've reduced your clozapine, which should reduce blurry vision.

1 hour ago, clinic said:

Met with another pdoc. He agrees and says i have clozapine induced ocd. He said i have tried most of the popular meds and said I should give CBT more time cuz I had only 3 sessions. He told me to keep myself busy. I told him my compulsions are very extreme and trying to reason it out is not working.

CBT for you could definitely not hurt, but it definitely shouldn't be the only treatment. You need to do something different for your psychosis other than clozapine in my opinion. If it were me in your shoes, I would either ask to lower the clozapine more and add a second agent I haven't tried before, or replace the clozapine with another agent I haven't tried before. There are still plenty that you haven't tried yet, some hard to find as you said but I think may be worth seeking out (loxapine and trifluoperazine).

Loxapine is very similar to clozapine in its structure and binding profile. That doesn't necessarily mean that it will also produce OCD-like symptoms though. It also produces the tetracyclic antidepressant amoxapine as an active metabolite which also has antipsychotic properties. In low doses (≤ 25 mg) it has "atypical" properties (5-HT2A ≥ D2), but above that, it starts behaving more like a typical antipsychotic with D2 > 5-HT2A and can cause hypereprolactinemia and whatnot (emphasis on can, not necessarily that it will).

Trifluoperazine is my favorite antipsychotic. It's also a typical antipsychotic, but it has very strong anti-anxiety effects even in low doses, and has (for me anyway) very strong mood-brightening effects which has been documented in medical literature. Before atypicals came out, it was used in patients for whom weight and sedation was a concern because it can often be stimulating (mostly in lower doses, as for most in the higher doses it can be a tad sedating). It's about half as potent as haloperidol mg-per-mg, but that doesn't speak for its clinical efficacy. For me, trifluoperazine is better than haloperidol because it doesn't hid me over the head like a sledge hammer, doesn't blunt my emotions, and relieves psychosis in pretty small doses relatively quickly. You may be different though and may need higher doses than me (I'm currently taking 5 mg twice daily as needed, but was on 6 mg/day in divided doses taken regularly at one point).

1 hour ago, clinic said:

On the med side, we discussed and decided we should try amisulpride 50mg again and slowly decrease clozapine.

Amisulpride, while it seems to be effective for you, has the dangerous side effect of raising your prolactin. Unless some measure is taken to prevent the increase in prolactin (like the adding of very low-dose aripiprazole along with the amisulpride when it is at full dose), then I personally would ask for an alternative solution.

Are other benzamide antipsychotics available to you like sulpiride (don't know brand names)? It can also raise prolactin too, pretty profoundly even I believe, but it may react differently with your individual body chemistry. Amisulpride is just especially bad for raising prolactin (not unlike risperidone but probably worse), and I think is still even worse than sulpiride. 

[Iceberg]

8 hours ago, mikl_pls said:

It may temporarily right after applying them, but as you blink the excess fluid out of your eyes and your eyes adjust to it being there, it should normalize and your eyes should feel very refreshed and "moisturized," especially if you're very prone to having dry eyes like I am. I wear contact lenses too, so my eyes dry out very badly several times a day, so I have to use special eye drops for contact lenses, then while my contacts are out at night, I use artificial tears to help restore moisture that was lost during the day while wearing the contacts. I'm not as diligent about doing it as I should be, so my contacts aren't as comfortable as they could be to wear and I get headaches.

If you're getting blurry vision still, it could be a medication side effect, but I don't know why, because you haven't really changed much of your meds. You've reduced your clozapine, which should reduce blurry vision.

CBT for you could definitely not hurt, but it definitely shouldn't be the only treatment. You need to do something different for your psychosis other than clozapine in my opinion. If it were me in your shoes, I would either ask to lower the clozapine more and add a second agent I haven't tried before, or replace the clozapine with another agent I haven't tried before. There are still plenty that you haven't tried yet, some hard to find as you said but I think may be worth seeking out (loxapine and trifluoperazine).

