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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 22 to 46 of 48. Go back in thread:
Posted by Phillipa on June 6, 2005, at 17:57:18
In reply to Re: Neurontin to Topomax » Larry Hoover, posted by Maxime on June 6, 2005, at 17:53:56
Scott may have been on to something with the cymbalta. The one good thing that it did for me was I no longer had any muscle, bone, or joint pain. I didn't realize this until I went off it and they all came back. Fondly, Phillipa
Posted by Larry Hoover on June 6, 2005, at 18:02:24
In reply to Re: Neurontin to Topomax » Larry Hoover, posted by SLS on June 6, 2005, at 17:56:10
> Larry,
>
> > Time to move on to a different med.
>
> I don't know if you noticed in one of my posts that I offered as suggestions either Cymbalta or Lyrica.
>
>
> - ScottI appreciate the thought, Scott, by neither one is available in Canada.
Lar
Posted by Larry Hoover on June 6, 2005, at 18:04:09
In reply to Re: Neurontin to Topomax » Larry Hoover, posted by ed_uk on June 6, 2005, at 17:52:08
> Hi Lar,
>
> >I cannot believe that this medication is going to be one that I tolerate nicely.
>
> Me neither :-(
>
> >oligohydrosis........
>
> Can be dangerous, permanent neuro damage has been reported to have occured following topiramate-induced hyperthermia. Topiramate is thought to decrease sweating by acting as a carbonic anhydrase inhibitor.
>
> Kind regards,
> Ed.As soon as I noticed it, I *mentally* blanched. My skin didn't, of course. I immediately knew the consequences.
No way I'm playing around with temperature regulation.
Lar
Posted by Larry Hoover on June 6, 2005, at 18:13:29
In reply to Re: Neurontin to Topomax » Larry Hoover, posted by ed_uk on June 6, 2005, at 17:47:46
> Desipramime, another norepinephrine reuptake inhibitor, is also sometimes effective for neuropathic pain. It is less likely to cause sedation than nortriptyline. Desipramine is sometimes quite 'activating' - it can cause insomnia. Nortriptyline is much less sedating than trimipramine- which I believe you've taken in the past.
I still take trimipramine, 25 mg QHS. Back on 30 mg temazepam QHS as well, as the Imovane interacted adversely with the Neurontin. Maybe the Imovane caused some of the problems I attributed to Neurontin? It all gets so friggin complicated. What role does the oxycodone play?
> Scott mentioned Cymbalta.
Not available in Canada, yet.
> If you want to try another anticonvulsant, I think Trileptal is worth considering. What do you think??? Depakote is another option - you said your doc suggested it.I dunno what to think about anticonvulsants. I've not had good luck with them so far. I've not looked to them on purpose, ya know?
> >Whoa.... I've got room, there, after all. I'm not even close.
>
> Like morphine, oxycodone does *not* have a maximum dose. Provided that it is titrated *gradually*, tolerance develops to the respiratory depressant effect of the drug, allowing the dose to be increased as required.Maybe that's the answer. The problem is, I don't like the psychoactive effect at all. I know, properly titrated, the psychoactive effect is minimized.....but as the dose escalates, it does get harder to manage, in some respects. I've been using the IR product. Maybe it's time to switch to the XR, or the Contin format.
> RE morphine, doses in excess of 2500mg every four hours have been recorded!!! Obviously, such a high dose would be rapidly fatal to a person who was not tolerant to the respiratory depressant effect of morphine.
Thanks. I grock it. (For any Heinlein fans.)
> >Maybe I need a referral to a pain specialist.
>
> That could be very useful :-)If the queue isn't too lengthy.
> >Or a copy of the manufacturer's recommendations.
>
> Here is the UK data sheet........Ta.
http://emc.medicines.org.uk/emc/industry/default.asp?page=displaydoc.asp&documentid=2579
>
> Kind regards,
> Ed.Thanks, buddy.
Lar
Posted by ed_uk on June 6, 2005, at 18:33:44
In reply to Re: Neurontin to Topomax » ed_uk, posted by Larry Hoover on June 6, 2005, at 18:13:29
Hi Lar!
>I've been using the IR product. Maybe it's time to switch to the XR, or the Contin format.
.........could be useful. You could take additional dose of IR oxycodone 'when required'.
Ed.
