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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by uncouth on December 18, 2013, at 17:38:45
Hi everyone.
It's been a while since I've posted on PB. Hope everyone here is still well.
Currently withdrawing from a bunch of stuff including atomoxetine and memantine and a bunch of herbs/supplements. Formally diagnosed BP2, main issues these days are motivation, cognition/memory, seasonal mood issues, attention regulation, social phobia/motivation, and sleep. So lots of prefrontal hypoactivity essentially. Strattera worked at the beginning when I started it this year, but it has pooped out.
WIll be staying on Pramipexole ER 2.25, Vyvanse 40mg (lowest semi-effective dose, been tapering down for the past year), and 2mg guanfacine.
Convinced my doc to let me try Amisulpride, low dose, due to what i've read over the years about it's effectiveness in mood issues, the fact that it's not a SSRI, and the fact that it may work on dopamine in a novel way. Amisulpride looks like a good one to try also given the role 5ht7 plays in sleep and cognition/memory/mood.
Been on mirapex various times over the years, this latest round its been about 6-8 weeks. It may be helping but just a bit, hard to tell.
Curious as to a few things:
1) Best way to start amisulpride -- both so it's not a "shock" to the dopaminergic system given i'm already on Mirapex and Vyvanse (i'm 220lbs, so vyvanse 40mg is barely enough to be noticable, and I still take a few nicotine lozanges).
Read a few conflicting things that starting from say 50 or 100 and going DOWN gives it a stronger action. Others say titrate up from 25mg. Not clear. Anyone have experience or insight into the psychopharmacology?
2) Possible conflict with Mirapex or Vyvanse -- mirapex especially. There was an old thread by SLS I think about Pramipexole and Amisulpride. Scott did you ever try? Why or why not?
3) Any other updated personal experiences with this drug. How long did it take to kick in? Any risk of mania? Novel subjective experience compared to other A/D or stimulants?
Thanks!
Uncouth
Posted by SLS on December 19, 2013, at 7:29:00
In reply to Amisulpride plus Pramipexole?, posted by uncouth on December 18, 2013, at 17:38:45
If your haven't tried Abilify yet, I would consider performing a 2 - 4 week trial. It works like a combination of Amisulpride and pramipexole at the same time, but doesn't carry with it the risks of hyperprolactinemia (amisulpride) or sleep attacks (pramipexole). Abilify (aripiprazole) is a dopamine D2/D3 receptor partial agonist. It works like an antipsychotic when dopamine activity is too high, and like an antidepressant when activity is too low. The major risk with Abilify is akathisia. Akathisia-like effects often occur during the first week or so with Abilify, but usually dissipate within a week. True akathisia will not dissipate. Abilify can also produce weight-gain. The only atypical antipsychotics that are weight neutral are Geodon (ziprasidone) an Latuda (lurasidone).
- Scott
Posted by Uncouth on December 19, 2013, at 13:28:09
In reply to Re: Amisulpride plus Pramipexole? » uncouth, posted by SLS on December 19, 2013, at 7:29:00
Hey scott thanks for your response. I've tried ability a number of times in the past mostly at 5-10-15 mg. My doc actually recommended this when I suggested the amisulpide. But the akithisia like effects were pretty rough for me, though I'm sure they did disappate. I'm mostly trying to understand how I can just antagonize autoreceptors, not clear on if or In what scenario ability targets that but have heard lower doses are much diffeent than higher.
Can you provide some suggestions on correct dosing? At what point does it antagonize post synaptic? I'm pretty over that effect and I do think I gained weight, tend to do it on all AP. Does it have 5ht7 action like amisulpide?
Posted by SLS on December 19, 2013, at 21:03:24
In reply to Re: Amisulpride plus Pramipexole?, posted by Uncouth on December 19, 2013, at 13:28:09
The dosages of amisulpride, when used specifically for dysthymia or depression, is 25 - 100 mg/day.
Amisulpride binds much more readily and tightly to presynaptic dopamine receptors than postsynaptic receptors. The lower dosages of amisulpride therefore are more pro-dopaminergic than higher dosages. Although I am not impressed with pramipexole for depression - either alone or in combination with other agents. However, amisulpride (and sulpiride) might be a special combination to help re-regulate the dopamine neuronal synapse.
I would start amisulpride first and try to establish a dosage of 50 mg/day. Then, you can add pramipexole. If you experience unacceptable side effects (particularly sleep-attacks), you will know that the pramipexole is responsible for them.
Abilify:
1. What dosage?
2. What side effects?
2. How long?
3. Improvement?If bipolar disorder is not an issue, dosages of Abilify as an augmenter to antidepressants are 2.5 - 5.0 mg/day.
- Scott
Posted by Christ_empowered on December 19, 2013, at 23:37:46
In reply to Re: Amisulpride plus Pramipexole? » Uncouth, posted by SLS on December 19, 2013, at 21:03:24
hey. I take Abilify (usually 30mgs/day) for bipolar I w/ psychotic features, mostly psychotic depression.Anyway, I think its easier to use Abilify for bipolar and schizo-disorders than for AD effects. Too much Abilify, you might lose the AD effect. But you have to take enough to help.
I've read that some docs use 2.5mgs/day or so every 2-3 days. That would make it more stimulating. This makes sense, as Abilify has a long half life and higher doses (or blood levels) tend to be tranquilizing.
What symptoms are you trying to address? The startup can be rough. In a way, I'm lucky that I have more severe problems, because docs tend to high dose it from the get-go which, weirdly enough, means less start up agitation.