Loxapine is very similar to clozapine in its structure and binding profile. That doesn't necessarily mean that it will also produce OCD-like symptoms though. It also produces the tetracyclic antidepressant amoxapine as an active metabolite which also has antipsychotic properties. In low doses (≤ 25 mg) it has "atypical" properties (5-HT2A ≥ D2), but above that, it starts behaving more like a typical antipsychotic with D2 > 5-HT2A and can cause hypereprolactinemia and whatnot (emphasis on can, not necessarily that it will).

Trifluoperazine is my favorite antipsychotic. It's also a typical antipsychotic, but it has very strong anti-anxiety effects even in low doses, and has (for me anyway) very strong mood-brightening effects which has been documented in medical literature. Before atypicals came out, it was used in patients for whom weight and sedation was a concern because it can often be stimulating (mostly in lower doses, as for most in the higher doses it can be a tad sedating). It's about half as potent as haloperidol mg-per-mg, but that doesn't speak for its clinical efficacy. For me, trifluoperazine is better than haloperidol because it doesn't hid me over the head like a sledge hammer, doesn't blunt my emotions, and relieves psychosis in pretty small doses relatively quickly. You may be different though and may need higher doses than me (I'm currently taking 5 mg twice daily as needed, but was on 6 mg/day in divided doses taken regularly at one point).

Amisulpride, while it seems to be effective for you, has the dangerous side effect of raising your prolactin. Unless some measure is taken to prevent the increase in prolactin (like the adding of very low-dose aripiprazole along with the amisulpride when it is at full dose), then I personally would ask for an alternative solution.

Are other benzamide antipsychotics available to you like sulpiride (don't know brand names)? It can also raise prolactin too, pretty profoundly even I believe, but it may react differently with your individual body chemistry. Amisulpride is just especially bad for raising prolactin (not unlike risperidone but probably worse), and I think is still even worse than sulpiride. 

Although if several tries of the “normal” stuff hasn’t worked for psychosis but clozapine has, I would be very careful trying to totally phase it out (not that it can’t be done) considering it is considered the most effective med for psychosis. 

[clinic]

On 3/7/2020 at 10:43 PM, mikl_pls said:

It may temporarily right after applying them, but as you blink the excess fluid out of your eyes and your eyes adjust to it being there, it should normalize and your eyes should feel very refreshed and "moisturized," especially if you're very prone to having dry eyes like I am. I wear contact lenses too, so my eyes dry out very badly several times a day, so I have to use special eye drops for contact lenses, then while my contacts are out at night, I use artificial tears to help restore moisture that was lost during the day while wearing the contacts. I'm not as diligent about doing it as I should be, so my contacts aren't as comfortable as they could be to wear and I get headaches.

Sometimes due to ocd i put artificial tears with preservatives 4-5 times in a day. Can that damage eyes ?

[mikl_pls]

49 minutes ago, clinic said:

Sometimes due to ocd i put artificial tears with preservatives 4-5 times in a day. Can that damage eyes ?

Probably not? I was told to put eye drops in my eyes anywhere from 3 to 5 times a day as needed if I recall correctly. If you have an eye doctor, I'd ask him or her. If you don't have one, I might see one just in case since you've been washing your eyes so much, you may have done some very light damage to the corneas of your eyes (nothing irreversible though I'm sure). They may also be able to recommend a good brand of eye drops for you for your special needs. I would recommend some, but I'm sure the brands in he US are not the same as what's available in India. I'm sorry I can't be of much else help. Just something to lubricate your eyes.

As long as the eye drops don't contain an antihistamine in them or "anti-reddening" agent in them, you should be good. You would know if it has this in it if they burn or sting when you put them in. If they just feel like saline or tears being dropped in your eyes, they should be fine.

Edited March 9, 2020 by mikl_pls

[clinic]

14 hours ago, mikl_pls said:

Probably not? I was told to put eye drops in my eyes anywhere from 3 to 5 times a day as needed if I recall correctly. If you have an eye doctor, I'd ask him or her. If you don't have one, I might see one just in case since you've been washing your eyes so much, you may have done some very light damage to the corneas of your eyes (nothing irreversible though I'm sure). They may also be able to recommend a good brand of eye drops for you for your special needs. I would recommend some, but I'm sure the brands in he US are not the same as what's available in India. I'm sorry I can't be of much else help. Just something to lubricate your eyes.

