![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 37. This is the beginning of the thread.
Posted by zeugma on September 30, 2004, at 17:21:24
and Ritalin doesn't? Here's my theory: my ADD is actually a form of movement disorder in which it is extremely difficult to coordinate my thoughts to motor output, including even verbal output. (Writing for me is sheer hell.) This abstract inspired my theory:
1: Neurosci Lett. 1998 Sep 4;253(2):135-8. Related Articles, Links
The effects of modafinil on striatal, pallidal and nigral GABA and glutamate release in the conscious rat: evidence for a preferential inhibition of striato-pallidal GABA transmission.Ferraro L, Antonelli T, O'Connor WT, Tanganelli S, Rambert FA, Fuxe K.
Department of Clinical and Experimental Medicine, University of Ferrara, Italy.
The effects of the anti-narcoleptic drug modafinil (30-300 mg/kg i.p.) on GABA and glutamate release were evaluated in the basal ganglia of the conscious rat, by using the microdialysis technique. Modafinil (100 mg/kg) inhibited striatal (85+/-4% of basal values) and pallidal (85+/-2%) GABA release without influencing local glutamate release. At the highest dose (300 mg/kg), modafinil induced a further reduction of pallidal (75+/-2%) but not striatal (82+/-7%) GABA release and increased striatal (134+/-11%) but not pallidal glutamate release. On the contrary, in the substantia nigra modafinil reduced GABA release only at the 300 mg/kg dose (59+/-5%) without affecting glutamate release. The preferential reduction in striato-pallidal GABA release at the 100 mg/kg dose of modafinil suggests that modafinil may be useful in the treatment of Parkinsonian diseases.
According to my textbook, the striato-pallidal region is the last CNS step before the motor system produces output. It was markedly easier for me to initiate physical actions while on provigil compared to Ritalin or any other med for that matter. I conclude from this that I have some kind of Prakinsonian disorder. Lending further support to this idea is the fact that nortriptyline also produced some improvement in this area, albeit to a vastly lesser degree than Provigil. Nortriptyline is anticholinergic and anticholinergic drugs have some efficacy in movement disorders such as Parkinson's. All of this is of theoretical interest, really, since I cannot tolerate Provigil's side effects, even at a low dose, and there is no other drug with similar actions to modafinil that I know of, other than its parent drug adrafinil, which produces modafinil as a metabolite. I am contemplating going back on Strattera as a desperation move, as my concentration is suffering on Ritalin and I do not have a job where my mind can wander in the mists for long periods of time.
-z
Posted by jlbl2l on September 30, 2004, at 17:43:52
In reply to why does Provigil help my ADD, posted by zeugma on September 30, 2004, at 17:21:24
provigil is a mild stimulant. it increases extraxellular dopamine.
Posted by zeugma on September 30, 2004, at 18:35:36
In reply to Re: why does Provigil help my ADD, posted by jlbl2l on September 30, 2004, at 17:43:52
> provigil is a mild stimulant. it increases extraxellular dopamine.
yes I know but Ritalin also increases extracellular dopamine. provigil has some actions that are unique to it, in that it operates on the GABA and glutamate systems. For instance in the abstract I quoted it inhibited GABA release in the striato-pallidal region, which would mean that there would be less inhibitory neurotransmitter in the region of the brain most directly associated with motor output (GABA is the major inhibitory transmitter in the brain). It is these other actions of Provigil that are associated with its therapeutic effects for me. Notably, too, I developed tolerance to the stimulating effects of Ritalin very rapidly, but tolerance did not develop with Provigil, and I suspect that I am not unique in this respect.
In any case, I called my pdoc and told him about my idea to add back Strattera. he told me to take about 20 mg of Strat with the Ritalin in the morning. i will be reporting soon on the effects of this addition.
-z
Posted by jlbl2l on September 30, 2004, at 18:44:37
In reply to Re: why does Provigil help my ADD » jlbl2l, posted by zeugma on September 30, 2004, at 18:35:36
ritalin is a dopamine reuptake inhibtor much like cocaine actually. yes provigil has unique effects, but i really think that its effects your add well because of the dopamine properties. the only way to test this tho is to see how it goes. i deveoped tolerance to provigil myself, had to keep upping the dose. good luck.
Posted by zeugma on September 30, 2004, at 19:04:15
In reply to Re: why does Provigil help my ADD, posted by jlbl2l on September 30, 2004, at 18:44:37
> ritalin is a dopamine reuptake inhibtor much like cocaine actually. yes provigil has unique effects, but i really think that its effects your add well because of the dopamine properties. the only way to test this tho is to see how it goes. i deveoped tolerance to provigil myself, had to keep upping the dose. good luck.
thanks. I know I have dopaminergic issues, and when I combined 100 mg Provigil with 20 mg ritalin, I became hyperdopaminergic-elevated sexual desire and explosive orgasm, intense mental focus, BUT also inability to shift my attention freely, it was like moving a mountain to turn my attention from one thing to the next. And I felt like I had been stunned, physically-- for a period of about seven or eight hours. Overall, not pleasant, although it had its moments.
Have you tried both provigil and Ritalin? What would you say their differences in effect are?
-z
Posted by karaS on September 30, 2004, at 22:34:08
In reply to why does Provigil help my ADD, posted by zeugma on September 30, 2004, at 17:21:24
z,
No need to answer my question above on how you're doing since I've read this thread. I just had one thing to add here. If you're thinking that it's possible you have a movement/Parkinson's type problem, then wouldn't it make sense to try selegiline or other dopaminergics?
-K
Posted by psychosage on October 1, 2004, at 6:46:23
In reply to Re: why does Provigil help my ADD » zeugma, posted by karaS on September 30, 2004, at 22:34:08
They are going to try to make Provigil in doses of 340mg and 425mg just for adhd.
I take 150mg for off label stuff {i'm bipolar with focus/energy issues}.
Cephalon Announces Positive Results with a New Modafinil Formulation for the Treatment of Children with Attention Deficit Hyperactivity Disorder
Results with New Pediatric Doses Were Highly Significant in All Three Studies; Regulatory Filing Accelerated to Late 2004
WEST CHESTER, Pa., Aug. 19 /PRNewswire-FirstCall/ -- Cephalon, Inc. (Nasdaq: CEPH) today announced results from three multi-center clinical trials, which show that new proprietary once-daily dosage forms of modafinil significantly improve symptoms of Attention Deficit Hyperactivity Disorder (ADHD) in children and adolescents.
In three nine-week, double-blind, placebo-controlled studies, 600 children and adolescents between the ages of six and 17 with ADHD were randomized to either placebo or an optimized new proprietary dosage form of modafinil. The primary endpoint in all studies was the teacher-completed school version of the ADHD Rating Scale IV. All of the modafinil treated groups showed a highly statistically significant improvement on the primary endpoint compared to placebo (p<0.0001). Modafinil was generally well tolerated, and the most common side effects observed in these studies were consistent with those observed in other studies of this compound and included insomnia, headache and loss of appetite. The complete Phase III study data are expected to be presented at major medical meetings over the next 12 months.
"Because children metabolize modafinil differently from adults, our clinical efforts focused on identification of optimal doses of modafinil for these studies," said Dr. Paul Blake, MB, FRCP, Senior Vice President of Clinical Research and Regulatory Affairs at Cephalon. "The result was the development of proprietary dosage strengths of 340 and 425 milligrams, which in these Phase III studies demonstrated robust symptom improvement in children and adolescents with ADHD. The most encouraging aspects of these results were the strength and consistency of the effects of modafinil across the three studies and the robust effects of modafinil on both the inattentive and hyperactive symptoms of ADHD."
Based upon the demonstrated strength of the study results, the company plans to accelerate the filing of its application with the Food and Drug Administration from the first quarter of 2005 to the fourth quarter of 2004.
Frank Baldino Jr., Ph.D., Chairman and CEO of Cephalon, said, "We are excited about these data and the promise they hold for the ADHD community. We expect this product, once approved, to command a substantial presence in this large and growing market that today exceeds several billion dollars. With its excellent clinical profile and strong intellectual property protection for use in ADHD, we anticipate this product will be an important contributor to Cephalon's revenue growth for many years to come."
Modafinil
Modafinil (PROVIGIL(R) C-IV Tablets) is currently available in 100 and 200 milligrams and is indicated for the treatment of excessive sleepiness associated with narcolepsy, obstructive sleep apnea and shift work sleep disorder. Modafinil for the treatment of children and adolescents with ADHD will be manufactured as smaller, film-coated tablets in unique dosage strengths.
Attention Deficit Hyperactivity Disorder
According to the National Institutes of Mental Health, ADHD is one of the most common psychiatric disorders among children, affecting three to five percent of American children. ADHD is associated with dysfunction in the prefrontal cortex area of the brain. The most common ADHD behaviors fall into three categories: inattention, hyperactivity, and impulsivity. A diagnosis of ADHD is generally made when these behaviors become excessive, long-term, and pervasive.
Cephalon, Inc.
Founded in 1987, Cephalon, Inc. is an international biopharmaceutical company dedicated to the discovery, development and marketing of innovative products to treat sleep and neurological disorders, cancer and pain.
