Akathisia

[jarn]

AUGH

Last night my right arm started feeling...uncomfortable.  Weird.  We were out and I went home early, I didn't finish my beer even (SHOCK!).  I just had to get out of there, I was so uncomfortable.  

By the time I was in bed I was rolling and flailing my arm around.  I couldn't hold still.  I'd taken .5mg of an Ativan to try to help, and I think it did eventually, because I fell asleep (and slept through my alarm).

I am working from home today so I can see a GP at my practice.  

I'm not flailing but feel uncomfortable.  

It sort of feels like my arm is falling asleep but also that it's overactive.  If that makes sense.  

I'm currently taking 15mg Zyprexa (have been for a week) and 20 or 30mg of loxapine (I am still having the odd breakthrough psychotic thought, but it doesn't stick).  I see my pdoc next Wednesday and I assume he'll take me off of loxapine then.  

I was thinking of asking the GP for Cogentin (or more Ativan). 

I'm not wrong about this being akathisia, am I?  I'm guessing it's because I'm on two antipsychotics.  Why it would start now though...

[mikl_pls]

3 hours ago, jarn said:

It sort of feels like my arm is falling asleep but also that it's overactive.  If that makes sense.

That doesn't sound like my experience with akathisia. Akathisia for me feels like I want to crawl out of my skin because I'm so profoundly uncomfortable inside my own body. It feels like such a profound inner sense of restlessness that cannot be sated by any amount or sort of motion, pacing, or anything. There is also a very profound affective component characterized by profound dysphoria and sometimes panic and anxiety, sometimes manifesting as a sense of impending doom or death, but mostly just absolute, pure, unadulterated dysphoria. 

Everyone is different though. You very well may be experiencing some sort of extrapyramidal side effect even if it isn't akathisia. It sounds like it very well could be though. The only way to find out is to take either Cogentin (benztropine) or Artane (trihexyphenidyl). If you've never taken Cogentin before, 0.5 mg 1-2 times per day as needed as needed should do you fine, but otherwise 1 mg should be fine. 2 mg I have taken before for extreme cases of akathisia and other EPS. I've personally never taken Artane before, so I have no dosing experience with it. I will warn you though, these meds cross into the CNS very potently, so you will get memory loss, confusion, blurry vision up close (inability to compensate), your pupils will dilate hugely (mydriasis), and you will subsequently be very sensitive to light, especially sunlight, especially if you take it for several days to weeks in a row. It really doesn't take much, especially if you are anticholinergic-naïve. Anticholinergic delirium can even set in if you're prone to it (I think if you're prone to psychosis, then you are more prone to anticholinergic delirium, so be careful! Less is more for your case, likely.)

Alternatives are beta-blockers like propranolol and benzos, but for me they do nothing whatsoever for akathisia or EPS. If you want a more mild anticholinergic, you can buy some Benadryl and take 50-100 mg and see how it does for you in the mean time. Lots of hospitals even use Benadryl PO pills or IM injections for EPS instead of Cogentin. Apparently Cogentin IM injections are very rare nowadays according to a hospital ER I went to for akathisia (they wound up misdiagnosing me again with mania and gave me a Zyprexa shot with Ativan... didn't phase me at all...).

3 hours ago, jarn said:

I'm currently taking 15mg Zyprexa (have been for a week) and 20 or 30mg of loxapine (I am still having the odd breakthrough psychotic thought, but it doesn't stick).  I see my pdoc next Wednesday and I assume he'll take me off of loxapine then. 

Perhaps if you get on Zyprexa 20 mg, you won't need the Loxitane, or if you do need it, you'd need a much lower dose of it. I can't remember, have you ever been on Seroquel? It supposedly has one of the least incidences of EPS besides Clozaril.

[browri]

When talking about dyskinesias or rather like restless leg syndrome (RLS) versus akathisia (EPS / extrapyramidal symptoms), USUALLY the feeling of akathisia comes from within the torso, like in the stomach/gut area, unlike RLS which manifests specifically in the legs. It wouldn't be unheard of I suppose for EPS to radiate outwards to the arms. And I will also point out that for me on loxapine, 25mg was my threshold dose for akathisia, which seems low really but, with olanzapine on-board it could be much lower. That being said, olanzapine is known for its anti-cholinergic effects like Cogentin or Artane (trihexyphenidyl) which means of the atypicals it carries the lowest risk of akathisia. HOWEVER, it is worth nothing that while its risk of akathisia is low, its risk of EPS overall as well as the long-term risk of tardive dyskinesia are just as bad. Combined with loxapine, it could be stronger.

Do you have 10mg loxapine capsules? If you do, it may be worth calling your pdoc to ask if you can take 10mg loxapine with the olanzapine instead.

[jarn]

Both pdoc and emerg doc (pdoc sent me to emerg, ugh) said it did not seem to be akathisia.  No idea what it is.  They tested strength (I assume to see if I'd had a stroke) and did bloodwork and everything was normal.  They gave me cogentin+benadryl and it didn't do anything/much.  

@browri I do have 10mg pills.  I'm tempted to just stop the loxapine entirely as I think being on two antipsychotics isn't helping things.  

Pdoc thought this was likelier to be the loxapine than the zyprexa, though he found it odd because I've been taking 20mg of the loxapine so I'm at a super low dose.  

AUGH!  So I guess I just put up with this.  I'm not so flail-y today, just tingling and pins and needles a bit.  

Oh and yes @mikl_pls I have been on seroquel multiple times and never again.  It doesn't work well for my psychosis and is SO awful to discontinue.

[browri]

19 hours ago, jarn said:

 I do have 10mg pills.  I'm tempted to just stop the loxapine entirely as I think being on two antipsychotics isn't helping things.  

