![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 61. This is the beginning of the thread.
Posted by Rick on June 8, 2000, at 0:50:53
Hope it's not too good to last:
Klonopin (1 mg morning, .25 mg afternoon)
Serzone (150 mg morning, 150 mg evening)
Provigil (200 mg morning)(Since these meds plus the Prilosec I'm taking are metabolized largely through the same liver enzymes, bioavailability may be increased for some of them...thus keeping my dosage requirements somewhat lower than usual.)
Klonopin's been great all along, but I've been looking for an even higher level of improvement. Everthing else I've tried, either before or since starting Klonopin, has failed to provide enhancement and/or has caused non-abating bothersome side effects.
The Provigil is incredible, at least for me. I was afraid it would cause counter-productive nervousness, especially when I upped the daily dose from 100 mg to the 200 mg generally recommended for the med's official narcolepsy indication. But instead, the Provigil consistently provides a great "non-wired" wakefulness (although with NO problem sleeping when I WANT to); enhances energy, motivation and cognition; and makes me more assertive and a lot more sociable. I just hope what some have said about a tendency for Provigil to poop out doesn't surface for me.
For the record, I've been taking Klonopin about ten months (but less now than previously); Serzone for about four weeks (added it to Celexa, then soon dumped the Celexa); and Provigil for about three weeks.
Just wanted to share a success story regarding treatment of my non-depressive Social Anxiety. Who knows if it will last? But so far *every* day for the last two weeks has been just wondeful -- morning to afternnon to night to snooze-land. And as good as everything is now, things seem to be headed nowhere but up.
Rick
Posted by JohnL on June 8, 2000, at 17:42:30
In reply to Social Phobia Cocktail -- WOW!!!, posted by Rick on June 8, 2000, at 0:50:53
But so far *every* day for the last two weeks has been just wondeful -- morning to afternnon to night to snooze-land. And as good as everything is now, things seem to be headed nowhere but up.
>
> Rick
Rick,That is so cool! Music to my ears! I love it. Thanks for sharing the good news!
JohnL
Posted by AndrewB on June 8, 2000, at 21:06:26
In reply to Social Phobia Cocktail -- WOW!!!, posted by Rick on June 8, 2000, at 0:50:53
Sounds like a great combo.
Why take Nardil when a combo. like this exists.
A previous poster said that ritalin plus klonopin was a great combo. for social anxiety. This sounds better though since Provigil isn't anxiety producing like ritalin can be.
I know the amisulpride that helps me so much with social anxiety is enhanced by reboxetine. I think reboxetine is similar to Provigil.
AndrewB
Posted by SLS on June 9, 2000, at 10:03:06
In reply to Re: Social Phobia Cocktail -- WOW!!!, posted by JohnL on June 8, 2000, at 17:42:30
> But so far *every* day for the last two weeks has been just wondeful -- morning to afternnon to night to snooze-land. And as good as everything is now, things seem to be headed nowhere but up.
> >
> > Rick
>
>
> Rick,
>
> That is so cool! Music to my ears! I love it. Thanks for sharing the good news!
> JohnLThat is so cool.
- Scott
Posted by DASH on June 9, 2000, at 11:30:32
In reply to Re: Social Phobia Cocktail -- WOW!!!, posted by AndrewB on June 8, 2000, at 21:06:26
> Sounds like a great combo.
>
> Why take Nardil when a combo. like this exists.
>
> A previous poster said that ritalin plus klonopin was a great combo. for social anxiety. This sounds better though since Provigil isn't anxiety producing like ritalin can be.
>
> I know the amisulpride that helps me so much with social anxiety is enhanced by reboxetine. I think reboxetine is similar to Provigil.
>
> AndrewB
JUST A WORD ON RITILAN. I TRIED IT W/KLONOPIN AND WALKED RIGHT OUT OF A JOB. I NEVER HAVE MUCH OF ATEMPER BUT IT BROUGHT OUT THE WORST IN ME. THINK I'LL LOOK INTO THE PROVIGIL. I'VE NEVER HEARD OF IT.
Posted by S.D. on June 9, 2000, at 14:40:46
In reply to Social Phobia Cocktail -- WOW!!!, posted by Rick on June 8, 2000, at 0:50:53
>
> For the record, I've been taking Klonopin about ten months (but less now than previously); Serzone for about four weeks (added it to Celexa, then soon dumped the Celexa); and Provigil for about three weeks.
>
> Just wanted to share a success story regarding treatment of my non-depressive Social Anxiety.
>
> RickCan you comment on the use of Celexa and Serzone (SSRIs) considering that you say you are non-depressive? I know that SSRIs are used for Social Anxiety but I was wondering if there was a reason for these particular ones - side-effect tolerance?
peace and health,
S.D.
(who has had some anti-social-anxiety effect from Kava Kava and Neurontin (separately), but is still struggling with it.)
Posted by S.D. on June 9, 2000, at 17:14:11
In reply to Social Phobia Cocktail -- WOW!!!, posted by Rick on June 8, 2000, at 0:50:53
>I just hope what some have said about a tendency
>for Provigil to poop out doesn't surface for me.
>
Maybe some of our resident pharmacology/neurochemistry experts can help out, but aren't Klonopin and Provigil kind of opposite? (Klonopin increasing GABA(†) and Provigil (modafinil) decreasing it(‡) ). Does this suggest any danger besides the two possibly counteracting each other's effect to some extent?† sorry, no ref. for this but I believe it's right
‡ "The effects of modafinil on glutamatergic and GABAergic transmission in the rat medial preoptic area (MPA) and posterior hypothalamus (PH), are analysed. Modafinil (30-300 mg/kg) increased glutamate and decreased GABA levels in the MPA and PH."
- from (according to http://www.modafinil.com/glutam.html):
"The vigilance promoting drug modafinil increases extracellular glutamate levels in the medial preoptic area and the posterior hypothalamus of the conscious rat: prevention by local GABAA receptor blockade"
by
Ferraro L, Antonelli T, Tanganelli S, O'Connor WT,
Perez de la Mora M, Mendez-Franco J, Rambert FA, Fuxe K
Department of Clinical and Experimental Medicine,
University of Ferrara, Italy.
Neuropsychopharmacology 1999 Apr; 20(4):346-56-------
Regarding, poop-out:
The information below may explain some cases of Provigil poop-out; in which case a dose increase should restore the effect. Don't know if this would mean dose would have to continue to be increased indefinitely.From: http://www.rxlist.com/cgi/generic2/modafinil_ad.htm#DI
"In a controlled study in patients with narcolepsy, chronic dosing of PROVIGIL at 400 mg/day once daily resulted in a ~20% mean decrease in modafinil plasma trough concentrations by week 9, relative to those at week 3 suggesting that chronic administration of PROVIGIL might have caused induction of its metabolism."peace and health,
S.D.