Cephalon currently employs more than 2,000 people in the United States and Europe. U.S. sites include the company's headquarters in West Chester, Pennsylvania, and offices and manufacturing facilities in Salt Lake City, Utah and Eden Prairie, Minnesota. Cephalon's major European offices are located in Guildford, England, Martinsried, Germany, and Maisons-Alfort, France.
The company currently markets three proprietary products in the United States: PROVIGIL, GABITRIL(R) (tiagabine hydrochloride) and ACTIQ(R) (oral transmucosal fentanyl citrate) [C-II] and more than 20 products internationally. Further information about Cephalon and full prescribing information on its U.S. products is available at http://www.cephalon.com or by calling 1-800-896-5855.
In addition to historical facts or statements of current condition, this press release may contain forward-looking statements. Forward-looking statements provide Cephalon's current expectations or forecasts of future events. These may include statements regarding anticipated scientific progress on its research programs, development of potential pharmaceutical products, interpretation of clinical results, including the results of the three multi- center clinical trials of modafinil in ADHD, prospects for regulatory approval of modafinil for ADHD and the anticipated timetable for filing a marketing application for the use of modafinil in ADHD, manufacturing development and capabilities, market prospects for its products, particularly with respect to the Company's ability to effectively compete in the ADHD marketplace with modafinil, sales and earnings guidance, and other statements regarding matters that are not historical facts. You may identify some of these forward-looking statements by the use of words in the statements such as "anticipate," "estimate," "expect," "project," "intend," "plan," "believe" or other words and terms of similar meaning. Cephalon's performance and financial results could differ materially from those reflected in these forward-looking statements due to general financial, economic, regulatory and political conditions affecting the biotechnology and pharmaceutical industries as well as more specific risks and uncertainties facing Cephalon such as those set forth in its reports on Form 8-K, 10-Q and 10-K filed with the U.S. Securities and Exchange Commission. Given these risks and uncertainties, any or all of these forward-looking statements may prove to be incorrect. Therefore, you should not rely on any such factors or forward-looking statements. Furthermore, Cephalon does not intend to update publicly any forward-looking statement, except as required by law. The Private Securities Litigation Reform Act of 1995 permits this discussion.
SOURCE Cephalon, Inc.
CONTACT: Media: Sheryl Williams, +1-610-738-6493, swilliam@cephalon.com,
or Investors: Robert (Chip) Merritt, +1-610-738-6376, cmerritt@cephalon.com,
both of Cephalon
Web site: http://www.cephalon.com
(CEPH)
Posted by zeugma on October 1, 2004, at 18:54:11
In reply to Re: New Provigil formulation 340mg/425mg for ADHD, posted by psychosage on October 1, 2004, at 6:46:23
I have no doubt that Provigil will prove to be an effective ADD med for many. It was for me. I simply could not tolerate its side effects.
-z
Posted by zeugma on October 1, 2004, at 19:14:26
In reply to Re: why does Provigil help my ADD » zeugma, posted by karaS on September 30, 2004, at 22:34:08
> z,
>
> No need to answer my question above on how you're doing since I've read this thread. I just had one thing to add here. If you're thinking that it's possible you have a movement/Parkinson's type problem, then wouldn't it make sense to try selegiline or other dopaminergics?
>
> -K
>
>
hi kara (and you're one of my favorite posters too :),yes i have thought about selegiline also. The dopaminergic Ritalin seems to be doing little for me, though who knows with these meds... at least I seem to be becoming tolerant to its s/e. I took about 20 mg Strattera this morning. The powder is noxious, and I simply dumped about half the contents of the 40 mg capsule onto my plate, replaced the cap and took it with 20 mg Ritalin LA and .5 mg Klonopin as per my pdoc's instructions. the stuff is somewhat caustic, and burned my hand a little when I shook the excess powder into the trash, but then that suits my current state of mind :)Familiar strattera effects: a 'hardening' of attention, a feeling of alertness without increased energy or anxiety. Very different from the supposedly similar nortriptyline. The drug has a definite antidepressant effect. It reduced the rise in anxiety from Ritalin, which was good. Some of this also may have had to do with my using an old trick, of getting up at 3 am so my circadian cycle is more closely aligned with my periods of peak wakefulness (for me, about 4 am).
I don't know what I'm going to do. I have to keep myself going, but have little faith in these meds. maybe Strattera combined with Ritalin will have some kind of changed effect. I'm going to call my pdoc on Monday cause I am running out of ritalin LA. I don't know what the Ritalin is doing for me, but maybe it creates a changed environment so the Strattera can work a little better. The way I see it, even an improvement of 5 - 10 % from current baseline could help me get through this demanding period of my life. I have also resigned myself to the necessity of massive caffeine intake, and am consuming my nightly full-strength pot so I will have the energy to make sure all alarm clocks are set (I am a comatose sleeper) and coffeemaker is set for the morning.Life comes down to these little things, in a pinch, and I am in quite a tight place right now.
-z
Posted by karaS on October 1, 2004, at 23:36:00
In reply to Re: why does Provigil help my ADD » karaS, posted by zeugma on October 1, 2004, at 19:14:26
> > z,
> >
> > No need to answer my question above on how you're doing since I've read this thread. I just had one thing to add here. If you're thinking that it's possible you have a movement/Parkinson's type problem, then wouldn't it make sense to try selegiline or other dopaminergics?
> >
> > -K
> >
> >
> hi kara (and you're one of my favorite posters too :),
>
> yes i have thought about selegiline also. The dopaminergic Ritalin seems to be doing little for me, though who knows with these meds... at least I seem to be becoming tolerant to its s/e. I took about 20 mg Strattera this morning. The powder is noxious, and I simply dumped about half the contents of the 40 mg capsule onto my plate, replaced the cap and took it with 20 mg Ritalin LA and .5 mg Klonopin as per my pdoc's instructions. the stuff is somewhat caustic, and burned my hand a little when I shook the excess powder into the trash, but then that suits my current state of mind :)Familiar strattera effects: a 'hardening' of attention, a feeling of alertness without increased energy or anxiety. Very different from the supposedly similar nortriptyline. The drug has a definite antidepressant effect. It reduced the rise in anxiety from Ritalin, which was good. Some of this also may have had to do with my using an old trick, of getting up at 3 am so my circadian cycle is more closely aligned with my periods of peak wakefulness (for me, about 4 am).
>
> I don't know what I'm going to do. I have to keep myself going, but have little faith in these meds. maybe Strattera combined with Ritalin will have some kind of changed effect. I'm going to call my pdoc on Monday cause I am running out of ritalin LA. I don't know what the Ritalin is doing for me, but maybe it creates a changed environment so the Strattera can work a little better. The way I see it, even an improvement of 5 - 10 % from current baseline could help me get through this demanding period of my life. I have also resigned myself to the necessity of massive caffeine intake, and am consuming my nightly full-strength pot so I will have the energy to make sure all alarm clocks are set (I am a comatose sleeper) and coffeemaker is set for the morning.Life comes down to these little things, in a pinch, and I am in quite a tight place right now.
>
> -z
>((((zeugma))))
I understand. I am in a very tight place myself right now. Sometimes it's so hard just to cover the basics. There's so much that "healthy" people take for granted. Anway, I hope that you get a synergistic response from the Ritalin with the Strattera. Thank goodness for coffee!
Keep me posted,
Kara
Posted by zeugma on October 2, 2004, at 18:24:56
In reply to Re: why does Provigil help my ADD » zeugma, posted by karaS on October 1, 2004, at 23:36:00
hi K,
The Strattera is an AD for me, without doubt. I never doubted that its primary action, besides its unwanted subsidiary ones, was as an AD as well as ADD treatment. In fact I always considered it an AD with positive effects on ADD, much like the TCA's.I felt some of that trouble doing attentional set-shifting today that I experienced on Ritalin and Provigil. But it was to a much less degree. These drugs have complex cognitive effects that I am going to try to discuss in another post. Basically, I don't know what the Ritalin is doing, it never had an easily identifiable effect on me like Provigil did: a "self-conscious" med; or Strattera, "transparency." Nortriptyline felt like a glacier was melting, but a lot of that could be because it was my first return to an AD in a decade, and the first one that worked in almost two - its predecessor was none other than itself.
I am going to run out of Ritalin after Monday. I am under so much pressure at work, and I can ill afford drug "vacations," and I don't know how the Ritalin is affecting the Strattera, or for the better or the worse. My next pdoc appt. is a week away. I hope he writes me a script for a week's worth of 30 mg Ritalin LA a day. The Ritalin side effects are wearing off, and weren't very disturbing to begin with. I will post below about the cognitive effects. But moodwise, I am ok, and for what it's worth, since this topic has come up elsewhere, Provigil is a stimulant that had some anxiolytic effect, and marginal antidepressant effect. Strattera has a strong antidepressant effect, which for me at least, kicks in immediately. It has some anxiolytic effect, because I was able to slightly reduce my clonazepam dosage, back to my maintainance dose of 1 mg/ day. I am happy about that.
-z
Posted by karaS on October 3, 2004, at 1:36:25
In reply to Re: why does Provigil help my ADD » karaS, posted by zeugma on October 2, 2004, at 18:24:56
z,
> The Strattera is an AD for me, without doubt. I never doubted that its primary action, besides its unwanted subsidiary ones, was as an AD as well as ADD treatment. In fact I always considered it an AD with positive effects on ADD, much like the TCA's.
