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Dr. Bob is Robert Hsiung, MD,
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Posted by Lamdage22 on January 18, 2015, at 5:19:41
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by ed_uk2010 on January 17, 2015, at 14:01:19
I hope it sticks with the higher doses.
Posted by Lamdage22 on January 18, 2015, at 5:20:38
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by Lamdage22 on January 18, 2015, at 5:19:41
I have headaches sometimes since i take amisulpride.
Posted by ed_uk2010 on January 18, 2015, at 6:53:27
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by Lamdage22 on January 18, 2015, at 5:20:38
>I have headaches sometimes since i take amisulpride.
Have you reduced your other meds? Amisulpride isn't a common cause of headaches. Maybe give it time and take paracetamol.
Posted by Lamdage22 on January 18, 2015, at 9:10:28
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals » Lamdage22, posted by ed_uk2010 on January 18, 2015, at 6:53:27
Should i measure my prolactin now as its not elevated by amisulpride yet to be able to compare?
Posted by Lamdage22 on January 18, 2015, at 9:22:59
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by Lamdage22 on January 18, 2015, at 9:10:28
How is Saphris'es side effect profile compared to Seroquel Zyprexa and amisulpride?
I have completely forgotten about it as an option.
Posted by ed_uk2010 on January 18, 2015, at 9:57:41
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by Lamdage22 on January 18, 2015, at 9:10:28
> Should i measure my prolactin now as its not elevated by amisulpride yet to be able to compare?
How do you know it's not elevated yet? Even low doses of amisulpride frequently elevate prolactin, and an increase in dose doesn't always elevate it much more. This is because low doses of amisulpride already produce relatively high levels in the pituitary gland, and a further increase in dose (with a correspondingly higher pituitary drug level) may not increase prolactin much further. It doesn't always work like that though - dose increases can produce more hyperprolactinaemia in some cases. Bear in mind that an increase in prolactin doesn't always cause any symptoms. Very large elevations are more likely to cause symptoms but do not always do so, especially in men.
Personally, I wouldn't bother measuring prolactin until you've.... a) been on your final/maintenance dose for several weeks or b) earlier, if symptoms occur. You can have it measured straight away if there are symptoms suggestive of hyperprolactinaemia.
I would not attempt to measure it now as a baseline because you're already on amisulpride ie. it wouldn't actually be a baseline. You can use the 'normal range' as a baseline in future. Assuming you have no symptoms, measuring prolactin now wouldn't tell you a great deal. It's likely to be somewhat above the normal range, but the final effect that amisulpride will have won't be clear yet because you've not been on amisulpride for long at all, and you're not at your final dose. Seroquel and Zyprexa normally only produce small elevations. I think it's fair to assume that your prolactin level before starting amisulpride probably floated around the upper end of the normal range. Prolactin levels do not remain constant, it goes up and down a lot, so one reading doesn't reveal much unless it's extremely high. A couple of readings may need to be taken to get an idea of what effect amisulpride has had, if indeed it has had an effect.
Amisulpride is a bit unusual in frequently producing hyperprolactinaemia even at low doses. Most antipsychotics (except Abilify, clozapine and Seroquel) produce variable but dose-dependent increases. The reason for this is that amisulpride doesn't penetrate the blood brain barrier very well. Subtherapeutic doses still produce high levels outside the BBB, and the D2 receptors of the pituitary are indeed outside the BBB. Therapeutic doses needed to produce adequate levels in the brain produce very high levels peripherally. Peripheral D2 receptors have several function apart from controlling prolactin release. One of their major functions appears to be in the control of the nausea/vomiting reflex and gastric emptying. D2 antagonists are therefore anti-nauseant, reduce gastric reflux, inhibit vomiting (to some extent) and speed up stomach emptying. D2 antagonists used primarily for this purpose include metoclopramide (Reglan, Maxolon) and in some countries, domperidone (Motilium). Levosulpride, similar to amisulpride, is used to treat nausea/vomiting and dyspepsia in some parts of the world, as well as depression and psychosis. Interestingly, Zyprexa appears to be one of the most potent anti-nausea drugs available, and is occasionally used to relieve severe nausea in terminal illness and during cancer chemotherapy when the usual meds have failed. It can be surprisingly effective. Haloperidol (Haldol) is often used in this situation but it's not as reliable. It is, however, inexpensive and less sedating than Zyprexa at the low doses normally used.