Posted by Rick on June 10, 2000, at 2:41:01
In reply to Celexa, Serzone? (Re: Social Phobia Cocktail...) » Rick, posted by S.D. on June 9, 2000, at 14:40:46
SD -SSRI's are typically the first-line meds tried for Social Phobia today, whether the patient has depression or not (although my pdoc prescribed Nardil first, with Xanax as-needed). The first-line use of SSRI's could be for a variety of reasons, including:
-- They are popular, have big marketing budgets, and are viewed as safe and tolerable (hmmm....)
-- Many (most?) Social Phobics ARE depressive and/or have other comorbid condtions such as Panic Disorder, which SSRI's can frequently treat efectively.
-- Many docs and patients are (usually unreasonably) benzo-phobic and don't want to have the patient take something like Klonopin on an ongoing basis.
-- Similarly, many doctors and patients shy away from MAOI's like Nardil because of the (somewhat overstated) safety/liability issues. Also, the side effects can be pretty severe for some people, like me.
I tried Celexa for a couple of reasons. One is that it showed great success in a Social Phobia study. However, that was a small open (non-placebo-controlled) study in South Africa. Another reason is that I knew two people who had great success with it, although that was for depression (with generalized -- not social -- anxiety in one case). Also, the manufacturer and researchers have claimed that Celexa has a more benign side-effect profile than other SSRI's, e.g., with less sexual dysfunction. Also, I had heard lots of horror stories about Paxil side effects (although some people seem to tolerate it very well, especially after the first 2-4 weeks).
At 20mg/day, the Celexa definitely seemed to add some benefit, but not a great amount. Raising the dose only seemed to cause side effects (especially fatigue and moderate sexual dysfunction) without increasing efficacy.
While technically an antidepressant, Serzone is known as having strong anti-anxiety qualities, and a few open studies have shown promising results for Social Phobia. As you may know, while Serzone increases serotonin (and to a lesser extent nor
Posted by Rick on June 10, 2000, at 2:54:47
In reply to Re: Celexa, Serzone? (Re: Social Phobia Cocktail...), posted by Rick on June 10, 2000, at 2:41:01
(Don't know why my post aborted midway...maybe I didn't read the "fine print", and missed some restriction on post length. Anyways, here's the rest -- I hope!)While technically an antidepressant, Serzone is known as having strong anti-anxiety qualities, and a few open studies have shown promising results for Social Phobia. As you may know, while Serzone increases serotonin (and to a lesser extent norepinephrine) it does so primarily through a different mechanism than the SSRI's. Many people seem to suffer side effects with Serzone, although I have not. Maybe that is because I am on a low-side dose. Also, sedation is one of the most common complaints when you get to theraputic dosages, so maybe the Provigil is counteracting such an effect for me. Further, unlike the SSRI's, it is very uncommon for Serzone to cause sexual difficulty, except perhaps at very high doses. Indeed, recent studies have shown that Serzone *enhances* sexual performance and desire for many people, especially women.
Moving on to the stimulant side of the equation: To help counter Celexa-induced fatigue and lack of motivation, my pdoc had me try adding a small dose of Wellbutrin. This helped with the fatigue, but brought back much of my Social Anxiety. Similary, when I felt a little slow on Klonopin in the early days of my treatment (I later discovered that this was because I was taking substantially more Klonopin than my body "wanted"), we added a small dose of Selegiline. Again, this was great for wakefulness and cognition (and added to my already-O.K. sex drive), but it produced nervousness which worked against the Social Phobia benefits of the Klonopin.
Now, Provigil is a different story! It actually provides more mental stimulation and wakefulness than the other "activating" meds, but with no increase in anxiety or peripheral shakiness. I feel pleasantly "up" but not wired. Provigil just makes me feel good and MORE socially comfortable. I feel confident, awake and motivated without the counte
Posted by Rick on June 10, 2000, at 3:12:39
In reply to REST OF POST (Re: Celexa, Serzone, Soc Phobia...) , posted by Rick on June 10, 2000, at 2:54:47
(O.K., This is not funny, cyber-gods. Here's more of my continually-aborted post):Now, Provigil is a different story! It actually provides more mental stimulation and wakefulness than the other "activating" meds, but with no increase in anxiety or peripheral shakiness. I feel pleasantly "up" but not wired. Provigil just makes me feel good and MORE socially comfortable. I feel confident, awake and motivated without the counterbalancing nervousness and daily "crashing" that stimulating AD's, and especially stronger stimulants, can cause in someone with an anxiety disorder. Provigil is the first non-amphetemine stimulant introduced in the U.S. in 40 years. It apparently works in a novel, selective way that creates all the desired effects without the secondary effects that are especially troublesome for anxiety sufferers. And you only need to take it once a day, in the morning. I view it as a "friendly" stimulant. The downside, if you don't have the right kind of insurance -- or any at all, is that it is extremely expensive. Also, I know that a small proportion of users have suffered some side effects including increased anxiety -- though this may go away as the body adjusts. Finally, Provigi's only official indication so far is narcolepsy, and there are many psychiatrists (let alone general practitioners) who are reluctant to try it until they have more feedback from peers, articles, etc. My own pdoc had never prescribed it, and I had to cajole him into letting me try it. He wanted to give me Ritalin instead (I do not have ADD). I showed him several articles and posts from the net to help make my case. One was from the respected Medscape site, where an article on psychiatric med dosing expressed surprise that modafinil (Provigil) has been highly under-utilized as an antidote to AD-caused fatigue. Hope this helps.
Rick
-----
Can you comment on the use of Celexa and Serzone (SSRIs) considering
that you say you are non-depressive? I know that SSRIs are used for So
Posted by Rick on June 10, 2000, at 16:20:28
In reply to Provigil poop out; klonopin counteracts provigil?, posted by S.D. on June 9, 2000, at 17:14:11
You're right, SD, this is certainly one for the neurology/psychopharmacology experts to chime in on. But at this stage, rat brain GABA-inhibition studies can provide nothing more than theoretical food for thought on the possible clinical effect of adding Provigil in Klonopin-treated human Social Phobia.
There are just so many factors to consider that I cannot even begin to enumerate them (and I'm sure there are even far more considerations that the experts could cite). But here are just a few of the thoughts that come to mind (with the disclaimer that a few of my layman satements *might* reflect incomplete or even plain-wrong understanding of pharmocological or psychiatric issues):
-- GABA reactions to Provigil could be different in socially anxious rats, and certainly could be different in humans.
-- Several of the studies of the anti-GABA effects of Provigil varied from significant in some regions of the brain to nil (or requiring a much higher dose of Provigil) in others.
-- While similar in many ways, different benzos vary in strength and theraputic value. For instance, Klonopin is a high-potency benzo that has been proven very effective in Social Phobia, while Valium usually has no value at all in treating this form of anxiety. Moreover, Klonopin's unique effects in a variety of non-anxiety disorders such as epilepsy, restless leg syndrome, dystonia, and tremor, suggestions a pharmacology which may involve more than simple GABA agonism.