Posted by Maxime on June 6, 2005, at 18:55:13
In reply to Re: Neurontin to Topomax » SLS, posted by Larry Hoover on June 6, 2005, at 18:02:24
Larry, Cymbalta will be available in Canada by July.
Maxime
> > Larry,
> >
> > > Time to move on to a different med.
> >
> > I don't know if you noticed in one of my posts that I offered as suggestions either Cymbalta or Lyrica.
> >
> >
> > - Scott
>
> I appreciate the thought, Scott, by neither one is available in Canada.
>
> Lar
>
>
Posted by Larry Hoover on June 6, 2005, at 18:55:19
In reply to Re: Neurontin to Topomax » Larry Hoover, posted by ed_uk on June 6, 2005, at 18:33:44
> Hi Lar!
>
> >I've been using the IR product. Maybe it's time to switch to the XR, or the Contin format.
>
> .........could be useful. You could take additional dose of IR oxycodone 'when required'.
>
> Ed.Having had the good response to the other non-opioid agents, though, I wonder if that's the best strategy. I wish I knew why I am Mr. Side Effect. Which drug? I know that's always the problem, but my sensitivity to both low-dose Neurontin and Topomax are exasperating.
Lar
Posted by ed_uk on June 6, 2005, at 19:14:15
In reply to Re: Neurontin to Topomax » ed_uk, posted by Larry Hoover on June 6, 2005, at 18:55:19
Hi Lar,
>Having had the good response to the other non-opioid agents, though, I wonder if that's the best strategy.
You could try another antiepileptic!!
About Trileptal........
J Pain Symptom Manage. 2003 May;25(5 Suppl):S31-5.
Rationale and evidence for the use of oxcarbazepine in neuropathic pain.Carrazana E, Mikoshiba I.
Neuroscience, Clinical Development and Medical Affairs, Novartis Pharmaceuticals, East Hanover, NJ 07936-1080, USA.
Oxcarbazepine is a second-generation antiepileptic drug (AED) with proven efficacy in managing partial epileptic seizures, with or without secondary generalization, in adults and children. The overlap between the underlying pathophysiologic mechanisms of some epilepsy models and neuropathic pain models supports the rationale for using certain AEDs in the treatment of neuropathic pain. Several AEDs have reportedly produced analgesia in a range of neuropathic pains, including painful diabetic neuropathy (PDN) and post-herpetic neuralgia. Increasing evidence suggests that oxcarbazepine can provide significant analgesia in several neuropathic pain conditions, including trigeminal neuralgia and PDN, and is also may be effective in treating neuropathic pain refractory to other AEDs, such as carbamazepine and gabapentin. The analgesic effects of oxcarbazepine, and its generally improved safety and tolerability profile compared with other standard AEDs, suggests that oxcarbazepine will be an important addition to the neuropathic pain armamentarium. The rationale and evidence to support the efficacy of oxcarbazepine are presented here.
Kind regards,
Ed.
Posted by Larry Hoover on June 6, 2005, at 19:58:07
In reply to Re: Neurontin to Topomax » Larry Hoover, posted by ed_uk on June 6, 2005, at 19:14:15
> Hi Lar,
>
> >Having had the good response to the other non-opioid agents, though, I wonder if that's the best strategy.
>
> You could try another antiepileptic!!
>
> About Trileptal........
>
> J Pain Symptom Manage. 2003 May;25(5 Suppl):S31-5.
>
> Rationale and evidence for the use of oxcarbazepine in neuropathic pain.
>
> Carrazana E, Mikoshiba I.
>
> Neuroscience, Clinical Development and Medical Affairs, Novartis Pharmaceuticals, East Hanover, NJ 07936-1080, USA.
>
> Oxcarbazepine is a second-generation antiepileptic drug (AED) with proven efficacy in managing partial epileptic seizures, with or without secondary generalization, in adults and children. The overlap between the underlying pathophysiologic mechanisms of some epilepsy models and neuropathic pain models supports the rationale for using certain AEDs in the treatment of neuropathic pain. Several AEDs have reportedly produced analgesia in a range of neuropathic pains, including painful diabetic neuropathy (PDN) and post-herpetic neuralgia. Increasing evidence suggests that oxcarbazepine can provide significant analgesia in several neuropathic pain conditions, including trigeminal neuralgia and PDN, and is also may be effective in treating neuropathic pain refractory to other AEDs, such as carbamazepine and gabapentin. The analgesic effects of oxcarbazepine, and its generally improved safety and tolerability profile compared with other standard AEDs, suggests that oxcarbazepine will be an important addition to the neuropathic pain armamentarium. The rationale and evidence to support the efficacy of oxcarbazepine are presented here.