In young and middle-aged women, the menstrual cycle can be used as a guide to the significance of raised prolactin. If prolactin is elevated but regular menstruation continues as normal, you can assume that the increased prolactin has not interfered much with other hormones such as oestrogen. This is good to know. If menstruation stops, this is normally because the elevated prolactin has caused mild oestrogen deficiency. Because this predisposes to osteoporosis in the long-term, it's a good idea to check vitamin D levels and to prescribe calcium and vitamin D supplementation where appropriate. Vitamin D deficiency is extremely common, especially in people with a history of mental health problems. Supplementation may help to protect the bones.
Posted by ed_uk2010 on January 18, 2015, at 10:10:09
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by Lamdage22 on January 18, 2015, at 9:22:59
>How is Saphris'es side effect profile compared to Seroquel, Zyprexa and amisulpride?
Efficacy and side effects are both relevant, but I'm not especially familiar with asenapine (Saphris, Sycrest) to be honest. It's infrequently used here. It was rejected in the EU as a treatment for schizophrenia/psychosis because the studies which were submitted were not sufficient to convince the European Medicines Agency that it was an effective treatment. It showed some efficacy in acute mania, and was approved for this purpose only.
Trials of asenapine have tended to be very short. It is therefore difficult to assess its long-term impact on weight with any certainty. I expect it causes a similar amount of weight gain to Risperdal. Less than Zyprexa but more than amisulpride.
Zyprexa and amisulpride have been pretty consistent in showing good results in the treatment of psychosis. Zyprexa has also been studied for mania and proven effective. Amisulpride hasn't been studied much for bipolar mania.
Efficacy data for Seroquel are reasonable in psychosis, but it's probably less effective than Zyprexa or amisulpride, and the drop out rate seems highest with Seroquel. Seroquel does not seem more effective than typical antipsychotics in schizophrenia. Seroquel has shown useful effects as an add-on in depressive states, however, and as monotherapy in some cases of bipolar depression.
Posted by Lamdage22 on January 18, 2015, at 10:47:39
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by ed_uk2010 on January 18, 2015, at 10:10:09
Thanks ed for your input.
I already take 40 000 iu d3. Prescribed after a blood test.
Posted by Lamdage22 on January 18, 2015, at 11:40:52
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by Lamdage22 on January 18, 2015, at 10:47:39
40 000 IU a week.
Posted by ed_uk2010 on January 18, 2015, at 12:18:35
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by Lamdage22 on January 18, 2015, at 11:40:52
> 40 000 IU a week.
I thought that's what you meant!
Usually, people take that dose for about 3 months and then reduce to a maintenance dose eg. 800-1000 units per day, or (alternatively) 20 000 units every 2 weeks. I wouldn't personally want to continue 40 000 units per week beyond ~3 months without a further blood test. If you're still deficient you can continue for longer, until the deficiency has been fully treated. If your vitamin D level is now normal, reduce to a maintenance dose.
Posted by Lamdage22 on January 18, 2015, at 13:50:31
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by ed_uk2010 on January 18, 2015, at 12:18:35
Im having another blood test! After 3m.
Doesnt high prolactin mean low testosterone? Im not particularly amused about that so i do wanna take that herb you recommended if it is too high!
Posted by ed_uk2010 on January 18, 2015, at 15:15:25
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by Lamdage22 on January 18, 2015, at 13:50:31
>Doesnt high prolactin mean low testosterone?