--If I was reading the studies correctly, the observed GABA-reduction with Provigil (and again, occuring only in selected site/dosage situations) maxed at 20%. (It was hard for me to understand the data as presented. I *believe* the 80% figure cited represented the amount of GABA *maintained* at those sites, but maybe it instead referred to GABA *reduction* levels.) A 20% maximum reduction would proably not have much clinical import, especially if other significant sites were unaffected.
-- For me, concurrent use of three C
Posted by Rick on June 10, 2000, at 16:32:05
In reply to Re: Provigil poop out; klonopin counteracts provigil?, posted by Rick on June 10, 2000, at 16:20:28
(I'm still having trouble getting everything to post at once, so here's more -- hopefully through the end):
-- For me, concurrent use of three CYP 450-metabolized drugs might be increasing the bioavailabily and clinical effect of some of them. A likely candidate this kind of potentiating effect would be the Klonopin, which would help offset any anti-GABA effects of Provigil. From everything I've read, Provigil shows little increase in benefit at dosages higher than the standard 200mg; while proportionally, bioavailabilty increases add to Klonopin's anxiolytic properties over a pretty wide range. Also, while not specifically tested, phrmacologists seem to widely believe that Serzone inhibits metabolism of Klonopin, and thus increases its blood levels. It has been demonstrated that Serzone doubles Xanax availability two-fold, and increases blood concentration of another benzo (was it triazolam?) so dramatically that concommitant (sp?) use is discouraged. Incidentally, the official Provigil monograph specifically cites studies that looked at its use with selected benzos, and does not report any watchouts for such a cobination While their focus was on safety of the combination (no problems found), I would suspect that loss of anxiolytic effect would have been led to a warning, contraindication, or suggestion to monitor benzo effectiveness and increase the benzo dosage if warranted. Finally, while new interactions are being uncovered for lots of psychoactive drugs every year (some of them beneficial), drug interaction sites such as Mayo Clinic, Drug Data Bank, and CVS show very few reported interactions with Provigil, and in particular none between Provigil and any benzo. While Provigil has only been in the U.S. about 18 months, France -- a country with heavy benzo usage -- has had over ten years to uncover interactions. (It would be interesting to see a French monograph for Provigil.)
-- To me, this is probably the best evidence of all that Provigil doesn't kill the ef
Posted by Rick on June 10, 2000, at 16:42:37
In reply to More:Provigil poop out;klono counteracts provigil?, posted by Rick on June 10, 2000, at 16:32:05
(Let's continue, shall we?)
--To me, this is probably the best evidence of all that Provigil doesn't kill the effects of Klonopin: When I take my small afternoon dose of Klonopin (0.25mg), I can really FEEL it, even more so than before I started the Provigil. The two meds feel like they are *complementing* each other by treating different components of my Social Phobia.
Anyways, those are just a few of my thoughts regarding the possibility of Klonopin and Proigil working at cross-purposes. Theory and narrowly-focused, vaguely-suggestive rat-brain studies aside, for me the bottom line is that everything other treatment I've tried has paled beside this combo. (Although I should reiterate that 1.5-2.0 mg Klonopin alone helped me an awful lot. What I'm doing now is "going for the gold".)
I'm thrilled with my Social Phobia cocktail of Serzone, Klonopin, and Provigil.Rick
-----> >I just hope what some have said about a tendency
> >for Provigil to poop out doesn't surface for me.
> >
> Maybe some of our resident pharmacology/neurochemistry experts can help out, but aren't Klonopin and Provigil kind of opposite? (Klonopin increasing GABA(†) and Provigil (modafinil) decreasing it(‡) ). Does this suggest any danger besides the two possibly counteracting each other's effect to some extent?
>
> † sorry, no ref. for this but I believe it's right
>
> ‡ "The effects of modafinil on glutamatergic and GABAergic transmission in the rat medial preoptic area (MPA) and posterior hypothalamus (PH), are analysed. Modafinil (30-300 mg/kg) increased glutamate and decreased GABA levels in the MPA and PH."
> - from (according to http://www.modafinil.com/glutam.html):
> "The vigilance promoting drug modafinil increases extracellular glutamate levels in the medial preoptic area and the posterior hypothalamus of the conscious rat: prevention by local GABAA receptor blockade"
> by
> Ferraro L, Antonelli T, Tanganelli S, O'Connor WT,
> Perez de la Mora M, Mendez-Franc
Posted by michael on June 10, 2000, at 17:22:46
In reply to More:Provigil poop out;klono counteracts provigil?, posted by Rick on June 10, 2000, at 16:32:05
Rick:(It would be interesting to see a French monograph for Provigil.)
>
http://www2.biam2.org/www/Sub4900.htmlVoila:
MODAFINIL
Introduction dans BIAM : 8/2/1993
Dernière mise à jour : 10/4/2000
Etat : validéeIdentification de la substance
Propriétés Pharmacologiques
Mécanismes d'action
Effets Recherchés
Indications thérapeutiques
Effets secondaires
Effets sur la descendance
Pharmaco-Dépendance
Précautions d'emploi
Contre-Indications
Voies d'administration
Posologie & mode d'administration
Pharmaco-Cinétique
Bibliographie
Spécialités contenant la substance
Identification de la substance
Formule Chimique :
[(Diphénylméthyl)sulfinyl]-2 acétamideEnsemble des dénominations
CAS : 68693-11-8
DCIR : MODAFINIL
bordereau : 2973 code expérimentation : CRL-40476
rINN : MODAFINIL
Regime : liste I
Remarque sur le regime : JO 20/09/92Proprietés Pharmacologiques
PSYCHOSTIMULANT (principale certaine)
Mécanismes d'actionprincipal
Substance éveillante de mécanisme différent des amphétamines. Son activité serait liée à l'activation de la transmission alpha adrénergique au niveau central par un mécanisme qui reste à préciser.
L'activité pourrait être due à une réduction de l'activité gabaergique corticale consécutive à une activation noradrénergique et sérotoninergique :
- Eur J Pharmacol 1995;273:63-71.
Effets RecherchésPSYCHOSTIMULANT (principal)
Indications ThérapeutiquesNARCOLEPSIE (principale)
Référence :
- Lettre du Pharmacologue 1995;9:3-42.
Etude positive sur 283 patients traités pendant 9 semaines:
- Ann Neurol 1998;43:88-97.
Etude multicentrique sur 283 patients traités 9 semaines; résultats positifs:
- Ann Neurol 1998;43:88-97.HYPERSOMNIE (principale)
Hypersomnie idiopathique.
Diminue la somnolence diurne associée aux apnées du sommeil.SYNDROME DE GELINEAU (principale)
Agit sur la composant narcoleptique du syndrome de Gélineau :
- Lettre du Pharmacologue 1995;9:3-42.