Hmmm. Double the benefit. Not bad. It might make sense for me to try Strattera someday if the Cymbalta doesn't work out.
> I felt some of that trouble doing attentional set-shifting today that I experienced on Ritalin and Provigil. But it was to a much less degree. These drugs have complex cognitive effects that I am going to try to discuss in another post. Basically, I don't know what the Ritalin is doing, it never had an easily identifiable effect on me like Provigil did: a "self-conscious" med; or Strattera, "transparency." Nortriptyline felt like a glacier was melting, but a lot of that could be because it was my first return to an AD in a decade, and the first one that worked in almost two - its predecessor was none other than itself.
If you don't know what the Ritalin is doing, is it possible that it's not doing anything for you at all? Are you still taking Nortriptyline now? (I remember when I started taking it, I had so much energy. It was so nice.)
> I am going to run out of Ritalin after Monday. I am under so much pressure at work, and I can ill afford drug "vacations," and I don't know how the Ritalin is affecting the Strattera, or for the better or the worse. My next pdoc appt. is a week away. I hope he writes me a script for a week's worth of 30 mg Ritalin LA a day. The Ritalin side effects are wearing off, and weren't very disturbing to begin with. I will post below about the cognitive effects. But moodwise, I am ok, and for what it's worth, since this topic has come up elsewhere, Provigil is a stimulant that had some anxiolytic effect, and marginal antidepressant effect. Strattera has a strong antidepressant effect, which for me at least, kicks in immediately. It has some anxiolytic effect, because I was able to slightly reduce my clonazepam dosage, back to my maintainance dose of 1 mg/ day. I am happy about that.Too bad you couldn't stand the side effects since it clearly seemed to help you. (Provigil did nothing for me but make my limbs heavy.) So as long as you take at least a little break from the Strattera, you're able to go back on it and get the benefits again? That's great. Now you just have to figure out what to do instead during the down time.
I'm starting on Cymbalta on Tuesday. I have the samples already. I just need to function on Monday so I don't want to start something new yet. I hope this helps with depression and focus - especially the focus because I have to get a job soon. If I do have some "soft bi-polar" tendencies, then I'll worry about adding something else in later. But for now, I really need to get functioning or else I'll be living with mom soon. (Horrors!)
-K
Posted by zeugma on October 3, 2004, at 10:05:46
In reply to Re: why does Provigil help my ADD » zeugma, posted by karaS on October 3, 2004, at 1:36:25
>>
>
> If you don't know what the Ritalin is doing, is it possible that it's not doing anything for you at all? Are you still taking Nortriptyline now? (I remember when I started taking it, I had so much energy. It was so nice.)
I am still taking nortriptyline. I found that when I reduced the dose to 50 mg, with an eye to getting off it entirely, my fatigue and depression worsened. So I went off the Strattera instead, last year. You are correct in wondering whether the Ritalin is doing anything for me at all. I don't know if it is. But if it is, I don't want to find out the hard way that it is, if you know what I mean. I am in the middle of a stressful period at work and one of the most stressful periods of my life, and my most reasonable guess is that possibly the Ritalin is creating a changed environment for the Strattera to work in, which might let me keep the Strat dosage low enough to keep it on board. Since I see my pdoc next week, I would like the discuss at length the rationales for the meds, but right now if something is working even minimally, I want to mess with as few variables as possible. It is very likely that I will end up going off Ritalin soon. I would prefer that to be a decision made by my pdoc and me, and not forced by circumstance.
>
>
>
> Too bad you couldn't stand the side effects since it clearly seemed to help you. (Provigil did nothing for me but make my limbs heavy.) So as long as you take at least a little break from the Strattera, you're able to go back on it and get the benefits again? That's great. Now you just have to figure out what to do instead during the down time.
>
Yes. some of the 'down time' was pretty far down.> I'm starting on Cymbalta on Tuesday. I have the samples already. I just need to function on Monday so I don't want to start something new yet. I hope this helps with depression and focus - especially the focus because I have to get a job soon. If I do have some "soft bi-polar" tendencies, then I'll worry about adding something else in later. But for now, I really need to get functioning or else I'll be living with mom soon. (Horrors!)
>
Are you currently on Effexor now? I would guess that Cymbalta would be better for you because of your focus problems and you might find the noradrenergic effects energizing. Also, did you take maprotiline as an antidepressant or simply as a sleep aid? MAP works exclusively as an NE reuptake inhibitor and you can use that as a guage of your response to noradrenergic drugs.Best of luck. Did your pdoc give you any reasons for thinking you are "soft bi-polar"?
The functioning part- yes, I completely understand. Nortriptyline got me functioning after years of joblessness and desperation. I hope Cymbalta gets you going in a similar way!-z
> -K
Posted by karaS on October 3, 2004, at 14:10:27
In reply to Re: why does Provigil help my ADD » karaS, posted by zeugma on October 3, 2004, at 10:05:46
> I am still taking nortriptyline. I found that when I reduced the dose to 50 mg, with an eye to getting off it entirely, my fatigue and depression worsened. So I went off the Strattera instead, last year. You are correct in wondering whether the Ritalin is doing anything for me at all. I don't know if it is. But if it is, I don't want to find out the hard way that it is, if you know what I mean. I am in the middle of a stressful period at work and one of the most stressful periods of my life, and my most reasonable guess is that possibly the Ritalin is creating a changed environment for the Strattera to work in, which might let me keep the Strat dosage low enough to keep it on board. Since I see my pdoc next week, I would like the discuss at length the rationales for the meds, but right now if something is working even minimally, I want to mess with as few variables as possible. It is very likely that I will end up going off Ritalin soon. I would prefer that to be a decision made by my pdoc and me, and not forced by circumstance.
Ok, now I understand.
> > I'm starting on Cymbalta on Tuesday. I have the samples already. I just need to function on Monday so I don't want to start something new yet. I hope this helps with depression and focus - especially the focus because I have to get a job soon. If I do have some "soft bi-polar" tendencies, then I'll worry about adding something else in later. But for now, I really need to get functioning or else I'll be living with mom soon. (Horrors!)
> >
>
> Are you currently on Effexor now? I would guess that Cymbalta would be better for you because of your focus problems and you might find the noradrenergic effects energizing. Also, did you take maprotiline as an antidepressant or simply as a sleep aid? MAP works exclusively as an NE reuptake inhibitor and you can use that as a guage of your response to noradrenergic drugs.I am only taking 9 mg. of Effexor right now. I will be entirely off of it soon. I am certainly hoping that the noradrenergic effects of Cymbalta will be energizing. Since I probably have hypersenstive dopamine autoreceptors, chances are slim that I'll be getting energy from dopaminergics. NE is my only hope for energy (aside from coffee but I can't use that much of it because of hypoglycemia). I only took a small amount of map. for sleep (you have a good memory!). I didn't find it stimulating at all but I found nort. and desipramine VERY stimulating.
> Best of luck. Did your pdoc give you any reasons for thinking you are "soft bi-polar"?
Yes. The fact that I have been having different sleep cycles. Sometimes I sleep too much and other times I can't seem to sleep at all. It could be extra anxiety kicking in at those times due to stress or even hormonal issues (esp. because this is a fairly recent occurrence in my life) so I'm not convinced of his theory yet but I think it's a possibility to explore in the future.
> The functioning part- yes, I completely understand. Nortriptyline got me functioning after years of joblessness and desperation. I hope Cymbalta gets you going in a similar way!Really, the nortriptyline did that much for you? That's encouraging. After all of my years of trying medications, I have never had one do anything like that. Actually, that's not true now that I think about it. Doxepin sent my panic attacks packing which in time got rid of my agoraphobia. That allowed me to go back to work eventually. I just haven't had much of an antidepressant effect from them nor have I found anything to help with concentration yet. The nort and des. may have helped with that but I wasn't on them for long or during a time when I needed to concentrate so I couldn't say for certain (though I'd bet that they probably would have helped).
Anyway, I hope you get through this difficult period you're going through soon. Any chance things will calm down in the near future? Isn't it always the way that when you need your meds to work the most, that you're having some kind of issue with them?
Kara
Posted by zeugma on October 4, 2004, at 18:11:58
In reply to Re: why does Provigil help my ADD » zeugma, posted by karaS on October 3, 2004, at 14:10:27
It wasn't like nortriptyline suddenly got me going. But as with your experience with doxepin, it sent my panic attacks packing, and I was able to slowly get the elements in place that would lead to progress after years of being hopelessly stalled. When you mention that doxepin worked for your panic attacks, it makes me wonder whether the TCA's aren't superior to SSRI's in terms of treating panic disorder. Le Doux (author of my textbook "Synaptic Self") is director of the Center for the Study of Fear and Anxiety at NYU, and yet in the index to his book, there is shockingly no mention of a structure long associated with anxiety disorders, the locus coeruleus (seat of CNS NE production). Norepinephrine has gotten a raw deal in popular culture, but more dismayingly, from distinguished professionals. Le Doux has interesting things to say about such phenomena as long term potentiation and the role of the hippocampus in memory, but considering that he is the author of "The Emotional Brain" and that his ostensible specialization is fear and anxiety, I do not consider him a thinker worth taking seriously for a moment, and in fact his contributions have a deleterious effect on the neurosciences. I get some basic information from him, but it is writers like Gerald Edelman ("A Universe of Consciousness") and J. Allan Hobson ("Dreaming as Delirium") whose ideas will outlast our time. Anyway...