I assume you are a man? Elevated prolactin in men often causes symptoms if tesotesterone levels are suppressed as a result. This is common if prolactin is very high, but not if it's marginally elevated. High prolactin causes symptoms in women more frequently than it causes symptoms in men. This is because it can induce lactation, disrupt the menstrual cycle and reduce oestrogen levels. Women who are not lactating normally have similar prolactin levels to men. In men, most symptoms of hyperprolactinaemia, if they occur at all, are due to moderately reduced testosterone levels. Reduced libido and erectile dysfunction can occur if testosterone levels are reduced (these symptoms are not permanent, they will disappear with treatment or a change in meds). Don't worry about it in advance, it may not happen.
If your prolactin is high, and you are a man, you can also have a blood test to check your testosterone. Gonadotrophins may also be checked. Testosterone is not usually measured in women. Aripiprazole (Abilify) is effective against elevated prolactin caused by most antipsychotics.... but is not very effective against amisulpride and you don't tolerate the side effects anyway. If you do experience high prolactin and blood tests also show low testosterone (assuming you're a man), testosterone supplementation could be prescribed if you have symptoms as a result. Testosterone gel might be suitable eg. the one you apply once daily to an area of skin, and it's absorbed into your body gradually over several hours. Mildly reduced testosterone not causing symptoms doesn't necessarily require any treatment. The herbal treatment I mentioned has been shown to be effective against the symptoms of hyperprolactinaemia... as well as improving the blood results. Sexual function was improved. I just don't know how easy it is to buy the correct product.
In the long term, obesity and diabetes caused by drugs like Zyprexa may cause more harm than the hormonal disturbances which are common with amisulpride. Diabetes causes erectile dysfunction very frequently, for example.
Posted by Lamdage22 on January 19, 2015, at 12:24:00
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals » Lamdage22, posted by ed_uk2010 on January 18, 2015, at 15:15:25
Thanks, ed. Yes im a man.
I hit the cr*pp*r 3 times today already oO.
Maybe i will hit it a fourth time.
Well, if its good for my overall health, so be it.
Posted by ed_uk2010 on January 19, 2015, at 13:19:09
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by Lamdage22 on January 19, 2015, at 12:24:00
So, when do you plan to increase amisulpride and decrease Zyprexa? Once you've increased amisulpride up to about 150-200mg twice a day you might be able to start tapering off Zyprexa slowly. You don't really want to be on three antipsychotics. If you suffer symptoms like insomnia during reduction of Zyprexa it may be useful to add a sleep med on a short-term basis. I suspect that trazodone will not be useful since its sedative properties are mainly due to activity at receptors already blocked by Seroquel (and Zyprexa). A small dose of zopiclone could be used temporarily, perhaps.
Do you have diarrhoea? Perhaps you could use rehydration sachets and a little bit of loperamide.
If you haven't already, you should have an ECG due to being on so many antipsychotics.
Posted by Lamdage22 on January 19, 2015, at 14:27:03
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by ed_uk2010 on January 19, 2015, at 13:19:09
Hey ed.
No stool is normal.
Getting my heart checked out? Hmm my psychiatrist seems to not find that necessary.
He doesnt do squat, i havent had that i months!
Almost a year.
Posted by Lamdage22 on January 19, 2015, at 14:39:50
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by Lamdage22 on January 19, 2015, at 14:27:03
Is being a good psychiatrist SO hard??
Seriously. Why the heck cant i just rely on my doctor!!
Posted by ed_uk2010 on January 19, 2015, at 14:44:27
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by Lamdage22 on January 19, 2015, at 14:27:03
Maybe just wait until you're on a higher dose of amisulpride and then get your GP/doctor to do an ECG (12 lead). ECG monitoring is recommended for all high dose antipsychotic treatment. Your current treatment counts as high dose due to the greater than maximum dose of Seroquel plus two other antipsychotics. The ECG is a precaution.
Posted by Lamdage22 on January 20, 2015, at 6:19:54
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by ed_uk2010 on January 19, 2015, at 14:44:27
Even more proof that my current psychiatrist is a dumbfuck.
Its really disheartening.