Effets secondairesEXCITATION PSYCHOMOTRICE (CERTAIN RARE)
Episodes d'excitation.INSOMNIE (CERTAIN RARE)
ANOREXIE (CERTAIN RARE)
NAUSEE (CERTAIN RARE)
SIALORRHEE (CERTAIN RARE)
DOULEUR EPIGASTRIQUE (CERTAIN RARE)
CEPHALEE (CERTAIN RARE)
ERUPTION CUTANEE (CERTAIN TRES RARE)
DYSKINESIE BUCCOFACIALE (CERTAIN TRES RARE)
TACHYCARDIE (CERTAIN TRES RARE)
Tachycardie modérée.
Effets sur la descendanceNON TERATOGENE CHEZ L'ANIMAL
Etude réalisée chez le rat, le lapin.INFORMATION MANQUANTE DANS L'ESPECE HUMAINE
Pharmaco-DépendanceNON
A ce jour, la non existence d'un potentiel de pharmacodépendance du modafinil n'a pas été nettement établie :
- Aviat Space Environ Med 1991;62:432-435.
Précautions d'emploiSPORTIFS
Substance interdite :
- Journal Officiel du 7 Mars 2000.INSUFFISANCE CORONARIENNE
TROUBLE DU RYTHME VENTRICULAIRE
INSUFFISANCE HEPATOCELLULAIRE GRAVE
Réduire la posologie de moitié.
Contre-IndicationsANXIETE
Anxiété majeure.GROSSESSE
Information manquante.ALLAITEMENT
Information manquante.
Voies d'administration
- 1 - ORALEPosologie et mode d'administration
Doses usuelles par voie orale :
Adultes : deux cents à quatre cents milligrammes par jour (200 à 400 mg/j) en deux prises, matin et soir.
Pharmaco-Cinétique
- 1 - REPARTITION 62 % lien protéines plasmatiques
- 2 - DEMI VIE 10 à 13 heure(s)
- 3 - ELIMINATION voie rénaleAbsorption
Résorption lente.
Pic plasmatique voisin de 3,7 mg/l après une prise orale de de 200 mg.
La biodisponibilité n'est pas modifiée par la prise d'aliments.
Le pic plasmatique est retardé et la biodisponibilité est doublée en cas d'insuffisance hépatique.
Répartition
Liaison aux protéines plasmatiques : 62%.
Demi-Vie
La demi-vie se situe entre 10 et 13 heures .
Les demi-vies d'élimination sont indépendantes de la dose administrée pour des doses comprises entre 50 et 400 mg.
La demi-vie est doublée chez l'insuffisant rénal ou hépatique.
Métabolisme
Le modafinil est métabolisé par le foie en modafinil acide et modafinil sulfone.
Elimination
(VOIE RENALE)
Principalement éliminé dans les urines sous forme de modafinil acide. Environ 10% de la dose administrée sont éliminés sous forme inchangée.
Bibliographie
- Dossier d'Information Médicale et Pharmaceutique du produit MODIODAL- 1994, Laboratoire LAFON. (CREATION)
Spécialités
Principe actif présent en constituant unique dans les spécialités françaises suivantes :
MODIODAL 100 mg comprimés
Principe actif présent en constituant unique dans les spécialités étrangères suivantes :
PROVIGIL (GRANDE-BRETAGNE)
Associations avec des substances
A SURVEILLER :CICLOSPORINE
CLOMIPRAMINE CHLORHYDRATE
Posted by michael on June 10, 2000, at 17:35:50
In reply to More:Provigil poop out;klono counteracts provigil?, posted by Rick on June 10, 2000, at 16:32:05
(It would be interesting to see a French monograph for Provigil.)
>
The french one's difficult to read - this one is from a brittish db. It appears they've been using it at least since 1997, possibly longer...Cephalon UK Limited
11/13 Frederick Sanger Road
Surrey Research Park
Guildford GU2 5YD
Telephone: 01483 453360 Facsimile: 01483 453324
PROVIGIL TM
Qualitative and quantitative composition
Modafinil 100 mg per tablet.Pharmaceutical form
Tablets.Clinical particulars
Therapeutic indications: Narcolepsy.
Posology and Method of Administration:Adults: The recommended daily dose is 200-400 mg. PROVIGIL may be taken as two divided doses in the morning and at noon, or as a single dose in the morning according to physician assessment of the patient and the patient's response.
Elderly: There are limited data available on the use of PROVIGIL in elderly patients. In view of lower clearance and increased AUC, it is recommended that patients over 65 years of age should commence therapy at 100 mg daily. The maximum dose of 400 mg per day should only be used in the absence of renal or hepatic impairment.
Hepatic and renal failure: The dose in patients with severe hepatic or renal failure should be reduced by half (100-200 mg/day).
Children: See Contra-indications.
Contra-indications: PROVIGIL is contra-indicated for use during pregnancy and lactation, in children, moderate to severe hypertension, and arrhythmia. Known hypersensitivity to PROVIGIL or any component of the preparation.
Special warnings and special precautions for use: Patients with major anxiety should only receive treatment with PROVIGIL in a specialist unit.
Sexually active women of child-bearing potential should be established on a contraceptive programme before taking PROVIGIL.
Blood pressure and heart rate should be monitored in hypertensive patients.
It is recommended that PROVIGIL tablets not be used in patients with a history of left ventricular hypertrophy or ischaemic ECG changes, chest pain, arrhythmia or other clinically significant manifestations of mitral valve prolapse in association with CNS stimulant use.
Whilst studies with modafinil have demonstrated a low potential for dependence, as with other psychoactive agents, the possibility of dependence with long term use cannot be entirely excluded.
Interactions with other medicaments and other forms of interaction:
Oral contraceptives: The effectiveness of oral contraceptives may be impaired due to enzyme induction activity of PROVIGIL. When oral contraceptives are used, a product containing 50 micrograms or more of ethinyl oestradiol should be taken. Adequate contraception will require continuation of the oral contraceptive for two cycles after stopping PROVIGIL.
Tricyclic antidepressants: In a single dose pharmacokinetic interaction study of PROVIGIL (200 mg) and clomipramine (50 mg), no clinically important alterations in the pharmacokinetic profile of PROVIGIL or clomipramine were noted, however, patients receiving such medication should be carefully monitored.
Anti-convulsant therapy: In view of the enzyme inducing potential of PROVIGIL, care should be observed with co-administration of these drugs.
Pregnancy and lactation: Modafinil has been shown to be non-teratogenic in preclinical reproductive toxicology investigations at doses greater than the maximum clinical dose. However, blood levels in preclinical safety studies, due to metabolic autoinduction, were less than or similar to that expected in patients. As there have been no adequate or well controlled studies of modafinil in pregnant women, PROVIGIL should be contra-indicated for use in pregnancy and lactation.
Effects on ability to drive and use machines: There is no information available concerning the effects of PROVIGIL on vehicle driving and/or the ability to use machinery.
Undesirable effects: Episodes of feelings of nervousness, excitation, aggressive tendencies, insomnia, personality disorder, anorexia, headache, CNS stimulation, euphoria, abdominal pain, dry mouth, palpitation, tachycardia, hypertension, and tremor have been reported.