I got my script for 30 mg Ritalin LA today. Like you, I am wary of making changes during a crucial time. So you have Tuesday off? for what it's worth, I can't rely on Ritalin for energy. Strattera is actually more energizing, and hopefully it will be the case that keeping it at a low dose will avoid its pitfalls. Best of luck tomorrow!
-z
Posted by karaS on October 9, 2004, at 20:48:42
In reply to rip van winkle syndrome » karaS, posted by zeugma on October 4, 2004, at 18:11:58
Hi z,
Sorry it's taken me a while to answer you. I've had quite a busy week working at both a catering job and a temp job. It's so nice to have a day off finally.
> It wasn't like nortriptyline suddenly got me going. But as with your experience with doxepin, it sent my panic attacks packing, and I was able to slowly get the elements in place that would lead to progress after years of being hopelessly stalled. When you mention that doxepin worked for your panic attacks, it makes me wonder whether the TCA's aren't superior to SSRI's in terms of treating panic disorder. Le Doux (author of my textbook "Synaptic Self") is director of the Center for the Study of Fear and Anxiety at NYU, and yet in the index to his book, there is shockingly no mention of a structure long associated with anxiety disorders, the locus coeruleus (seat of CNS NE production). Norepinephrine has gotten a raw deal in popular culture, but more dismayingly, from distinguished professionals. Le Doux has interesting things to say about such phenomena as long term potentiation and the role of the hippocampus in memory, but considering that he is the author of "The Emotional Brain" and that his ostensible specialization is fear and anxiety, I do not consider him a thinker worth taking seriously for a moment, and in fact his contributions have a deleterious effect on the neurosciences. I get some basic information from him, but it is writers like Gerald Edelman ("A Universe of Consciousness") and J. Allan Hobson ("Dreaming as Delirium") whose ideas will outlast our time. Anyway...
I have not read any of the books you mention so I can't comment but I do think that TCAs are excellent for anxiety. The SSRIs seem to prevent anxiety attacks in me as well but the action of the TCAs (at least doxepin) felt more direct. I don't know how to explain it really but I think you're on to something there.
> I got my script for 30 mg Ritalin LA today. Like you, I am wary of making changes during a crucial time. So you have Tuesday off? for what it's worth, I can't rely on Ritalin for energy. Strattera is actually more energizing, and hopefully it will be the case that keeping it at a low dose will avoid its pitfalls. Best of luck tomorrow!
I haven't started the Cymbalta yet because I didn't want to have unexpected side effects while working. I'll start it this weekend. I hate starting new drugs. Can you tell?
How are you doing balancing the Strattera and Ritalin?
Kara
Posted by karaS on October 9, 2004, at 20:50:02
In reply to rip van winkle syndrome » karaS, posted by zeugma on October 4, 2004, at 18:11:58
P.S. Based on your subject title, are you now back to thinking that you have narcolepsy versus a movement disorder?
Posted by zeugma on October 9, 2004, at 21:43:42
In reply to Re: rip van winkle syndrome » zeugma, posted by karaS on October 9, 2004, at 20:48:42
> Hi z,
>
> Sorry it's taken me a while to answer you. I've had quite a busy week working at both a catering job and a temp job. It's so nice to have a day off finally.Yes. Tomorrow will be my day off (sort of). And the day after. But there's so much I have to do. It is almost more exhausting for me to be in my chaos of an apt. than to be in my workplace. I think I'm going to listen to music, and let my mind drift. My ADD really feels like a REM state: directionless, random processes that follow their own course. I think Strattera had such an effect on my ADD because it is such a powerful norepinephrine reuptake inhibitor, and suppressor of REM sleep. But I can't take it (see below).
>
> > It wasn't like nortriptyline suddenly got me going. But as with your experience with doxepin, it sent my panic attacks packing, and I was able to slowly get the elements in place that would lead to progress after years of being hopelessly stalled. When you mention that doxepin worked for your panic attacks, it makes me wonder whether the TCA's aren't superior to SSRI's in terms of treating panic disorder. Le Doux (author of my textbook "Synaptic Self") is director of the Center for the Study of Fear and Anxiety at NYU, and yet in the index to his book, there is shockingly no mention of a structure long associated with anxiety disorders, the locus coeruleus (seat of CNS NE production). Norepinephrine has gotten a raw deal in popular culture, but more dismayingly, from distinguished professionals. Le Doux has interesting things to say about such phenomena as long term potentiation and the role of the hippocampus in memory, but considering that he is the author of "The Emotional Brain" and that his ostensible specialization is fear and anxiety, I do not consider him a thinker worth taking seriously for a moment, and in fact his contributions have a deleterious effect on the neurosciences. I get some basic information from him, but it is writers like Gerald Edelman ("A Universe of Consciousness") and J. Allan Hobson ("Dreaming as Delirium") whose ideas will outlast our time. Anyway...
>
> I have not read any of the books you mention so I can't comment but I do think that TCAs are excellent for anxiety. The SSRIs seem to prevent anxiety attacks in me as well but the action of the TCAs (at least doxepin) felt more direct. I don't know how to explain it really but I think you're on to something there.
>I am sure that TCA's have a more direct action on panic. Don't have the energy to speculate further, but what you have said corroborates my own experience.
> > I got my script for 30 mg Ritalin LA today. Like you, I am wary of making changes during a crucial time. So you have Tuesday off? for what it's worth, I can't rely on Ritalin for energy. Strattera is actually more energizing, and hopefully it will be the case that keeping it at a low dose will avoid its pitfalls. Best of luck tomorrow!
>
> I haven't started the Cymbalta yet because I didn't want to have unexpected side effects while working. I'll start it this weekend. I hate starting new drugs. Can you tell?
>No I couldn't :)
> How are you doing balancing the Strattera and Ritalin?The Strattera is gone. it tore my stomach apart, and it seemed that I got a response only from doses that came close to 40 mg. Plus it would wear off around 1 or 2 pm necessitating bid dosing, and of course, more side effects. It did its job for a little but it is not a medicine that I can tolerate. I am now taking 30 mg ritalin LA am plus 10 mg at noon. It is not doing wonders for me, but I tolerate it better than Strattera, and I need something I can take that does not feel worse than the original condition. If I needed Strattera to work full-time, I would opt for part-time and try to scrape by. I would have no choice.
I explained to my pdoc that Ritalin simply is not as effective for my symptoms as Provigil or Strattera, but that the latter two are not tolerable. I told him that Ritalin's inefficacy in itself causes anxiety, so he let me increase my clonazepam. There is nothing more anxiogenic, for me, than to know that my focus is slipping away, and that others can see it (I have a job that calls for constant interaction, and trust me: they can). My pdoc told me also to decrease caffeine as much as possible, as they compete for the same receptors. I had much the same thought. But if Ritalin at the higher dose doesn't help, it will be caffeine all the way. I am not having serious s/e from Ritalin, so I suppose the dose could go higher. We'll see.
By the way, to answer your question in your last post: I think I have both. A fun combination :) I am also restarting buspirone, 15 mg hs, as I told him it blocked hypnagogic hallucinations when I knew I would be vulnerable to them (ie, when I am stressed or have gotten inadequate sleep previously). I took it last night without problems. I tolerate buspirone well at low dosages.
So you are starting Cymbalta today? I am getting impatient!
-z
>
> Kara
>
>
Posted by karaS on October 10, 2004, at 4:03:10
In reply to Re: rip van winkle syndrome, posted by zeugma on October 9, 2004, at 21:43:42
> > Hi z,
> >
> Yes. Tomorrow will be my day off (sort of). And the day after. But there's so much I have to do. It is almost more exhausting for me to be in my chaos of an apt. than to be in my workplace. I think I'm going to listen to music, and let my mind drift. My ADD really feels like a REM state: directionless, random processes that follow their own course. I think Strattera had such an effect on my ADD because it is such a powerful norepinephrine reuptake inhibitor, and suppressor of REM sleep. But I can't take it (see below).Music has always been my salvation - until recently that is. My stereo system and most of my tapes and CDs are all boxed up. I haven't opened them from my last move. I never wanted to stay in this apartment so I haven't unpacked a lot of things. Hopefully I will move soon and get more music back in my life (literally and figuratively).
It's hard for me to focus sometimes but I don't feel like my thoughts are "directionless random processes". That must be a strange feeling.
> I am sure that TCA's have a more direct action on panic. Don't have the energy to speculate further, but what you have said corroborates my own experience.
>
> > I haven't started the Cymbalta yet because I didn't want to have unexpected side effects while working. I'll start it this weekend. I hate starting new drugs. Can you tell?
> >
>
> No I couldn't :)
>
>
> > How are you doing balancing the Strattera and Ritalin?
>
> The Strattera is gone. it tore my stomach apart, and it seemed that I got a response only from doses that came close to 40 mg. Plus it would wear off around 1 or 2 pm necessitating bid dosing, and of course, more side effects. It did its job for a little but it is not a medicine that I can tolerate. I am now taking 30 mg ritalin LA am plus 10 mg at noon. It is not doing wonders for me, but I tolerate it better than Strattera, and I need something I can take that does not feel worse than the original condition. If I needed Strattera to work full-time, I would opt for part-time and try to scrape by. I would have no choice.I don't understand. I thought that in the past you had taken Strattera for at least a year and had done well on it. Why is it irritating your stomach now? Is is possible for compounding pharmacies to put the medication into a patch?
