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Posted (edited)
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 by clinic

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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. 

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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. 

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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 ?

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Posted (edited)
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 by mikl_pls

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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

 

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Posted (edited)

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 by clinic

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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.

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Posted (edited)
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 by clinic

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Posted (edited)

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 by clinic

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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 

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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.

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Posted (edited)

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 by clinic

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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!

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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. 

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