Gastrointestinal disturbances (nausea, gastric discomfort) have been reported in clinical trials, usually regressing when tablets are taken during meals. There have also been reports of pruritic skin rashes and, very rarely, cases of buccofacial dyskinesia.
A dose related increase in alkaline phosphatase has been observed.
The safety of PROVIGIL has not been studied beyond 40 weeks of continuous use.
Overdose: The chief symptom following massive ingestion is insomnia.
Management: Induced emesis or gastric lavage should be considered. Hospitalisation and surveillance of psychomotor status; cardiovascular monitoring or surveillance until the patient's symptoms have resolved.
Pharmacological properties
Pharmacodynamic properties: Modafinil promotes wakefulness in a variety of species, including man. The precise mechanism(s) through which modafinil promotes wakefulness is unknown, although the wake-promoting effects of modafinil can be attenuated by alpha-adrenergic antagonists.
Modafinil in man restores and/or improves the level of wakefulness and daytime alertness in relation to the dose administered. Starting from the dose of 100 mg in the morning, changes are found in electrophysiological parameters reflecting alertness (ratio of power of alpha rhythm to power of ;gq rhythm). Starting from 200 mg in the morning, an increase is seen in latency periods in the multiple sleep latency test. It opposes the impairment of cognitive (memory in particular), psychomotor and neurosensorial performances induced by sleep deprivation. This activity is obtained in the absence of any modifications concerning behaviour, appetite and habituation.Morning administration of 200 mg does not appear to affect nocturnal sleep. Administration of 100 mg morning and noon may prolong the subjective time taken to fall asleep. Evening administration may disturb sleep. This pharmacodynamic activity does not appear to affect the autonomic nervous system.
Pharmacokinetic properties: The pharmacokinetics of modafinil are linear and independent of the dose administered. Absorption of modafinil following oral administration is good but slow. Peak plasma concentration is reached two to three hours after ingestion. Amounts absorbed increase in proportion to doses administered.
Modafinil is moderately bound to plasma proteins (62%), essentially to albumin. This degree of protein binding is such that the risk of interaction with strongly bound drugs is unlikely.
Modafinil is metabolised by the liver. The chief metabolite (40-50% of the dose), acid modafinil, has no pharmacological activity. The excretion of modafinil and its metabolites is chiefly renal, with a small proportion being eliminated unchanged (< 10%).
The elimination half-life of modafinil is long (10-12 hours) and enables a treatment regimen based upon one or two doses/day.
Preclinical safety data: Toxicology studies by single and repeated dosing have revealed no particular toxic action in animals.
Reproduction function studies have revealed no effect on fertility, nor any teratogenic effect, nor any effect on viability, growth or development of the offspring.
This drug is not considered to be mutagenic or carcinogenic.
Animal exposure to modafinil, based on actual blood levels in the general toxicology, reproductive and carcinogenicity studies, was less than or similar to that expected in humans. This circumstance is the result of metabolic auto-induction noted in the preclinical studies. However, animal exposure on a mg/kg dose basis to modafinil in the general toxicology, reproductive and carcinogenicity studies was greater than the expected exposure, calculated on a similar basis, in humans.
Pharmaceutical particulars
List of excipients: Lactose monohydrate, corn starch, magnesium silicate, croscarmellose sodium, povidone K90, talc and magnesium stearate.
Incompatibilities: None knownShelf life: Three years
Special precautions for storage: Store at less than 25°C in a dry place. Protect from direct heat and sunlight.
Nature and contents of container: 30 tablets in PVC/PE/Aclar/Aluminium blister
60 tablets in PVC/PE/Aclar/Aluminium blister
90 tablets in PVC/PE/Aclar/Aluminium blister
Instructions for use/handling: Not applicable.
Marketing authorisation number
PL 16260/0001Date of first authorisation/renewal of authorisation
14 October 1997Date of (partial) revision of text
22 June 1998
Posted by Rick on June 10, 2000, at 20:06:04
In reply to how about a brittish monograph? » Rick, posted by michael on June 10, 2000, at 17:35:50
Thanks for the European monograhps on modafinil, Michael.
I ran the French monograph (the original, not your copy) through Alta-Vista translation, and it turned out to say pretty much the same thing as the British one.
Wow, I never realized how much more thorough U.S. monograhps are! Maybe that's reflective of the amount of testing that's required before the FDA will approve a drug.
None of the monographs discourage combination benzo/Provigil use. In fact, the U.S. monograph has references to Provigil use with triazolam (no safety issues found) and diazepam. It says that Provigil may increase blood levels of diazepam (and other drugs which share Provigil's elimination mechanisms), thus calling for possible diazepam dosage reduction.
There are no absolute contraindications given at all in the U.S. monograph, except for known hyper-sensitivity to the drug. In terms of worsening of CNS-related disorders, the only problem seen was in one patient with a history of psychosis.
The French and British mongraphs, but not the U.S.'s -- warn against prescribing Provigil to patients with moderate-to-severe hypertension (BTW, it hasn't affected my blood pressure). The European, but not the American, guidelines also say that Provigil should be prescribed to patients with "Major Anxiety" only by a "specialist" (I assume this means a psychiatrist instead of a general practitioner.) I think that's prudent advice, but needn't be an "absolute". General practitioners often seem pretty much in the dark about depression, but they can be even more clueless when it comes to anxiety disordes like Panic, GAD, OCD. and Social Phobia. "Fun Fact": Did you know that in England the first-line medication for GENERALIZED Social Phobia is beta blockers??!!
Posted by SLS on June 11, 2000, at 10:27:50
In reply to Re: More:Provigil poop out;klono counteracts provigil?, posted by Rick on June 10, 2000, at 16:42:37
What are the current thoughts regarding the role of NE alpha-1 agonism in the wakefulness-promoting properties of Provigil?
> -- While similar in many ways, different benzos vary in strength and theraputic value. For instance, Klonopin is a high-potency benzo that has been proven very effective in Social Phobia, while Valium usually has no value at all in treating this form of anxiety. Moreover, Klonopin's unique effects in a variety of non-anxiety disorders such as epilepsy, restless leg syndrome, dystonia, and tremor, suggestions a pharmacology which may involve more than simple GABA agonism.
As far as the varied effects of the benzodiazepines are concerned, one factor underlying them may be that there are different subtypes of benzo-receptors to which they bind with varying affinities. In addition, I recall that Klonopin (clonazepam) was thought to have serotonergic properties.
> --If I was reading the studies correctly, the observed GABA-reduction with Provigil (and again, occuring only in selected site/dosage situations) maxed at 20%. (It was hard for me to understand the data as presented. I *believe* the 80% figure cited represented the amount of GABA *maintained* at those sites, but maybe it instead referred to GABA *reduction* levels.) A 20% maximum reduction would proably not have much clinical import, especially if other significant sites were unaffected.
I think 20% may be a pretty big number under certain conditions. Just think what a difference a 20% change in the dosage of a drug can make.