Is there a reason that you never consider or try Adderall or Dexedrine?> I explained to my pdoc that Ritalin simply is not as effective for my symptoms as Provigil or Strattera, but that the latter two are not tolerable. I told him that Ritalin's inefficacy in itself causes anxiety, so he let me increase my clonazepam. There is nothing more anxiogenic, for me, than to know that my focus is slipping away, and that others can see it (I have a job that calls for constant interaction, and trust me: they can). My pdoc told me also to decrease caffeine as much as possible, as they compete for the same receptors. I had much the same thought. But if Ritalin at the higher dose doesn't help, it will be caffeine all the way. I am not having serious s/e from Ritalin, so I suppose the dose could go higher. We'll see.
Doesn't coffee rip you insides out as well? Or do you take caffeine pills?
> By the way, to answer your question in your last post: I think I have both. A fun combination :) I am also restarting buspirone, 15 mg hs, as I told him it blocked hypnagogic hallucinations when I knew I would be vulnerable to them (ie, when I am stressed or have gotten inadequate sleep previously). I took it last night without problems. I tolerate buspirone well at low dosages.That made me nauseous. But I'm glad it's helpful to you. Maybe you won't need to keep the clonazepam at the higher rate once you've taken this a while.
> So you are starting Cymbalta today? I am getting impatient!You mean you're getting tired of hearing about it. :-) I was planning on taking it today but i've been having allergy and sinus problems with headache and pressure and swollen membranes for several days now. I couldn't bear the thought of adding on a drug to give me worse symptoms. I wish I could figure out what I'm having this reaction to. It might be the Armour thyroid medication. I'll be going back to the synthetic T4 tomorrow so we'll see if that changes anything.
Hopefully I'll be in the mood to start the Cymbalta soon. I probably shouldn't have said anything about it until I had actually started on it.
K
Posted by zeugma on October 10, 2004, at 8:45:23
In reply to Re: rip van winkle syndrome » zeugma, posted by karaS on October 10, 2004, at 4:03:10
> > > Hi z,
> > >
> > Yes. Tomorrow will be my day off (sort of). And the day after. But there's so much I have to do. It is almost more exhausting for me to be in my chaos of an apt. than to be in my workplace. I think I'm going to listen to music, and let my mind drift. My ADD really feels like a REM state: directionless, random processes that follow their own course. I think Strattera had such an effect on my ADD because it is such a powerful norepinephrine reuptake inhibitor, and suppressor of REM sleep. But I can't take it (see below).
>
> Music has always been my salvation - until recently that is. My stereo system and most of my tapes and CDs are all boxed up. I haven't opened them from my last move. I never wanted to stay in this apartment so I haven't unpacked a lot of things. Hopefully I will move soon and get more music back in my life (literally and figuratively).
>Hi kara, I hope so too! Btw I read your comment in Social but was too shy to respond ;)
> It's hard for me to focus sometimes but I don't feel like my thoughts are "directionless random processes". That must be a strange feeling.
>It's why I have described my waking life as 'dream-like' to all my therapists since my early 20's. They displayed no understanding of what I meant. My current doctor says my symptoms are not typical of any disorder she knows of, although she concurs that I definitely have ADD in addition to other problems (learning disabilities, severe anxiety, vulnerability to depression). the research doctor at the university study I interviewed for said much the same. This doctor, who I admired for her candor (not something I have found typical of therapists or doctors) told me I needed to see a specialist in whatever disorder I thought most imperative to treat, rather than participate in a general study on depression. She did tell me I qualified for it, as I did exhibit symptoms of depression consistent with DSM criteria. I now see, however, that while her candor was appreciated, it is the fashion now for drug companies sponsoring studies to do their best to weed out the difficult cases so the product they are sponsoring can demonstrate significant separation from placebo. This is one reason the new meds are simply not as effective as those from the first generation. Imipramine was tried on everyone in the hospital, and its clinical profile slowly emerged from its being tested on a vast range of individuals with numerous disorders.
> > I am sure that TCA's have a more direct action on panic. Don't have the energy to speculate further, but what you have said corroborates my own experience.
> >
> > > I haven't started the Cymbalta yet because I didn't want to have unexpected side effects while working. I'll start it this weekend. I hate starting new drugs. Can you tell?
> > >
> >
> > No I couldn't :)
> >
> >
> > > How are you doing balancing the Strattera and Ritalin?
> >
> > The Strattera is gone. it tore my stomach apart, and it seemed that I got a response only from doses that came close to 40 mg. Plus it would wear off around 1 or 2 pm necessitating bid dosing, and of course, more side effects. It did its job for a little but it is not a medicine that I can tolerate. I am now taking 30 mg ritalin LA am plus 10 mg at noon. It is not doing wonders for me, but I tolerate it better than Strattera, and I need something I can take that does not feel worse than the original condition. If I needed Strattera to work full-time, I would opt for part-time and try to scrape by. I would have no choice.
>
> I don't understand. I thought that in the past you had taken Strattera for at least a year and had done well on it. Why is it irritating your stomach now? Is is possible for compounding pharmacies to put the medication into a patch?I did not explain myself well enough (following my dr.s injunction to cut down the caffeine is making it harder to write!). I did take Strattera for almost a year. It had a powerful effect on my ADHD; powerful enough to allow me to actually follow through on an unexpected opportunity I was offered in my field (not my academic field, unfortunately). I had received similar opportunities previously but the ADHD was so pronounced that the opportunities were lost. The Strattera always hurt my stomach. But since it worked, I put up with it, tried different strategies (changing diet, taking FiberCon and other supplements, etc.) which worked somewhat but were hardly curative. The stomach problems were not the reason I discontinued. I stopped it because it made me more and more fatigued, and I cannot tolerate a med that elevates my fatigue above baseline. The fatigue was not evident in the beginning, but gradually became more and more severe. It was not due to insomnia or anything treatable. it simply drained me, and I am being slowly drained, energywise, anyway, by the narcolepsy (ie I am more tired now than I was 2 years ago, and the fatigue has a progressive character that makes it rather frightening. Being fairly sure that I do have narcolepsy (pdoc concurred) is comforting, as the forum boards of narcolepsy are full of stories of worsening fatigue through the 20's, increasing through the early and mid 30's till almost complete anergia results. Stims reverse this partially but not completely, and experts on narcolepsy are more candid about the limitations of stims in narcolepsy than Pfizer, Lilly, et al. are in plugging the dramatic effects of their newest AD's: stims only partially reverse the terrible fatigue. That does console me a little. I would rather get an honest picture of what to expect than an inflated one. Do you know I appreciate candor?)
Back to Strat, 2nd trial. Immediate AD effects, immediate 'clearing' of my thought process. But it does intensify the fatigue. And a med that does this is off my list, period. (I mean fatigue that does not subside with time. I can discriminate between the antihistaminic effect of nortriptyline, which is 'sedating', and the peculiar, recalcitrant fatigue of Strattera. Sedation I can deal with, since it passes in 2 weeks and what is left is the propensity to sleep, which is why the TCA's are so great for insomnia. Nortriptyline does not increase my fatigue. if it did, I would chuck it too, and was prepared to do so last year when I systematically lowered my meds one by one to see which one was draining me beyond my usual, awful draining.)
> Is there a reason that you never consider or try Adderall or Dexedrine?
>
I would try them. I don't know my pdoc's rationale for preferring Ritalin. But I think what he is doing is making sure I give Ritalin an adequate trial by increasing the dosage to what is therapeutic *for me*. I am a rapid metabolizer of drugs and I know that I need to take Ritalin LA every six hours despite the fact that it's marketed as an eight-hour formulation. If the higher dose of Ritalin simply does nothing, then I will bring up the other stims. But as he said, "We shouldn't give up on it yet," and I agree. It may work at this dose, or a higher one. I'm skeptical, but I think he is being conscientious. Also, the little I have been able to find on this topic suggests that Ritalin is safer than amphetamines when combined with a TCA. That may be his rationale.
> > I explained to my pdoc that Ritalin simply is not as effective for my symptoms as Provigil or Strattera, but that the latter two are not tolerable. I told him that Ritalin's inefficacy in itself causes anxiety, so he let me increase my clonazepam. There is nothing more anxiogenic, for me, than to know that my focus is slipping away, and that others can see it (I have a job that calls for constant interaction, and trust me: they can). My pdoc told me also to decrease caffeine as much as possible, as they compete for the same receptors. I had much the same thought. But if Ritalin at the higher dose doesn't help, it will be caffeine all the way. I am not having serious s/e from Ritalin, so I suppose the dose could go higher. We'll see.
>
> Doesn't coffee rip you insides out as well? Or do you take caffeine pills?
>
Coffee rips up my insides, and my therapist suggested I take caffeine pills. If Ritalin doesn't work, and then Adderall etc. doesn't either, I am going to make the stockholders of the company that makes NoDoz very happy.Of course, coffee rips up my insides less than Strattera...>
> > By the way, to answer your question in your last post: I think I have both. A fun combination :) I am also restarting buspirone, 15 mg hs, as I told him it blocked hypnagogic hallucinations when I knew I would be vulnerable to them (ie, when I am stressed or have gotten inadequate sleep previously). I took it last night without problems. I tolerate buspirone well at low dosages.