Has your doc ever tried short term sedatives (Neurontin, lyrica, benzos, etc.) with Abilify, maybe for 1 month or so? Abilify is sorta like an AD...some people need a sedative when they first start it, to counter agitation/akathisia.Good luck!
Posted by uncouth on December 20, 2013, at 12:20:08
In reply to Re: Amisulpride plus Pramipexole?, posted by Christ_empowered on December 19, 2013, at 23:37:46
Thanks! 30mg is a lot -- clearly antipsychotic and antagonizing at that dose?
I am bipolar but rarely hypomanic...only in the summers, when it is usually fairly mixed and complicated by drug/supplement compulsions.
What else do you take it with? Did you gain weight?
I don't think I have ever started on less than 5-10mg. Certainly never tried 2.5mg every 2-3 days...where did you read this? Would love to check out what people have to say about that protocol.
Symptoms are: mood, prefrontal activation, MOTIVATION, libido, ADD (inattentive, not ADHD) symptoms, working memory, and social phobia. Not really social anxiety per se, though there is some of that. Just like, social anhedonia and "social learned helplessness". I am very attractive 33 year old male, intelligent, and though I have persistent psychiatric issues, usually can present myself reasonably well. But I have a constant unfriendly/disengaged look on my face, and don't know what to say to men/women I meet at bars or parties, and tend to withdraw. So it's more like "social learned helplessness".
I tend to gain weight that is near-impossible to shed (abdominal) on A/Ps. I probably did so even on abilify last time I was on it though I forgot.
Why does such a low dose cause MORE agitation/akithisia? I though that was a hypodopamenrgic/antagonist state? And I thought super low doses were exclusively agonistic? (But where, post or pre?)
Thanks!
Posted by uncouth on December 20, 2013, at 12:43:58
In reply to Re: Amisulpride plus Pramipexole? » Uncouth, posted by SLS on December 19, 2013, at 21:03:24
Thanks Scott.
I know "lower dosages are more prodopaminergic", but that's usually comparing 25-100 vs 400+. Does that also hold when comparing say 100mg to 25mg? That part doesn't make sense to me, seems like at that level, a higher dose, up to some limit, will further antagonize presynaptic. I will probably start at 50mg...the real point of my original question I guess is -- which direction do I go from there if the effect isn't strong or sustained?Why aren't you impressed with pramipexole? What has been your experience, and at what dose?
I have already been taking Mirapex ER 2.25 mg for about the past 6 weeks. To limited effect, though the more I read about it, the more I feel like perhaps this is still a low dose for BP 2 (depression) and for general hypodopamergic state as it may still be operating too presynaptically. But honestly, who knows? I can't profess to have this level of self-insight into my neuronal activity! Never had sleep attacks.
So I guess given that I'm already on mirapex, want to be a bit cautious about adding amisulpride, and would want to start with a conservative dose---which is why I ask whether starting at 25mg would be more "risky" in combo with mirapex than 100mg.
I am based in the US, so of course my psych doesn't have experience or much knowledge of amisulpride.
In addition, I want a high enough dose to get effective 5ht7 effects as I have significant sleep and cognitive issues I'm hoping are helped.
I can't remember too many details regarding my Abilify experiene, but i've been on it a number of times in the past 9 years, mostly at the 5-15mg range. Definite side effects of akithisia which I can't recall if they ever abated 100%. If I remember correctly, I probably took it as long as 6-12 months at one particular time. Also can't recall improvement, but my bias would be to say yes. However my symptoms have changed over the years.
I am bipolar 2/3, have rare hypomanias, more frequent mixed/irritable/compulsive/"racing thought" states but usually in teh summer. Higher dose A/P are too flattening and demotivating. And weight gain always tends to be an issue with A/Ps, though I also can't recall specifically my experience with abilify.
To be honest, the biggest concern I'd have with dopaminergics would be enhancement of impulsivity/compulsivity (e.g. gambling, sexual disinhibition, and especially internet addiction).
Thanks
UncouthP.S.-- curious as to what you are on these days? i Seem to remember last time I actively checked this forum you had a really good response to something very non-traditional (minocycline?). Have you achieved anything close to remission or improvement in your cognitive symptoms?
Posted by SLS on December 20, 2013, at 14:23:05
In reply to Re: Amisulpride plus Pramipexole?, posted by uncouth on December 20, 2013, at 12:43:58
Uncouth...
Before I forget, it is critical to understand that a good portion of amisulpride's antidepressant effect might be mediated through serotonin 5-HT7 receptor antagonism. It is a very potent drug at this receptor. Two other neuroleptic antipsychotic drugs that are also potent 5-HT7 receptor antagonists are risperidone (Risperdal; Invega) and lurasidone (Latuda). Do not overlook lurasidone. It might go well with a more DA/NE antidepressant like bupropion (Wellbutrin).
Just a thought.
- Scott
Posted by uncouth on December 23, 2013, at 14:34:17
In reply to Re: Amisulpride plus Pramipexole? » uncouth, posted by SLS on December 20, 2013, at 14:23:05
Scott, yes, I know and I agree. I have been on latuda before but the d2 antagonism was at least at the time a bit too much and demotivation was a concern. Plus weight gain, which is always an issue for me with A/P, no matter what anyone says.
Why lurasidone plus bupropion specifically?
Thanks for the reply. Could you help me out with the questions I asked in my previous post?
A
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