As you have mentioned, an important variable that is sometimes overlooked when attempting to understand the differing effects of drugs and neurotransmitters is in which locations or structures within the brain they accumulate and act.
From what I was able to glean from abstracts, despite my misspelling in the thread below, Provigil increases the extracellular concentration of glutamate in the hippocampus and thalamus. I believe it is this increase in glutamate that is responsible for the inhibition of GABAergic neurons there. Perhaps it is the inhibition of efferent GABAergic pathways that is responsible for the increased release of dopamine in the nucleus accumbens observed with Provigil. This may account for some of its psychostimulant effects - motivation, vigilance, reward-seeking, euphoria. Provigil also has been reported to increase the release of glutamate in the hypothalamus. Through similar mechanisms, this may be what is responsible for its ability to produce anxiety and activation. I don't know what the observed increased release of glutamate in the cerebral cortex is all about.
How would you compare modafinil and adrafinil in the treatment of depression? Is there a trend towards greater "poop-out" with modafinil?
What sorts of effects does adrafinil have on the liver, and what is the rate of occurrence?
- Scott
Posted by Rick on June 11, 2000, at 16:49:29
In reply to Re: More:Provigil poop out;klono counteracts provigil?, posted by SLS on June 11, 2000, at 10:27:50
(NOTE: Given the posting difficulties I've had recently, this post may end up getting cut-off in the middle. If so, I will post the second half in a follow-up message)
Scott -
You clearly have a deeper knowledge of pharmocology than I do. I found your observations very interesting.
I've never used adrafinil, and have little knowledge about it other than what I've read here on Psycho-Babble and the smart-drug sites. What I do know is that in France, quarterly liver-function tests are now required for adrafinil users because there have been some cases of significant hepatic toxicity. Modafinil (Provigil) does not share this requirement.
From what I've read recently, Provigil's mechanisms are still mostly a mystery. It is still usually referred to as an adrenergic drug, although a recent review from U.S. Pharmicist says that the original theory of direct or indirect NE alpha-1 agonism has fallen out of favor. Nonetheless, it appears that that Provigil won't promote wakefulness unless the alpha-adrenergic system is functioning properly. As for poop-out, again I can't speak to adrafinil, but as was noted earlier in the thread, poop-out reports reflect Provigil's tendency to sometimes start self-inducing production of metabolizing enzymes. The manufacturer says that this be corrected by a modest (and temporary?) dosage increase. I saw one nine-month study that showed sustained effectiveness (at a constant dose) for all responders.
The following from Lexi-Com seems to sum up the current theories pretty well, incuding the possibility of GABA reduction effects at certain sites:
"The exact mechanism of action is unclear, it does not appear to alter the release of dopamine or norepinephrine, it may exert its stimulant effects by decreasing GABA-mediated neurotransmission, although this theory has not yet been fully evaluated; several studies also suggest that an intact central alpha-adrenergic system is required for modafinil's activity; the drug increases high-frequ
Posted by Rick on June 11, 2000, at 17:02:22
In reply to Re: More:Provigil poop out;klono counteracts provigil?, posted by Rick on June 11, 2000, at 16:49:29
(As anticipated, my response to Scott was cut off midway. Continuing...)
"The exact mechanism of action is unclear, it does not appear to alter the release of dopamine or norepinephrine, it may exert its stimulant effects by decreasing GABA-mediated neurotransmission, although this theory has not yet been fully evaluated; several studies also suggest that an intact central alpha-adrenergic system is required for modafinil's activity; the drug increases high-frequency alpha waves while decreasing both delta and theta wave activity, and these effects are consistent with generalized increases in mental alertness."
Finally, I just ran across an interesting new Medline abstract of a small study of Provigil augmentation of antidepressants. I'll post that separately.
Rick
> What are the current thoughts regarding the role of NE alpha-1 agonism in the wakefulness-promoting properties of Provigil?
>
> > -- While similar in many ways, different benzos vary in strength and theraputic value. For instance, Klonopin is a high-potency benzo that has been proven very effective in Social Phobia, while Valium usually has no value at all in treating this form of anxiety. Moreover, Klonopin's unique effects in a variety of non-anxiety disorders such as epilepsy, restless leg syndrome, dystonia, and tremor, suggestions a pharmacology which may involve more than simple GABA agonism.
>
> As far as the varied effects of the benzodiazepines are concerned, one factor underlying them may be that there are different subtypes of benzo-receptors to which they bind with varying affinities. In addition, I recall that Klonopin (clonazepam) was thought to have serotonergic properties.
>
> > --If I was reading the studies correctly, the observed GABA-reduction with Provigil (and again, occuring only in selected site/dosage situations) maxed at 20%. (It was hard for me to understand the data as presented. I *believe* the 80% figure cited represented the amount of GABA *maintained* at those
Posted by Aimee on September 21, 2000, at 18:55:39
In reply to Social Phobia Cocktail -- WOW!!!, posted by Rick on June 8, 2000, at 0:50:53
Bless you, Rick! Thank you so much for detailing
your experiences with the various medications and
for coming up with your amazing cocktail.
My question for you is, do you take a generic form
of Klonopin or the original?Take Care,
Aimee
> Hope it's not too good to last:
>
> Klonopin (1 mg morning, .25 mg afternoon)
> Serzone (150 mg morning, 150 mg evening)
> Provigil (200 mg morning)
>
> (Since these meds plus the Prilosec I'm taking are metabolized largely through the same liver enzymes, bioavailability may be increased for some of them...thus keeping my dosage requirements somewhat lower than usual.)
>
> Klonopin's been great all along, but I've been looking for an even higher level of improvement. Everthing else I've tried, either before or since starting Klonopin, has failed to provide enhancement and/or has caused non-abating bothersome side effects.
>
> The Provigil is incredible, at least for me. I was afraid it would cause counter-productive nervousness, especially when I upped the daily dose from 100 mg to the 200 mg generally recommended for the med's official narcolepsy indication. But instead, the Provigil consistently provides a great "non-wired" wakefulness (although with NO problem sleeping when I WANT to); enhances energy, motivation and cognition; and makes me more assertive and a lot more sociable. I just hope what some have said about a tendency for Provigil to poop out doesn't surface for me.
>
> For the record, I've been taking Klonopin about ten months (but less now than previously); Serzone for about four weeks (added it to Celexa, then soon dumped the Celexa); and Provigil for about three weeks.
>
> Just wanted to share a success story regarding treatment of my non-depressive Social Anxiety. Who knows if it will last? But so far *every* day for the last two weeks has been just wondeful -- morning to afternnon to night to snooze-land. And as good as everything is now, things seem to be headed nowhere but up.
>
> Rick
Posted by Rick on September 22, 2000, at 2:18:23
In reply to Re: Social Phobia Cocktail -- WOW!!!, posted by Aimee on September 21, 2000, at 18:55:39
Aimee -
You're quite welcome! Am I correct in assuming that this is a combo you're considering, rather than currently taking?