>
> That made me nauseous. But I'm glad it's helpful to you. Maybe you won't need to keep the clonazepam at the higher rate once you've taken this a while.Buspirone does not work as an anxiolytic for me. It does work as an AD. But it is useless for social phobia, and it's the (very realistic) fear of being perceived as being 'half-asleep' that drives the anxiety to the point of near panic. Clonazepam actually helps the ADD symptoms since the anxiety worsens them. Buspirone doesn't, and I have pushed its dose to its limit of tolerability (for me, 30 mg) with no effect on this kind of anxiety. My pdoc wants me to take 15 mg at night because of its effects on my strange sleep disturbances, and as he said, "it may help in some crazy way with the cycles underlying these disturbances." Again, I think his reasoning is sound here. But it is simply not a viable anxiolytic.
>
> > So you are starting Cymbalta today? I am getting impatient!
>
> You mean you're getting tired of hearing about it. :-) I was planning on taking it today but i've been having allergy and sinus problems with headache and pressure and swollen membranes for several days now. I couldn't bear the thought of adding on a drug to give me worse symptoms. I wish I could figure out what I'm having this reaction to. It might be the Armour thyroid medication. I'll be going back to the synthetic T4 tomorrow so we'll see if that changes anything.OK then, tell me if the T4 helps! That's not as interesting as Cymbalta, but I have to be grateful for small things :)
>
> Hopefully I'll be in the mood to start the Cymbalta soon. I probably shouldn't have said anything about it until I had actually started on it.
>
It would be too shocking, at this point, for me to deal with your taking Cymbalta without advance notice. if you value my cardiac health, please let me know in advance!-z
> K
>
Posted by karaS on October 10, 2004, at 18:15:34
In reply to effects and side effects » karaS, posted by zeugma on October 10, 2004, at 8:45:23
Hi z,
> Hi kara, I hope so too! Btw I read your comment in Social but was too shy to respond ;)
You're too cute!
> > It's hard for me to focus sometimes but I don't feel like my thoughts are "directionless random processes". That must be a strange feeling.
> >
>
> It's why I have described my waking life as 'dream-like' to all my therapists since my early 20's. They displayed no understanding of what I meant. My current doctor says my symptoms are not typical of any disorder she knows of, although she concurs that I definitely have ADD in addition to other problems (learning disabilities, severe anxiety, vulnerability to depression). the research doctor at the university study I interviewed for said much the same. This doctor, who I admired for her candor (not something I have found typical of therapists or doctors) told me I needed to see a specialist in whatever disorder I thought most imperative to treat, rather than participate in a general study on depression. She did tell me I qualified for it, as I did exhibit symptoms of depression consistent with DSM criteria. I now see, however, that while her candor was appreciated, it is the fashion now for drug companies sponsoring studies to do their best to weed out the difficult cases so the product they are sponsoring can demonstrate significant separation from placebo. This is one reason the new meds are simply not as effective as those from the first generation. Imipramine was tried on everyone in the hospital, and its clinical profile slowly emerged from its being tested on a vast range of individuals with numerous disorders.On the otherhand, if there are several other conditions that a person has, it might make it dificult to judge how effective the medication has been. Too many other factors invovled - how do you separate things out?
> > > > How are you doing balancing the Strattera and Ritalin?
> > I don't understand. I thought that in the past you had taken Strattera for at least a year and had done well on it. Why is it irritating your stomach now? Is is possible for compounding pharmacies to put the medication into a patch?
>
> I did not explain myself well enough (following my dr.s injunction to cut down the caffeine is making it harder to write!). I did take Strattera for almost a year. It had a powerful effect on my ADHD; powerful enough to allow me to actually follow through on an unexpected opportunity I was offered in my field (not my academic field, unfortunately). I had received similar opportunities previously but the ADHD was so pronounced that the opportunities were lost. The Strattera always hurt my stomach. But since it worked, I put up with it, tried different strategies (changing diet, taking FiberCon and other supplements, etc.) which worked somewhat but were hardly curative. The stomach problems were not the reason I discontinued. I stopped it because it made me more and more fatigued, and I cannot tolerate a med that elevates my fatigue above baseline. The fatigue was not evident in the beginning, but gradually became more and more severe. It was not due to insomnia or anything treatable. it simply drained me, and I am being slowly drained, energywise, anyway, by the narcolepsy (ie I am more tired now than I was 2 years ago, and the fatigue has a progressive character that makes it rather frightening. Being fairly sure that I do have narcolepsy (pdoc concurred) is comforting, as the forum boards of narcolepsy are full of stories of worsening fatigue through the 20's, increasing through the early and mid 30's till almost complete anergia results. Stims reverse this partially but not completely, and experts on narcolepsy are more candid about the limitations of stims in narcolepsy than Pfizer, Lilly, et al. are in plugging the dramatic effects of their newest AD's: stims only partially reverse the terrible fatigue. That does console me a little. I would rather get an honest picture of what to expect than an inflated one. Do you know I appreciate candor?)Yes, I can see why you would prefer the truth. There are too many decisions you need to make and it's hard to plan when you have false promises or
expectations. I didn't realize that narcolepsy was a progressive condition. I thought it was more treatable than that. Of course there's always hope for better future treatments.Do either of your parents have any of your conditions? If so, how have they managed to deal wtih them?
You didn't respond earlier to my idea of Strattera in a patch. Is that at all possible? I don't know why they don't make more medications in patch form. There are so many people I've read about on the boards here who can't take medications orally because of stomach, IBS or other problems.
> Back to Strat, 2nd trial. Immediate AD effects, immediate 'clearing' of my thought process. But it does intensify the fatigue. And a med that does this is off my list, period. (I mean fatigue that does not subside with time. I can discriminate between the antihistaminic effect of nortriptyline, which is 'sedating', and the peculiar, recalcitrant fatigue of Strattera. Sedation I can deal with, since it passes in 2 weeks and what is left is the propensity to sleep, which is why the TCA's are so great for insomnia. Nortriptyline does not increase my fatigue. if it did, I would chuck it too, and was prepared to do so last year when I systematically lowered my meds one by one to see which one was draining me beyond my usual, awful draining.)I don't remember if I've ever asked you if you've tried desipramine. If you tolerate the TCAs well but need more stimulation, would that or even propityline be a possibility?
> > Is there a reason that you never consider or try Adderall or Dexedrine?
> >
> I would try them. I don't know my pdoc's rationale for preferring Ritalin. But I think what he is doing is making sure I give Ritalin an adequate trial by increasing the dosage to what is therapeutic *for me*. I am a rapid metabolizer of drugs and I know that I need to take Ritalin LA every six hours despite the fact that it's marketed as an eight-hour formulation. If the higher dose of Ritalin simply does nothing, then I will bring up the other stims. But as he said, "We shouldn't give up on it yet," and I agree. It may work at this dose, or a higher one. I'm skeptical, but I think he is being conscientious. Also, the little I have been able to find on this topic suggests that Ritalin is safer than amphetamines when combined with a TCA. That may be his rationale.Now that I read your response, I think I remember asking you that question before. Sorry. It's good to know that there are other options to try though if increasing the Ritalin isn't enough.
> Coffee rips up my insides, and my therapist suggested I take caffeine pills. If Ritalin doesn't work, and then Adderall etc. doesn't either, I am going to make the stockholders of the company that makes NoDoz very happy.
> Of course, coffee rips up my insides less than Strattera...>
>
> > > By the way, to answer your question in your last post: I think I have both. A fun combination :) I am also restarting buspirone, 15 mg hs, as I told him it blocked hypnagogic hallucinations when I knew I would be vulnerable to them (ie, when I am stressed or have gotten inadequate sleep previously). I took it last night without problems. I tolerate buspirone well at low dosages.
>
> Buspirone does not work as an anxiolytic for me. It does work as an AD.... "it may help in some crazy way with the cycles underlying these disturbances."
That's a different usage for it. I hadn't heard of that.
> > > So you are starting Cymbalta today? I am getting impatient!> It would be too shocking, at this point, for me to deal with your taking Cymbalta without advance notice. if you value my cardiac health, please let me know in advance!
My pdoc will be sorry to hear that I haven't started it yet. He's eager to hear how his first patient is doing on it. Fortunately I'll get his voicemail and let him know that way. (Cluck, cluck)
Well, one of these days that shock does have to come. So be prepared! Aside from working and my allergy/sinus problems and my fear of meds in general, I don't want to face the possibility of it not working for me. (I think it's fairly safe to assume that I also have Avoidant Personality Disorder.)
Well, I'd better go attend to my long list of chores now. I can hardly wait.
Talk to you later,
Kara
Posted by zeugma on October 11, 2004, at 11:53:16
In reply to Re: effects, side effects and procrastination » zeugma, posted by karaS on October 10, 2004, at 18:15:34
hi kara,
you raised a number of interesting points, and also noted my tendency to glaringly omit certain details :) anyway, here goes:
I don't know much about getting a pharmacy to compound a patch. I imagine it would be very expensive. A Strattera patch might be interesting, but it would still intensify the fatigue as a delayed reaction (Strattera is a very difficult drug to pin down- its metabolite interacts with the opioid system in a complex way, which could be both beneficial and hurtful, and also disceprepancies have been noted between its plasma half-life and clinical effect.). But it is something to think about. I am not going to throw my Strattera out. But its peculiar combination of alerting and fatiguing makes it only a short-term solution, as far as I can see.