As long as the eye drops don't contain an antihistamine in them or "anti-reddening" agent in them, you should be good. You would know if it has this in it if they burn or sting when you put them in. If they just feel like saline or tears being dropped in your eyes, they should be fine.

ok, what if u put 3 times the drops at once without gap ?

My drops r called "refresh tears". It has following ingredients

Carboxymethylcellulose Sodium (0.5%)
Purified water
stabilized oxychloro complex
Boric acid; 
calcium chloride
magnesium chloride; 
sodium borate
sodium chloride

 

[clinic]

Update: Hi guys, so i took amisulpride 50-100mg(50mg for 4 days and then 100mg for 3 days) for 1 week. And within a week prolactin shot up to 45ng/ml (2-17).

Last year when i tried the same med for 1 week(50mg for 4 days and then 100mg for 3 days), it shot up to 53 ng/ml (2-17)

So it fluctuates in 50s.

I'm stopping amisulpride for now. I can't accept its long term side effects.

Any suggestions ? @mikl_pls

Edited March 14, 2020 by clinic

[mikl_pls]

On 3/14/2020 at 10:22 AM, clinic said:

Update: Hi guys, so i took amisulpride 50-100mg(50mg for 4 days and then 100mg for 3 days) for 1 week. And within a week prolactin shot up to 45ng/ml (2-17).

Last year when i tried the same med for 1 week(50mg for 4 days and then 100mg for 3 days), it shot up to 53 ng/ml (2-17)

So it fluctuates in 50s.

I'm stopping amisulpride for now. I can't accept its long term side effects.

Any suggestions ? @mikl_pls

I've made several, several suggestions. I have no more to offer, and I will not repeat what I have already said. I suggest rereading what I have recommended. If you don't like what I suggested, then I'm sorry I don't have any more suggestions.

[clinic]

12 hours ago, mikl_pls said:

I've made several, several suggestions. I have no more to offer, and I will not repeat what I have already said. I suggest rereading what I have recommended. If you don't like what I suggested, then I'm sorry I don't have any more suggestions.

Went to pdoc last night. He added 0.5 Flupenthixol to my med regimine and removed amisulpride. He said it does increase prolactin but not that much high at this dose.

I'm seriously considering typical antipsychotics now instead of atypical antipsychotics, cuz i want to reduce clozapine. I forgot to take list of typical antipsychotics to my pdoc. I will print out list of typical antipsychotics and ask him which will be best for me on my next visit. I will see which convensional antipsychotics causes the least side effects.

He also said i should try lexapro for 1 week even if i cry daily.

Edited March 18, 2020 by clinic

[clinic]

oops it says, Flupenthixol causes Tardive dyskinesia (risk increases with duration of treatment and with dose) and Neuroleptic-induced deficit syndrome

Should i take it ?

Stahl says "Awakenings have been observed on rare occasions in association with treatment with other atypical antipsychotics, but almost never in association with conventional antipsychotic treatment. Although patients treated with clozapine may occasionally experience an “awakening” (in the Oliver Sachs sense), characterized by return to a near-normal level of cognitive, interpersonal, and vocational functioning, and not just significant improvement in positive symptoms of psychosis, this is unfortunately rare"

Edited March 18, 2020 by clinic

[Iceberg]

8 hours ago, clinic said:

oops it says, Flupenthixol causes Tardive dyskinesia (risk increases with duration of treatment and with dose) and Neuroleptic-induced deficit syndrome

Should i take it ?

Stahl says "Awakenings have been observed on rare occasions in association with treatment with other atypical antipsychotics, but almost never in association with conventional antipsychotic treatment. Although patients treated with clozapine may occasionally experience an “awakening” (in the Oliver Sachs sense), characterized by return to a near-normal level of cognitive, interpersonal, and vocational functioning, and not just significant improvement in positive symptoms of psychosis, this is unfortunately rare"

Is it possible you are maybe overthinking this? You’ve tried many meds and presented many options, maybe it’s time to trust your pdoc 

[mikl_pls]

On 3/18/2020 at 4:38 AM, clinic said:

Went to pdoc last night. He added 0.5 Flupenthixol to my med regimine and removed amisulpride. He said it does increase prolactin but not that much high at this dose.