>
> Kind regards,
> Ed.I really appreciate the effort, Ed.
When I checked the monograph for Trileptal, however, the frequencies for e.g. nausea and dizziness are greater for this med than for Topomax. How does that come through as being more tolerable?
Lar
Posted by Maxime on June 6, 2005, at 20:11:39
In reply to Re: Neurontin to Topomax » ed_uk, posted by Larry Hoover on June 6, 2005, at 19:58:07
Hi Larry. I take Trileptal and the nausea and dizziness went away in about a week. Plus I take it at night so it wasn't too much of an issue. Tegretol I couldn't even walk straight on. I've been on all the mood stabilisers available in Canada and Trileptal has been the best one for me in terms of effect and side effects.
Maxime
> > Hi Lar,
> >
> > >Having had the good response to the other non-opioid agents, though, I wonder if that's the best strategy.
> >
> > You could try another antiepileptic!!
> >
> > About Trileptal........
> >
> > J Pain Symptom Manage. 2003 May;25(5 Suppl):S31-5.
> >
> > Rationale and evidence for the use of oxcarbazepine in neuropathic pain.
> >
> > Carrazana E, Mikoshiba I.
> >
> > Neuroscience, Clinical Development and Medical Affairs, Novartis Pharmaceuticals, East Hanover, NJ 07936-1080, USA.
> >
> > Oxcarbazepine is a second-generation antiepileptic drug (AED) with proven efficacy in managing partial epileptic seizures, with or without secondary generalization, in adults and children. The overlap between the underlying pathophysiologic mechanisms of some epilepsy models and neuropathic pain models supports the rationale for using certain AEDs in the treatment of neuropathic pain. Several AEDs have reportedly produced analgesia in a range of neuropathic pains, including painful diabetic neuropathy (PDN) and post-herpetic neuralgia. Increasing evidence suggests that oxcarbazepine can provide significant analgesia in several neuropathic pain conditions, including trigeminal neuralgia and PDN, and is also may be effective in treating neuropathic pain refractory to other AEDs, such as carbamazepine and gabapentin. The analgesic effects of oxcarbazepine, and its generally improved safety and tolerability profile compared with other standard AEDs, suggests that oxcarbazepine will be an important addition to the neuropathic pain armamentarium. The rationale and evidence to support the efficacy of oxcarbazepine are presented here.
> >
> > Kind regards,
> > Ed.
>
> I really appreciate the effort, Ed.
>
> When I checked the monograph for Trileptal, however, the frequencies for e.g. nausea and dizziness are greater for this med than for Topomax. How does that come through as being more tolerable?
>
> Lar
>
>
Posted by ed_uk on June 6, 2005, at 20:16:49
In reply to Re: Neurontin to Topomax » ed_uk, posted by Larry Hoover on June 6, 2005, at 19:58:07
Hi Lar,
>When I checked the monograph for Trileptal, however, the frequencies for e.g. nausea and dizziness are greater for this med than for Topomax. How does that come through as being more tolerable?
Well, it does seem to be more tolerable than Tegretol!
A lot of babblers seem to have initiated Trileptal at very low doses and increased gradually. Most people seem to have tolerated it quite well. Maxime finds it useful for hypomania, perhaps you could talk to her about it.
How do you feel about nortriptyline/desipramine?
Kind regards,
Ed.
Posted by ed_uk on June 6, 2005, at 20:21:04
In reply to Re: Neurontin to Topomax » Larry Hoover, posted by ed_uk on June 6, 2005, at 20:16:49
>perhaps you could talk to her about it........
Maxi already came to the rescue!!!
Ed
Posted by Larry Hoover on June 7, 2005, at 7:59:03
In reply to Re: Neurontin to Topomax » Larry Hoover, posted by Maxime on June 6, 2005, at 20:11:39
> Hi Larry. I take Trileptal and the nausea and dizziness went away in about a week. Plus I take it at night so it wasn't too much of an issue. Tegretol I couldn't even walk straight on. I've been on all the mood stabilisers available in Canada and Trileptal has been the best one for me in terms of effect and side effects.