I repeatedly asked my pdoc about desipramine last year. In his estimation nortriptyline and desipramine produce similar clinical effects. Now nortrip is definitely more sedating for most. So for me, if i take nortriptyline at 7 pm, I can expect to be asleep by 10:30. I don't think desipramine would have this effect. It's a moot point though, as I can't afford to stay up late anymore with any frequency anyway. The narcolepsy worsens with any degree of sleep deprivation, and I can't do the 'all-nighters' I used to that got me through college and most of the way through grad school. Another point to consider is pharmacokinetic. Nortriptyline has a longer average half-life than desipramine. That would mean that I would probably have to take larger amounts of DMI to make up for its shorter half-life, say at 6 am and 7 pm, and the dosing guidelines for DMI are higher than for NOR. As it is, there is a 'trough period' with NOR where I am vulnerable to cataplexy. Plus, NOR is more anticholinergic than DMI, and this is believe it or not probably a point in NOR's favor. Pro-cholinergic drugs intensify cataplexy. Anti-cholinergic drugs reduce it.
Protriptyline: now that one is interesting. It is like Prozac in its snail-like pharmacokinetics. It also is the most stimulating of the TCA's. So one benefit would be that I would avoid the 'trough period' that NOR leaves open for cataplexy. It also might stimulate me a little, and it is anti-cholinergic to boot. To see clearly the relationship between TCA's, as well as other AD's, (unfortunately Cymbalta was left offf this list), see http://www.primarypsychiatry.com/pdf/art_453.pdf
and scroll down to the end where you will see a chart outlining receptor affinities of these various drugs. As King Vultan said a long time ago (sorry, I have a hyper-cholinergic memory for certain things, though unmedicated I forget my keys when i go to the laundry room) protriptyline is almost exactly between nortriptyline and desipramine in its pharmacodynamic profile. It is interesting nonetheless, because of its slow clearance. In clinical trials with narcoleptics, however, it did not have impressive results as a stimulant and so is used mostly as an anti-cataplectic agent. But it is a valid suggestion, and I am going to do some more research on this one.My parents do not have narcolepsy. They do both have 'shadow syndromes' for ADHD and social anxiety, and if you combine their traits and intensify them I will result (I did!). My brother is free of these disorders. My sister has some of my own symptoms: panic disorder, and a propensity for sleep paralysis. She takes Prozac for panic with lorazepam for situational anxiety. She gets sleep paralysis about once a month. But she does not get the painful maifestations that I do (I got them last night too- ouch!) and does not have full-blown narcolepsy. She is in her late 20's and generally narcolepsy manifests in the late teens to early 20's. There is clearly genetic input, plus it is believed there is some kind of autoimmune reaction that impairs orexigenic transmission that combines with the inborn propensity to produce the full disorder. Provigil acts on this obscure transmitter, hence its special value for narcolepsy.
Buspirone is a strange drug that, like the TCA's, has multiple mechanisms of action. It is a partial agonist at 5-HT 1A receptors, and a weak blocker of D2 receptors. Now I may be wrong, but aren't presynaptic D2 receptors the analogues of 5HT1A presynaptic receptors and alpha-2 noradrenergic receptors, ie inhibitory autoreceptors? If dopamine autoreceptor hypersensitivity is part of your problem, then presynaptic D2 blockade should help it. I know you tried buspar and it didn't help you. The only other drugs I know of that block D2 autoreceptors would be amisulpiride ( not available in the US) and possibly Abilify. Abilify might be worth a shot. Unlike other atypical AP's it only produces a partial agonism of D2 receptors. Also Seroquel might be worth a shot.
I agree, and disagree, with your point about modern trials being more selective. If depression were a nice homogeneous disorder, then yes, I would say don't include those with comorbidities in trials. This may well actually be good for the vast majority who take Lexapro and don't hang out at Psycho-Babble for long periods. So you may be right overall. Still, most of us here at PB have comorbidities and require multiple psych meds, and I also think there is something to the idea of slowly seeing a pattern emerge from trying out the drug on a heterogeneous group, rather than a priori projecting an 'antidepressant' effect and then looking for separation from placebo in a specially selected group. But no drug company can afford to be so profligate with their resources as the early companies were, who had no idea what imipramine was for ( they wrongly guessed it to be an AP), given the enormous costs of drug development. So I'll concede half your point, and I'll wish we lived in a different world.
Do you have AvPD? So do I. There are advantages to this condition you know. Circumspection and evading the point(not that I'm accusing you of this, it is me with my endless parentheses that evade the point!) can be great assets in certain professions, such as diplomacy. They also result in fewer PBC's and bans on this carefully civil site. :)Do you take/have you taken Klonopin? To my knowledge, Klonopin and Nardil are best for AvPD. Marplan and Parnate might work too, but they've been less studied. Then there's the new pregabalin. have you tried its older analogue, Neurontin?
An advantage to AvPD, too, is a heightened awareness of others' reactions. But the anxiety has to be controlled first.
I realize I have not responded to your point about narcolepsy not being fully treatable. People with narcolepsy need to be extremely up on their sleep hygiene, ie they cannot miss any sleep without repurcussions later, regardless of meds. I have had two cataplectic attacks in the last week that are due to staying up later than planned due to work obligations. I am currently considering leaving my job for one less taxing on my time for this reason. But this would not be something I would want to do (I like my job a lot). Hence my increased anxiety level, and more desperate search for a solution.
Have you told your dr. about your suspicion of AvPD? This could be important to the outcome of your treatment. Obviously you can't take Nardil concurrently with Cymbalta. Med anxiety kept me away from meds for many years. Desperation sent me back.
-z
Posted by karaS on October 16, 2004, at 17:17:37
In reply to Re: effects, side effects (long) » karaS, posted by zeugma on October 11, 2004, at 11:53:16
z,
Thanks for posting the message asking where I've been. It was so nice to feel missed. I finally have the time to tackle this post so here goes.
> hi kara,
>
> you raised a number of interesting points, and also noted my tendency to glaringly omit certain details :) anyway, here goes:
>
> I don't know much about getting a pharmacy to compound a patch. I imagine it would be very expensive. A Strattera patch might be interesting, but it would still intensify the fatigue as a delayed reaction (Strattera is a very difficult drug to pin down- its metabolite interacts with the opioid system in a complex way, which could be both beneficial and hurtful, and also disceprepancies have been noted between its plasma half-life and clinical effect.). But it is something to think about. I am not going to throw my Strattera out. But its peculiar combination of alerting and fatiguing makes it only a short-term solution, as far as I can see.
If it weren't for the fatiguing effect that Stratter has on you, I'd say try to get your insurance to cover the cost of a patch. (Maybe if your doctor claimed that it was imperative for your functioning that you could get it covered - but it's a moot point because of the other side effect.)
> I repeatedly asked my pdoc about desipramine last year. In his estimation nortriptyline and desipramine produce similar clinical effects. Now nortrip is definitely more sedating for most. So for me, if i take nortriptyline at 7 pm, I can expect to be asleep by 10:30. I don't think desipramine would have this effect. It's a moot point though, as I can't afford to stay up late anymore with any frequency anyway. The narcolepsy worsens with any degree of sleep deprivation, and I can't do the 'all-nighters' I used to that got me through college and most of the way through grad school. Another point to consider is pharmacokinetic. Nortriptyline has a longer average half-life than desipramine. That would mean that I would probably have to take larger amounts of DMI to make up for its shorter half-life, say at 6 am and 7 pm, and the dosing guidelines for DMI are higher than for NOR. As it is, there is a 'trough period' with NOR where I am vulnerable to cataplexy. Plus, NOR is more anticholinergic than DMI, and this is believe it or not probably a point in NOR's favor. Pro-cholinergic drugs intensify cataplexy. Anti-cholinergic drugs reduce it.It's definitely a dificult choice to replace the nort. because it fits in so well with your routine. You'd have to switch a lot of things around to make "room" for something else - all the while risking some dysfunction. OTOH, what choice do you have if the current combination isn't taking care of all of your needs?
Anticholinergics also have benefit for me in that they mask my cholinergic urticaria. OTOH, the anti choline effect is not great for optimal brain function. It so often comes down to a balancing act, doesn't it?
> Protriptyline: now that one is interesting. It is like Prozac in its snail-like pharmacokinetics. It also is the most stimulating of the TCA's. So one benefit would be that I would avoid the 'trough period' that NOR leaves open for cataplexy. It also might stimulate me a little, and it is anti-cholinergic to boot. To see clearly the relationship between TCA's, as well as other AD's, (unfortunately Cymbalta was left offf this list), see http://www.primarypsychiatry.com/pdf/art_453.pdf
> and scroll down to the end where you will see a chart outlining receptor affinities of these various drugs. As King Vultan said a long time ago (sorry, I have a hyper-cholinergic memory for certain things, though unmedicated I forget my keys when i go to the laundry room) protriptyline is almost exactly between nortriptyline and desipramine in its pharmacodynamic profile. It is interesting nonetheless, because of its slow clearance. In clinical trials with narcoleptics, however, it did not have impressive results as a stimulant and so is used mostly as an anti-cataplectic agent. But it is a valid suggestion, and I am going to do some more research on this one.I wonder why it wouldn't be good as a stimulant but clinical trials are probably better predictors than theory. Let me know what your research shows on this one. (BTW, I believe that SLS's chart shows receptor affinities for Cymbalta.)