I'm seriously considering typical antipsychotics now instead of atypical antipsychotics, cuz i want to reduce clozapine. I forgot to take list of typical antipsychotics to my pdoc. I will print out list of typical antipsychotics and ask him which will be best for me on my next visit. I will see which convensional antipsychotics causes the least side effects.

He also said i should try lexapro for 1 week even if i cry daily.

0.5 mg is a super low dose. I don't mean to worry you, but it's such a low dose, actually, that it may in fact worsen your psychosis due to increasing dopamine release, so do pay close attention. I'm not trying to discourage you or scare you out of taking it. I implore you to follow through with your pdoc's orders. Doses used for psychosis (as monotherapy) are 1 mg 3 times per day initially titrating up as needed to a max of 6-12 mg/day. Low doses of flupentixol are used actually as an antidepressant and for negative symptoms of psychosis, and don't really control positive symptoms that well at all—higher doses are required to block the postsynaptic D2 receptors. But I do understand that this is an adjunct to your clozapine which you are trying to reduce.

From my experience, trifluoperazine had the least side effects and is very effective. If you can find it, it'd be well worth it, I believe. It too can definitely increase prolactin as it is a high potency first generation antipsychotic, and the effect on prolactin with these antipsychotics is dose-related, but definitely not quite as severe as amisulpride, risperidone, paliperidone, or haloperidol I wouldn't think.

If you are taking an antipsychotic that raises prolactin, the addition of aripiprazole at 5 mg to 15 mg can be done, but you probably don't want to be on 3 antipsychotics at once. (This could be done though if you switched from clozapine to amisulpride or risperidone or something like that.)

Olanzapine, quetiapine, and ziprasidone are also prolactin-sparing antipsychotics.

16 hours ago, Iceberg said:

Is it possible you are maybe overthinking this? You’ve tried many meds and presented many options, maybe it’s time to trust your pdoc 

I do also think that you may be overthinking this though. You have to at some point trust your pdoc and go with his ideas. If side effects arise, then deal with them as they come up.

[clinic]

I have good news. I'm able to tolerate SSRIs after reducing my clozapine dose to 175mg. Its first time in 4 years I'm able to figure out what is wrong with me.

It turns out like i said the more clozapine dose u take, the more your chances of worsening ocd and even anxiety. In my case I couldnt tolerate SSRIs/SNRIs when I was on clozapine 200mg and above. I start crying after taking first pill of any SSRI.

Last night i took first dose of lexapro(escitalopram) 5mg and i was shocked that i didnt cried at all after taking it. My anxiety is better on clozapine 175mg. I can't go above clozapine 175mg. If in future i get psychotic relapse, we can add risperidone.

I will report how lexapro(escitalopram) works out for ocd in coming weeks.

Edited March 19, 2020 by clinic

[mikl_pls]

4 minutes ago, clinic said:

I have good news. I'm able to tolerate SSRIs after reducing my clozapine dose to 175mg. Its first time in 4 years I'm able to figure out what is wrong with me.

It turns out like i said the more clozapine dose u take, the more your chances of worsening ocd and even anxiety. In my case I couldnt tolerate SSRIs/SNRIs when I was on clozapine 200mg and above. I start crying after taking first pill of any SSRI.

Last night i took first dose of lexapro(escitalopram) 5mg and i was shocked that i didnt cried at all after taking it. My anxiety is better on clozapine 175mg. I can't go above clozapine 175mg. If in future i get psychotic relapse, we can add risperidone.

I will report how lexapro(escitalopram) works out for ocd in coming weeks.

Glad to hear that!

[Equilibrium022x]

I would recommend perphenazine, I lowered the dose from 15 to 10 mg once daily. It really feels, my mood improving. Also started again olanzapine 10mg and like always works well for me. They mention Stelazine and I definetly have to agree, is a potent but safe neuroleptic. Finally I would recommend trying risperidone at a low dose i'm on 1 mg and works very well for ocd. Good luck.