I mean I think you're right and many here would probably tend to agree, but of course it's always good just to confirm with your pdoc first. For me, if I'm at that point where I'm titrated up on one med and titrating off another and having issues I would just call the office and ask to speak with him. Especially if it's to get his permission to just discontinue something you were already planning to but ahead of schedule.

[mikl_pls]

@jarn Maybe ask if based on your continued presence of symptoms at Zyprexa 15 mg with the loxapine if you need Zyprexa 20 mg without the loxapine. Just an idea.

[jarn]

Thanks @mikl_pls and @browri.  

 

I did end up stopping loxapine and maybe it's psychosomatic but the weird feelings have largely gone away.  

I think I'm relatively stable on 15mg zyprexa though close to tipping over.  I'm thinking 15mg plus 5mg PRN?  I do find 15mg much more sedating than 10mg, which I found activating.  

[Wonderful.Cheese]

@jarn

I take 20 mg zyprexa zydis daily and I also can take up to two, 5 mg zyprexa zydis pills daily PRN. Don’t be afraid to ask for 20 mg plus a PRN dose if you need it. I’m worried about you because you say you are close to tipping over. I worry. I would not hesitate to ask for both an increase and a PRN if you think it would help.

But I do find myself needing a PRN at times so thank goodness my pdoc understands that and suggested introducing a PRN zyprexa zydis and what dose it should be, etc. I find a PRN AAP is better than a PRN benzo, but when I tend to need a PRN is when I tend to get very agitated and have monitoring thoughts and voices and messages that are upsetting. So for me a PRN AAP makes the most sense I guess my pdoc figured. I respond best to zyprexa zydis anyway and best to AAP’s in general. They help me the most. Hell, I'm on 3 because I have treatment resistant psychosis according to my pdoc. But this is as good as it gets for me.

I’m glad your arm feels better and the weird feelings have gone away. Thank goodness. I think you made the right call to stop the loxapine. I know I know, it’s best to get dr approval. But I’ve stopped a med before too w/o dr approval first (vraylar, which was killing my stomach). So I get it.

[Iceberg]

18 hours ago, jarn said:

Thanks @mikl_pls and @browri.  

 

I did end up stopping loxapine and maybe it's psychosomatic but the weird feelings have largely gone away.  

I think I'm relatively stable on 15mg zyprexa though close to tipping over.  I'm thinking 15mg plus 5mg PRN?  I do find 15mg much more sedating than 10mg, which I found activating.  

I have done a 5 mg PRN zyprexa too. Sounds like a reasonable idea. Will you bring that to the pdoc? 

[jarn]

Yes, I'll ask about a PRN.  Thanks @Wonderful.Cheese and @Iceberg.  

The arm thing is much better though I felt a hint of it last night - I was also fairly agitated last night, and feel a bit agitated this morning (though also fine).  I feel like my brain is trying to get out and pushing.  I wonder if the physical sensations were agitation, rather than akathisia.  Of course, loxapine has worked very well for agitation...sigh.

[Wonderful.Cheese]

33 minutes ago, jarn said:

Yes, I'll ask about a PRN.  Thanks @Wonderful.Cheese and @Iceberg.  

The arm thing is much better though I felt a hint of it last night - I was also fairly agitated last night, and feel a bit agitated this morning (though also fine).  I feel like my brain is trying to get out and pushing.  I wonder if the physical sensations were agitation, rather than akathisia.  Of course, loxapine has worked very well for agitation...sigh.

Darn. I really hope things start getting better for you ASAP jarn. I’m sorry about the agitation. I get it too. The PRN really helps me. I hope a possible dose increase and a PRN will solve this for you. If that’s what your dr thinks will help and if you want that too. Thinking of you. ❤️

[jarn]

Thanks Cheese @Wonderful.Cheese

I described the agitation to pdoc in detail, and he said - that's akathisia.  I've stopped flailing other than that first night, but feel these energy pulsing through me in a really uncomfortable way, super restless feeling even though I'm holding still.  Said ativan was the best thing for it.  So he's refilling my ativan PRN script.  Also upping zyprexa to 20mg (I still have some paranoid thinking) and the metformin to 1500mg.  I haven't filled the scripts yet, will tomorrow.  I've taken my zyprexa and metformin for the night.  

[Blahblah]

Good description @mikl_pls ...Is it RLS when you bounce your leg up & down repetitively while sitting? I used to get that sometimes when I first started my stimulant, I did not feel "agitated" and I could stop moving it, but it was like a bit of excess energy and the repetitive foot/leg bouncing felt soothing for some reason.

I also experienced what I *think* was TD on A/Ps. My experience it was more mild, an unconscious "twitching" or suddenly my torso or shoulder blade would sort of move abnormally. These small "adjustments" in my shoulders or torso...It wasn't continuous, just intermittent. And people around me really noticed it...

[mikl_pls]

On 3/12/2020 at 8:53 AM, Blahblah said:

Is it RLS when you bounce your leg up & down repetitively while sitting? I used to get that sometimes when I first started my stimulant, I did not feel "agitated" and I could stop moving it, but it was like a bit of excess energy and the repetitive foot/leg bouncing felt soothing for some reason.

That is called stereotypy.

On 3/12/2020 at 8:53 AM, Blahblah said:

I also experienced what I *think* was TD on A/Ps. My experience it was more mild, an unconscious "twitching" or suddenly my torso or shoulder blade would sort of move abnormally. These small "adjustments" in my shoulders or torso...It wasn't continuous, just intermittent. And people around me really noticed it...

May or may not have been TD, but APs can cause all sorts of dystonic movement disorders.