While I'm usually fairly open to generics, I've heard so many users comment on a lower/variable potency for generic clonazepam that I've stuck with .5 mg (orange) branded Klonopin from the start. If you end up needing to split a .5 as I do, I suggest getting a good pill splitter. They're rather delicate, despite the scoring. Provigil 200 mg tabs, on the other hand, are pretty easy to simply break in half by hand along the score. (As I will discuss, I now typically need only 100 mg. Provigil to get the full benefits.)
Assuming you haven't started yet, I think there's a great chance you will enjoy the same luck I have had with this combo. Unless you're clinically depressed, I would take the Klonopin alone for the first two-four weeks, so that you can feel out what it does for you and how much you need, while ramping up to a full dose and working through any early sedation. (In a benzo/AD combination, why is the benzo the med always assumed to be causing sedation??) After the Klonopin calms your anxiety, then you can add the Serzone and Provigil together. (I started the Serzone first, but the Provigil seems to have "jump-started" it... and replaced some minor fatigue with major motivation and cognitive benefit.)
If you do have major depression, you might need to try any of several different approaches that could includie starting all three at once (although perhaps a little unorthodox and less analyzable). You'll have to work with your pdoc. But don't worry, even if the timing/sequencing causes some bumps along the way, you'll get there.
Over the last few months, I've stabilized on 1.25 mg/day of Klonopin (1.00 upon awakening, and .25 early afternoon; 450 mg/day Serzone (300 upon awakening, and 150 early afternoon); and 100 mg/day of Provigil when I get up. Once in awhile, for a day or two, I'll take an extra 100 mg. of Provigil at noon or just a little later. (I've always found that 200 mg doses of Provigil work better when staggered this way. You should avoid taking any less than ten hours before bedtime.)
If this cocktail IS "too good to last", I haven't seen any signs of poop-out yet!:
I've just been attending a big company convention at an out-of-town resort -- same locale as two years ago (pre-meds) -- and the difference in how I feel and behave is incredible. I can't believe this calm but highly participatory individual (me) is the same person who's heart felt as if it was going to jump out of my chest just at the *thought* of speaking up last time I was here. When especially challenging situations are coming up, I sometimes take up to .5 mg extra Klonopin. As it turns out, I took .25 mg extra (before our "gala supper") yesterday, and didn't feel the need to take any extra today.Good Luck!
Rick
> Bless you, Rick! Thank you so much for detailing
> your experiences with the various medications and
> for coming up with your amazing cocktail.
> My question for you is, do you take a generic form
> of Klonopin or the original?
>
> Take Care,
> Aimee
>
>
>
>
>
>
> > Hope it's not too good to last:
> >
> > Klonopin (1 mg morning, .25 mg afternoon)
> > Serzone (150 mg morning, 150 mg evening)
> > Provigil (200 mg morning)
> >
> > (Since these meds plus the Prilosec I'm taking are metabolized largely through the same liver enzymes, bioavailability may be increased for some of them...thus keeping my dosage requirements somewhat lower than usual.)
> >
> > Klonopin's been great all along, but I've been looking for an even higher level of improvement. Everthing else I've tried, either before or since starting Klonopin, has failed to provide enhancement and/or has caused non-abating bothersome side effects.
> >
> > The Provigil is incredible, at least for me. I was afraid it would cause counter-productive nervousness, especially when I upped the daily dose from 100 mg to the 200 mg generally recommended for the med's official narcolepsy indication. But instead, the Provigil consistently provides a great "non-wired" wakefulness (although with NO problem sleeping when I WANT to); enhances energy, motivation and cognition; and makes me more assertive and a lot more sociable. I just hope what some have said about a tendency for Provigil to poop out doesn't surface for me.
> >
> > For the record, I've been taking Klonopin about ten months (but less now than previously); Serzone for about four weeks (added it to Celexa, then soon dumped the Celexa); and Provigil for about three weeks.
> >
> > Just wanted to share a success story regarding treatment of my non-depressive Social Anxiety. Who knows if it will last? But so far *every* day for the last two weeks has been just wondeful -- morning to afternnon to night to snooze-land. And as good as everything is now, things seem to be headed nowhere but up.
> >
> > Rick
Posted by Billb on September 22, 2000, at 16:16:25
In reply to Re: Social Phobia Cocktail -- WOW!!!, posted by AndrewB on June 8, 2000, at 21:06:26
These sound like exciting and promising cocktail combinations. Am I the only one who has a Pdoc who is not open to suggestions and is very non-agressive in trying new meds? At my present rate, it would take my Pdoc years to agree to evolve thru trials of these meds. What I currently get when I meet with him every three months is, "if it doesn't improve soon I'll up your paxil again."
Any tips on how to state my desires to my Pdoc to trial differnt meds. so that I can quickly identify a cocktail that works for me? Or is finding a new Pdoc the only solution. For me, that would mean driving out of this small town to an urban area.
By the way, thanks for the great posts!
Posted by Rick on September 23, 2000, at 3:21:26
In reply to Re: Social Phobia Cocktail -- WOW!!!, posted by Billb on September 22, 2000, at 16:16:25
> These sound like exciting and promising cocktail combinations. Am I the only one who has a Pdoc who is not open to suggestions and is very non-agressive in trying new meds? At my present rate, it would take my Pdoc years to agree to evolve thru trials of these meds. What I currently get when I meet with him every three months is, "if it doesn't improve soon I'll up your paxil again."
>
> Any tips on how to state my desires to my Pdoc to trial differnt meds. so that I can quickly identify a cocktail that works for me? Or is finding a new Pdoc the only solution. For me, that would mean driving out of this small town to an urban area.
>
> By the way, thanks for the great posts!That's a tough one to answer, since every pdoc's different. I'm still using my first one, who I picked out from the phone book, believe it or not. Even though he was expensive and out-of-network (i.e., lower insurance reimbursement), I was attracted by his listing which said "Phd, MD, 25 years experience" and "Psychobiologically Oriented, Psyhoanalytically Aware". I had done plenty of research, and I frankly wanted someone who I knew would be med-oriented and not bound by convention. (It turns out the "biological" part also involved a lot of dietary advice and an "insistence" that I lose at least 50 pounds, i.e., drop to 180. And as it turns out, his card says simply "psychoanalytically aware" -- what happened to "biological"?)
When he spent 3/4 of our second session explaining the history of the medication he was about to give me, and why it receives a bum rap, I knew I had probably selected the guy I wanted. The medication he gave me was Nardil, plus as-needed Xanax. I don't get the impression Social Anxiety treatment is really a specialty of his (even though the usually-avoided Nardil HAS proven to be the best AD for Social Phobia).