>
> MaximeThank you for your feedback.
Thank you, everybody.
Inherent in the discussion, it seems, is that feedback tends to come from people who have used these drugs for mood effects. My mood is within stable parameters already. I need a drug for an off-label use. I don't need a mood stabilizer. Maybe that's why I'm having such a problem with adverse effects.
That said, I will discuss Trileptal, nortryptiline, and my own doctor's earlier recommendation of valproic acid, as possible successors to Topomax.
Lar
Posted by Larry Hoover on June 7, 2005, at 8:12:24
In reply to Re: Neurontin to Topomax, posted by ed_uk on June 6, 2005, at 20:21:04
It is a bizarre place I have been. Sometimes, only hindsight reveals the journey.
I can only say that Topomax required me to expend extremes of energy and focus to achieve only minimal degrees of cognitive performance. In this man's body, I do believe that it deserves its nickname of Stupimax. I also believe that it is little wonder that people lose weight on this stuff, given the degree of GI disturbance wrought by it. I wonder if topiramate is one of the toxic saccharide conjugates released by pathogenic enteric bacteria? <sarcastic>
Anyway, I'm halfway feeling somewhat myself, though still greatly fatigued. Thanks for the help.
Lar
Posted by ed_uk on June 7, 2005, at 8:52:01
In reply to General update, posted by Larry Hoover on June 7, 2005, at 8:12:24
Lar,
Which antidepressants have you reacted badly to in the past? I'm a bit concerned that you might react badly to nortriptyline. Which noradrenergic drugs have you taken in the past?
I know you're worried about anticholinergic side effects but......... have you considered replacing trimipramine with amitriptyline?? I don't think trimipramine has any analgesic properties. Amitriptyline is practically the 'gold standard' for neuropathic pain, it can be effective at very low doses compared with those needed for depression. Although nortriptyline is less anticholinergic than amitriptyline, amitriptyline might be a better replacement for trimipramine because it could help your insomnia.
Kind regards,
Ed.
Posted by Larry Hoover on June 7, 2005, at 13:46:52
In reply to Re: General update » Larry Hoover, posted by ed_uk on June 7, 2005, at 8:52:01
We went with Trileptal. Don't be looking for immediate feedback on response. The last prescription took eight days for the bureaucracy to approve (written prescription already at the pharmacy).
Doctor gave me the week off to rest. Will provide note if required.
Got a double the usual script for oxycodone.
Will also write letter to get Comp off my back. We shall see about the latter.
Lar
Posted by ed_uk on June 7, 2005, at 15:11:31
In reply to Updater update, posted by Larry Hoover on June 7, 2005, at 13:46:52
>We went with Trileptal.
OK, start with a nice low dose. You could try taking 75mg at night for a few days. The 150mg tablets are scored- I think.
Ed.
Posted by Larry Hoover on June 7, 2005, at 16:08:17
In reply to Re: Updater update » Larry Hoover, posted by ed_uk on June 7, 2005, at 15:11:31
> >We went with Trileptal.
>
> OK, start with a nice low dose. You could try taking 75mg at night for a few days. The 150mg tablets are scored- I think.
>
> Ed.Ya, they are. I got the doctor to prescribe the entire dose in the smallest possible pills (the 150's), so I can titrate as slowly as I desire.
Third time's the charm, right?
Lar
Posted by ed_uk on June 7, 2005, at 19:36:39
In reply to Re: Updater update » ed_uk, posted by Larry Hoover on June 7, 2005, at 16:08:17
>Third time's the charm, right?
Hope so :-) Are you gonna have any blood tests for hyponatremia??
Ed
Posted by Larry Hoover on June 7, 2005, at 21:32:13
In reply to Re: Updater update » Larry Hoover, posted by ed_uk on June 7, 2005, at 19:36:39
> >Third time's the charm, right?
>
> Hope so :-) Are you gonna have any blood tests for hyponatremia??
>
> EdI think I'll wait and see if I get past the 33% incidence of nausea, et al, first.
That would be kidney-mediated, right? I do get more than my fair share of sodium intake. I'm a salt-aholic. But I'd bet that has no bearing on this hyponatremia, would it?
Lar
Posted by ed_uk on June 8, 2005, at 8:14:33
In reply to Re: Updater update » ed_uk, posted by Larry Hoover on June 7, 2005, at 21:32:13
Hi Lar,
As far as I know, oxcarbazepine increases the responsiveness of the renal tubules to vasopressin.