> My parents do not have narcolepsy. They do both have 'shadow syndromes' for ADHD and social anxiety, and if you combine their traits and intensify them I will result (I did!). My brother is free of these disorders. My sister has some of my own symptoms: panic disorder, and a propensity for sleep paralysis. She takes Prozac for panic with lorazepam for situational anxiety. She gets sleep paralysis about once a month. But she does not get the painful maifestations that I do (I got them last night too- ouch!) and does not have full-blown narcolepsy. She is in her late 20's and generally narcolepsy manifests in the late teens to early 20's. There is clearly genetic input, plus it is believed there is some kind of autoimmune reaction that impairs orexigenic transmission that combines with the inborn propensity to produce the full disorder. Provigil acts on this obscure transmitter, hence its special value for narcolepsy.
I think you're amazing in terms of not feeling sorry for yourself - or at least not showing it. I would have written a comparable response about my sister getting all of the good mental health genes and I would surely have added a "lucky me" in there somewhere.
I forgot - what was the side effect that keeps you from taking Provigil?
> Buspirone is a strange drug that, like the TCA's, has multiple mechanisms of action. It is a partial agonist at 5-HT 1A receptors, and a weak blocker of D2 receptors. Now I may be wrong, but aren't presynaptic D2 receptors the analogues of 5HT1A presynaptic receptors and alpha-2 noradrenergic receptors, ie inhibitory autoreceptors? If dopamine autoreceptor hypersensitivity is part of your problem, then presynaptic D2 blockade should help it.
That's music to my ears. It's a mystery to me why Dr. Jay Goldstein and my own pdoc have said that we don't have medication for this condition yet. I'll have to do some serious research on this one. Todd (King Vultan) has suggested (if I’m understanding him correctly) that we should be able to downregulate the dopamine autoreceptors in the same way that the SSRIs do for serotonin autoreceptors. Any thoughts on this?
>I know you tried buspar and it didn't help you.
I don't know that it wouldn't have helped me had I been able to tolerate it. It made me very nauseous and that side effect didn't go away.
>The only other drugs I know of that block D2 autoreceptors would be amisulpiride ( not available in the US) and possibly Abilify. Abilify might be worth a shot. Unlike other atypical AP's it only produces a partial agonism of D2 receptors. Also Seroquel might be worth a shot.
Amisulpride has been on my list to explore for a while now because of the success of many on this board who are TRDs with dopamine inadequacies. I'm sure I could find it (and hopefully I could convince my doctor to write a script). My pdoc also recently suggested I try Abilify - but for other reasons. He thought it might help me because of my possible "soft bi-polar" tendencies. I'm still afraid of APs though. I know that the newer ones are more safe but I still worry about movement disorders.
> I agree, and disagree, with your point about modern trials being more selective. If depression were a nice homogeneous disorder, then yes, I would say don't include those with comorbidities in trials. This may well actually be good for the vast majority who take Lexapro and don't hang out at Psycho-Babble for long periods. So you may be right overall. Still, most of us here at PB have comorbidities and require multiple psych meds, and I also think there is something to the idea of slowly seeing a pattern emerge from trying out the drug on a heterogeneous group, rather than a priori projecting an 'antidepressant' effect and then looking for separation from placebo in a specially selected group. But no drug company can afford to be so profligate with their resources as the early companies were, who had no idea what imipramine was for ( they wrongly guessed it to be an AP), given the enormous costs of drug development. So I'll concede half your point, and I'll wish we lived in a different world.Speaking as a TRD who hangs out at Psycho-Babble, I see both sides as well.
> Do you have AvPD? So do I. There are advantages to this condition you know. Circumspection and evading the point(not that I'm accusing you of this, it is me with my endless parentheses that evade the point!) can be great assets in certain professions, such as diplomacy. They also result in fewer PBC's and bans on this carefully civil site. :)Do you take/have you taken Klonopin? To my knowledge, Klonopin and Nardil are best for AvPD. Marplan and Parnate might work too, but they've been less studied. Then there's the new pregabalin. have you tried its older analogue, Neurontin?I've never been diagnosed with AvPD. I just assumed I have it based on the fact that I endlessly procrastinate. I am in such serious financial trouble and yet I haven't been able to push myself to job hunt. Maybe that's just depression and not actually AvPD though. I don't know. I would make a good diplomat however. After getting addicted to Ativan over very little usage, I've stayed away from benzos. I never would have guessed that one of them would be good for AvPD. Neurontin made me very sick. I have yet to try an MAOI but they are a good next choice for me for many reasons. I'd prefer to start wtih Marplan and then Parnate though. I don't want to take anything that could make me more tired or lethargic.
> An advantage to AvPD, too, is a heightened awareness of others' reactions. But the anxiety has to be controlled first.
I do have a heightened awareness of others' feelings as well as their reactions to me. Rejection sensitivity is probably an adequate description of the latter. I used to have problems with GAD but don't seem to have that problem now. Even though i went off of all meds recently, I still am not having that constant knot in my stomach or the panic attacks. Maybe years of SSRI usage has numbed me out for life.
> I realize I have not responded to your point about narcolepsy not being fully treatable. People with narcolepsy need to be extremely up on their sleep hygiene, ie they cannot miss any sleep without repurcussions later, regardless of meds. I have had two cataplectic attacks in the last week that are due to staying up later than planned due to work obligations. I am currently considering leaving my job for one less taxing on my time for this reason. But this would not be something I would want to do (I like my job a lot). Hence my increased anxiety level, and more desperate search for a solution.That would be too bad if you had to quit a job that you really like. Would it be possible for you to get something in your field that you would like as much that isn't as demanding of your energy and time? What field are you in? I'm very curious after reading your posts. (You don't have to answer that in this forum if you aren't comfortable with it. You could BabbleMail me or just not answer.)
I have an MBA though I haven't really had any jobs that required it. It's amazing to me that I was able to get it (it was a grueling program too) considering my lack of drive.> Have you told your dr. about your suspicion of AvPD? This could be important to the outcome of your treatment. Obviously you can't take Nardil concurrently with Cymbalta. Med anxiety kept me away from meds for many years. Desperation sent me back.
Yes, that desperation can be quite powerful, can't it? I saw another post of yours regarding Cymbalta. You said it was just an updated version of imipramine. Why? It has an SSRI added in, it doesn't seem to produce the tachycardia that many TCAs do and it doesn't seem to have the anticholinergic effects either. Maybe they have affinities for the same receptor sites, but it still seems like there are significant differences (improvements?) to me.
No, I haven't told my doctor yet about my AvPD suspicions. I'll have to bring it up with him next time I can afford to see him. I've seen him a number of times though and he knows my situation so I would think this might have crossed his mind once or twice.
Hope you're doing ok. Talk to you later,
K
Posted by karaS on October 17, 2004, at 4:21:27
In reply to Re: effects, side effects (very long) » zeugma, posted by karaS on October 16, 2004, at 17:17:37
I'm having a rare moment of clarity and wanted to make some changes to my last couple of posts in this thread.
- First of all, I confused anticholinergic with antithistaminic when discussing cholinergic urticaria.
- I forgot that Amisulpride was an AP.
- Thanks for recognizing that I meant protriptyline when I typed propityline.
- After looking at Scott's chart, I can see now why you compared Cymbalta with imipramine. I hadn't realized earlier that imipramine has significant 5-HT reuptake inhibition as well.
k
Posted by zeugma on October 17, 2004, at 11:59:14
In reply to Re: corrections - what was I thinking?, posted by karaS on October 17, 2004, at 4:21:27
> I'm having a rare moment of clarity and wanted to make some changes to my last couple of posts in this thread.
>
> - First of all, I confused anticholinergic with antithistaminic when discussing cholinergic urticaria.O.K. But thanks for making me break out my dictionary :)
>
> - I forgot that Amisulpride was an AP.
>
Did you? I didn't notice any confusion on your part.> - Thanks for recognizing that I meant protriptyline when I typed propityline.
>
"Propityline" might make me more self-pitying. But I would REALLY pity myself if I even noticed that's what you typed :)> - After looking at Scott's chart, I can see now why you compared Cymbalta with imipramine. I hadn't realized earlier that imipramine has significant 5-HT reuptake inhibition as well.
>
Yes, but it's an open question as to whether Cymbalta will actually turn out to be useful in conditions that imipramine isn't. I wonder, since the tachycardia you experienced on NOR was like the tachycardia on DMI, which latter doesn't have much in the way of anticholinergic properties, if the speeded heart wasn't due to what Stahl calls 'pseudo-anticholinergic' properties, i.e. indirect anticholinergic effects mediated by NE potentiation. I think you mentioned that Effexor IR gave you tachycardia, but not XR. Did you go high enough on Effexor XR to get a significant noradrenergic effect?-z
> k
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