Frankly, he has about the worst "couchside" manner I could imagine, and is very conservative in some ways (including one GOOD one: the "start low, go slow" philosophy"). I saw him at least once a month (if the expense isn't a big difficulty, that may be one way for you to move thigs along more quickly). After "playing along" with several trials of drugs that made little sense for Social Phobia, I had a very troubling work experience, and went to him distraught that day (actually, I think I was overstating my anguish, but I WAS frustrated), and he gave me Tranxene (!). It was soon after this that I came back and politely but firmly said that nothing was working thus far, and that I wanted to try the Klonopin that I had read was so very effective for Social Phobia in placebo-based studies. He grudgingly said "O.K." (remember, this guy is no Social Phobia expert", and I was soon filled with delight that something was actually working -- WELL and QUICKLY -- and with no side effects except good ones (!) after the first week.
Since then, it's been mainly "stick with whatever works for you (Klonopin). Now, what have your dreams been lately". The other thing we've done in the last year is fine-tune. I've been pretty aggressive about what I wanted to add in an attempt to "go for the gold", although I certainly gave his ideas a try. Fortunately (but incorrectly, except perhaps for benzos), this guy expects patients to start showing response to a drug very quickly if its going to work, regardless of disorder. Thus, we could move on fairly quickly, after one or two quick dosage-adjustment attempts.
Our ideas on various Klonopin+ combos have ranged from very convergent to very divergent. I believe he was hoping I might be able to replace the Klonopin. It's NOT that he's benzophobic; he simply prefers AD's and other anti-anxiety drugs like BuSpar abd Neurontin. One thing that has worked in my favor, in addition to the frequent visits (that have become infrequent since I've found my powerful Anti-Social Phobia cocktail), is that I came armed with plenty of knowledge and research about the meds I wanted to try. It was hardest to get him to prescribe Provigil, which he had never used, and which he said had virtually no track record (True, in the U.S., anyways). But after I was looking for something to make more "up", and had failed trials of selegiline and Wellbutrin (with the Celexa I was taking then) due to increased anxiety, he wanted me to try Ritalin. I really didn't want Ritalin (he's a big fan), and kept talking to him about the supposedly gentler, non-addicting, and less side-effect-prone (NONE for me) stimulant Provigil. He had been intrigued by stories about the (French?) government giving soldiers Provigil in Desert Storm. But even as I pummelled him with research, and even as he was astounded that Caremark had sent outa notice advocating the use of this very-expensive drug over traditional amphetamine-based anti-narcoleptics, he was starting to write a prescription for Ritalin. But I kept insisting, and he said, "O.K., if you want to be the guinea pig, even though you're already doing pretty well...". I'm REALLY glad I prevailed there.
Sorry for getting carried away with the details of the story (actually, that was just a topline review!). Anyways, if you have to stick with the pdoc you have and you're not getting what you want, I would try to (1) Go as often as possible, and note your lack of any (good) response, especially after a dosage increase. (2) Inundate him with reputable research! If you want to try Klonopin, show him those Duke University abstracts I gave Donna Lynn the links to, addressing both high placebo-controlled efficacy, safety in long-term use and discontinuation, and continued effectiveness at maintenance doses. Better yet, obtain and print a copy of the complete journal articles. These are rigorous, reputable studies by Dr, Davidson of Duke, recognized in the psychiatric community as one of the nations pre-eminent Social Phobia experts. (Fyi, today Dr. Davidson goes along with the recommendation of an SSRI as the first-line treatment, even though none of the Paxil cntrolled studies have come anywhere near Klonopin's 78% response rate.) There are also studies available showing Serzone to be highly effective in Social Phobia, although they were not placebo controlled (3) Emphasize your continued mental (and side effect?) distres. If he's totally unresponsive, exaggerate or be more dramatic in your presentaton (4) Be politely pushy (of course, this became easier for me after I was aready on Klonopin!) (5) When push comes to shove, tell him/her that while you apreciate his/her efforts, you have researched other strategies, and that at this point you will have to look elsewhere, even if it means leaving town, and so you want to begin carefully weaning off the Paxil. (In the doc's defense, many patients do not see their biggest increase in AD anti-anxiety benfits until a full 8 to 12 weeks at a theraputic dose.) If you need to go back on Paxil, almost any GP will give it to you, although you might have to explain to them what Social Phobia is, and that Paxil has an FDA-approved indication for treatment of SP.
As for endorsing the foreign meds, I highly doubt your guy would go along. While I'm not too cofortable with the idea myself, you've seen that many on ths board seem to have had great success with legally-ordered (I think?) meds.
Good Luck,
Rick
Posted by MarkinBoston on September 25, 2000, at 22:51:36
In reply to Re: Social Phobia Cocktail -- WOW!!!, posted by Billb on September 22, 2000, at 16:16:25
>
> Any tips on how to state my desires to my Pdoc to trial differnt meds. so that I can quickly identify a cocktail that works for me? Or is finding a new Pdoc the only solution. For me, that would mean driving out of this small town to an urban area.After hearing people's problem's with doc's, I'm glad I have a good p-doc (a good endocrinologist is the opposite story). Over the last 8 years I've been seeing the same 50-something Dutch woman who believes in high doses for treatment resistant depressions like mine and is curious about papers I've read while also adding the clinical experience she and other doctors have at the psyc ward of a hospital where she also works some weekends. She knows I'm not suicidal, addictive, or stupid - so she will usually let me try what I want and may want to combine it with some suggestion. She had given me Klonipin at one time, but I couldn't really feel much effect from that for jitters caused by another anti-d (I forget which one now). This time, when I was really upset after withdrawing from the testosterone patch, I asked for diazapam because I was having some back soreness and Klonipin was just too weak for me. It did the trick, and I have a little extra on hand for when I need it. She is a little reluctant to try non-US drugs, as I havn't exhausted them all, but I may well working on JohnL's cocktail. She'll be ok with that, I'm sure.
Bottom line is that she's seen me for years, and in the past, only for major episodes. 9 months or a year would go by and I'd call her again once I start having trouble sleeping, thinking, and remembering. Otherwise, I'd been acceping of my dysthymia/anhedonia. So, that would make me non-drug seeking too. She's suggested I just stay on meds to prevent re-occurance of the major episodes, but I'm not willing to put up with the side effects full time. This time I told her my plan was to resolve the major episode and then concentrate on the dysthymia/anhedonia. Serzone as an anti-depressant taken at night is pretty free of side effects. Some dopamine agonist in the AM (Ritalin, adrafinil, modrafinil...) would then replace the Effexor XR which I dislike the side effects of sweating, anorgasmia, and apathy.
Now, if I could get an endrocrinologist to give me an estogen antagonist along with the testosterone suppliment I'd be joyous. Unfortunately, the best estrogen agonists are all FDA labeled as breast cancer drugs.
Posted by JohnB on September 25, 2000, at 23:17:09
In reply to Re: Social Phobia Cocktail -- WOW!!!, posted by Billb on September 22, 2000, at 16:16:25
Bill,
I think Rick's post is great advice and very informative. It's certainly worth a try. I would pose a different variation: Drive to the city. For this reason: Time is passing. You are not getting any younger my friend. Your pdoc sounds like he has all the time in the world. Do you?
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