~Ed
Posted by Larry Hoover on June 8, 2005, at 9:25:18
In reply to Re: Updater update » Larry Hoover, posted by ed_uk on June 8, 2005, at 8:14:33
> Hi Lar,
>
> As far as I know, oxcarbazepine increases the responsiveness of the renal tubules to vasopressin.
>
> ~EdI really appreciate the help. I'm still having waves of cognition block, nausea, dizziness, paresthesia. Very unpleasant drug for me.
So, is the bloodwork routine with this med, or is it done on presentation with persistent side-effects suggestive of hyponatremia? My doctor doesn't tend to order "unnecessary" tests.
Lar
Posted by Larry Hoover on June 8, 2005, at 14:23:12
In reply to Re: Updater update » Larry Hoover, posted by ed_uk on June 8, 2005, at 8:14:33
Worker's Comp has thoroughly thrown a spanner in the works by functioning efficiently. The new prescription (Trileptal) was approved in only 24 hours! My doc and I assumed a week or so, as is the norm. The Topomax took eight days. The pharmacist said some scripts take three weeks to go through. I guess I am an efficient complainer. Well, I know I am.
Do you think I should wait a little longer to let the Topamax clear? Its half-life is estimated at 21 hours, my last dose was 53 hours ago, and I'm still experiencing moderate continuous symptoms from that stuff.
Standard tox practise has clearance at 5 half-lives, i.e. 105 hours, or thereabouts. I don't want to have to deal with additive effects.
Thanks, bro.
Lar
Posted by ed_uk on June 8, 2005, at 16:27:09
In reply to One last question, Ed » ed_uk, posted by Larry Hoover on June 8, 2005, at 14:23:12
Hi Lar,
Well.......the manufacturer suggests that 'if clinical symptoms suggestive of hyponatraemia occur on Trileptal therapy, serum sodium measurement may be considered.'
........on the other hand, some journal articles do recommend 'routine' monitoring.
The UK Trileptal warning.........
BLOOD, HEPATIC OR SKIN DISORDERS. Patients or their carers should be told how to recognise signs of blood, liver, or skin disorders, and advised to seek immediate medical attention if symptoms such as lethargy, confusion, muscular twitching, fever, sore throat, rash, blistering, mouth ulcers, bruising, or bleeding develop
>So, is the bloodwork routine with this med.......
I guess that depends on your doc!
>The new prescription (Trileptal) was approved in only 24 hours!
Wow :-)
>Do you think I should wait a little longer to let the Topamax clear?
Yes, I think that's a good idea. You could start Trileptal once all your Topamax side effects have disappeared. You could start by taking 75mg at night.
>I don't want to have to deal with additive effects.
Good point. If the side effects overlap, you might not know what's causing what.
Kind regards,
Ed.PS. You're not allergic to Tegretol are you? People who are allergic to Tegretol are often also allergic to Trileptal.
Posted by Larry Hoover on June 8, 2005, at 17:21:59
In reply to Re: One last question, Ed » Larry Hoover, posted by ed_uk on June 8, 2005, at 16:27:09
> Hi Lar,
>
> Well.......the manufacturer suggests that 'if clinical symptoms suggestive of hyponatraemia occur on Trileptal therapy, serum sodium measurement may be considered.'I think I'm a good observant patient. I'll watch for it, now I'm aware of the risk.
> >Do you think I should wait a little longer to let the Topamax clear?
>
> Yes, I think that's a good idea. You could start Trileptal once all your Topamax side effects have disappeared. You could start by taking 75mg at night.That's exactly the way I plan to proceed.
> >I don't want to have to deal with additive effects.
>
> Good point. If the side effects overlap, you might not know what's causing what.No point adding nausea to nausea, in any case, eh? I can see why people lose weight on Topomax. With nausea and taste perversion, who wants to eat? I had plain soda water last night that tasted like some bizarre mixture of rotten pineapple and something metallic.
> Kind regards,
> Ed.
>
> PS. You're not allergic to Tegretol are you? People who are allergic to Tegretol are often also allergic to Trileptal.Allergic? Unknown. I'll be sure to observe.
Thanks, my man.
Lar
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Dr. Bob is Robert Hsiung, MD,
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