Posted by medlib on April 26, 2003, at 0:18:54
In reply to Re: Where to go from here? Ron and » Ritch, posted by Dinah on April 23, 2003, at 10:10:41
Hi Dinah--
Ron and Mitch have offered some excellent ideas. So long as you'll be researching, I thought I'd add a couple of thoughts to your mix.
Re APs: Either Abilify or Geodon might be able to chill out your meltdown week without the EPS or the 2 week hangover. Both are considered slightly activating, I think. Certainly, neither will mess with your triglycerides. Geodon has appetite suppressant effects for most. I don't know if either has been taken PRN; you might need to blaze a trail there. If you decide to experiment, I'd begin with the lowest possible dose as soon as you feel an MD coming on. (And I'd keep some Klonopin or Xanax and Benadryl in reserve for potential disaster control.) I think you could ramp up during the week if the lowest level isn't enough. (With Geodon, I'd take half the 10 mg. size twice a day to start with.) Seroquel, on the other hand, might turn your stupor into a coma; I slept 'round the clock on the lowest dose of S. Your pdoc should have samples of both A and G. If neither of those APs do the job, you might have to ask him to let you try some low dose Cogentin with your Risperdal. It helps control movement disorders. That would be my third choice, though. If you do have to continue with R., a mild stim. such as Provigil might help with the post-MD fog. Stims usually are easy to PRN.
After you establish the best meltdown med and dose, you could try finding a mood stabilizing drug or drugs which might lengthen or eliminate your cycling. For the record, I wouldn't consider Lithobid as an anti-cycling agent, adjunct or stand alone. Most gain weight on it, and I imagine you know what that does to triglycerides and insulin resistance. Augmenting Depakote to better control rapid cycling sounds good (especially with an AED that's less sedating than Depakote); both Lamictal and Trileptal are often prescribed as adjuncts. Unfortunately, Depakote (valproic acid) does not play well with other AEDs (they squabble over liver metabolizing enzymes). This isn't an insurmountable problem, but it would require careful titration. Definitely not a 5 minute job. I've summarized the effects on plasma concentrations (PC) of various combos below.
VPA (Depakote) + Trileptal -> lower Trileptal PC
VPA + Lamictal -> lower VPA PC
VPA + Topamax -> lower PCs of both medsTrileptal is somewhat sedating, so it probably wouldn't help. But, you might want to ask your pdoc if either Topamax or Lamictal alone could stabilize your cycling as well as Depakote. Since neither is sedating, if either worked at all, you might be able to take enough to reduce or eliminate cycling.
Bottom line? I think you've done a good job identifying the dynamics of your problem--and I think that a med solution that will improve upon your current results is quite doable. You may end up with a med cocktail which varies with the phases of your cycles; but, once established, those changes would be regular and predictable. I suspect you'll have to be your own bartender, though. The problems that may arise playing musical meds probably will be with your pdoc and your patience. To deal with the first, I'd ask for a "double" appointment (minimum 30 min.) as soon as you finish researching--to discuss your options, formulate an overall strategy and establish a viable between-appointment method of communication. You could ask him up front if he's willing to work *with* you on an intensive basis to find the best mix for you. If you're not satisfied, value yourself enough to find someone better. I expect that you know better than I what to do about the second problem. For all of us, doing it's the rub.
Btw, I can empathize re pdoc problems. Mine recently retired--in his 40's! Hope I didn't drive him to it. Can you imagine having *me* as a patient? I go see his replacement in June. Hope she has a sense of humor.
Good luck!---medlib
poster:medlib
thread:221270
URL: http://www.dr-bob.org/babble/20030423/msgs/222497.html