Posted by ed_uk2010 on January 20, 2015, at 8:27:46
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by Lamdage22 on January 20, 2015, at 6:19:54
Please can you write an up-to-date list of your current meds and doses. Not certain quite what you're on.
Posted by ed_uk2010 on January 20, 2015, at 8:55:49
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by Lamdage22 on January 20, 2015, at 6:19:54
High dose antipsychotic treatment can include above maximum doses of single drugs, combinations which count as high doses when taken together, or in your case - both. In terms of physical monitoring, intermittent ECGs, pulse and blood pressure monitoring, and weight/BMI checks should be sufficient for you. Temperature monitoring is more important for the elderly, and in those treated with high-potency neuroleptics like haloperidol (due to the higher risk of neuroleptic malignant syndrome with these drugs).
Blood tests performed to monitor antipsychotic safety may include:
Plasma glucose, and possibly HbA1c - diabetes checks. Early morning glucose level after an overnight fast is useful.
Plasma lipids - cholesterol, triglycerides. Triglycerides in particular are often elevated by olanzapine. Quetiapine sometimes does the same. Amisulpride causes much milder metabolic changes.
Plasma electrolytes and kidney function - electrolytes such as potassium must be normal for high doses of antipsychotics to be used. Kidney function should be checked in metformin and amisulpride users. Amisulpride and metformin are eliminated predominantly by the kidneys. Olanzapine and quetiapine are excreted following metabolism by the liver.
Full blood count and liver function tests - may be performed occasionally. Quetiapine sometimes leads to abnormal results here but they are usually minor. Full blood counts are useful for general health monitoring, however.
Prolactin - can be measured if sexual dysfunction or loss of libido occurs, or once or a maintenance dose of amisulpride has been established, or after 3 months of treatment (in the absence of symptoms). It's useful to have a baseline before starting antipsychotics (or a new antipsychotic), but in your case it was probably normal or mildly elevated before starting amisulpride. Quetiapine rarely causes significant prolactin elevation. Olanzapine sometimes causes mild elevations, but marked elevations are uncommon. I think you should assume minor/insignificant elevation before starting amisulpride, and take that as your baseline. Prolactin is best measured around an hour after waking, and an hour after breakfast. Stress should be minimised because it can cause a spike in prolactin levels. It is often necessary to re-test if a moderate elevation is found. If it is normal, or if it is extremely high - that tells you more.
I imagine you'll be able to get most physical monitoring and blood tests through your non-psych doctor. Apart from prolactin, all the tests are very routine indeed.
Posted by Lamdage22 on January 21, 2015, at 5:59:55
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by ed_uk2010 on January 20, 2015, at 8:55:49
i must say im not feeling very well and i suspect it is from amisulpride!
Posted by ed_uk2010 on January 21, 2015, at 6:57:55
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by Lamdage22 on January 21, 2015, at 5:59:55
> i must say im not feeling very well and i suspect it is from amisulpride!
In what way are you not feeling well? Also, have you changed the doses of your other meds? How much amisulpride are you on now?
Posted by Lamdage22 on January 21, 2015, at 10:40:05
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by ed_uk2010 on January 21, 2015, at 6:57:55
Havent changed my other meds. 100mg of amisulpride and i feel like sh*t.
I havent been very motivated before but now?? Terrible
Posted by ed_uk2010 on January 21, 2015, at 10:59:15
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by Lamdage22 on January 21, 2015, at 10:40:05
> Havent changed my other meds. 100mg of amisulpride and i feel like sh*t.
>
> I havent been very motivated before but now?? TerribleSo you were more motivated on 50mg and less on 100mg?
To be honest, you're on three antipsychotics. You may not be able to tolerate amisulpride without reducing Zyprexa.
Posted by Lamdage22 on January 21, 2015, at 11:39:11
In reply to Re: Mutiple mechanism with Zyprexa and some atypicals, posted by ed_uk2010 on January 21, 2015, at 10:59:15
Initially i thought it was mood lifting.
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