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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 48 to 72 of 107. Go back in thread:
Posted by zeugma on February 7, 2005, at 11:39:36
In reply to Re: To Zeugma, posted by zeugma on February 7, 2005, at 11:24:49
it is doubly irresponsible of him to retry it when this was not merely the 2nd time I had done so. I had used it in Oct. or Nov. when on a subtherapeutic dose of Ritalin and it induced dysphoria then, too, which was why I stopped it (I can deal with stomach pain, but not sustained dysphoria and increased fatigue). It was notable that this time when I retried it it was purely out of trust in him, as there is no pharmacological evidence that it is superior to TCA's in terms of efficacy or tolerability (I had brought up desipramine and he maintained Strattera was better for ADD. I do not believe Lilly has conducted trials against desipramine so how could he say this? Also I am sure desipramine would not induce this kind of dysphoric reaction.)
-z
Posted by zeugma on February 7, 2005, at 11:46:44
In reply to Re: Strattera » zeugma, posted by ed_uk on February 7, 2005, at 11:38:05
Posted by ed_uk on February 7, 2005, at 11:52:18
In reply to one more thing, posted by zeugma on February 7, 2005, at 11:39:36
Hello,
>I do not believe Lilly has conducted trials against desipramine so how could he say this?
Some doctors have a habit of thinking that new drugs are always better, they are very susceptible to Big Pharma's propaganda! I very much doubt that Lilly would dare to conduct such a trial. In one of my lectures the other day we got taught 'New drugs are only approved after it has been demonstrated that they are clearly superior to existing drugs.' (I do pharmacy btw). Our minds are being filled with bulls**t!
Ed.
Posted by zeugma on February 7, 2005, at 12:45:55
In reply to Re: one more thing » zeugma, posted by ed_uk on February 7, 2005, at 11:52:18
Our minds are being filled with bulls**t!
Yes, only too literally in this case.I became sick of arguing with my pdoc about this last year, as he was neither going to produce evidence nor budge. I also became sick of arguing it with my therapist, who took the line that 'newer is better' (well, this is america after all). I should have dumped them both, unfortunately one tries to play along with mental health professionals for as long as possible in the hope of getting relief despite atavistic attitudes (and in my case, it is hard for me to function, period, without chemical help).
I've come to expect a certain lack of reason from people in mental health professions. I'll derive what grim amusement I can from today from pondering that one :)
-z
Posted by zeugma on February 7, 2005, at 18:05:34
In reply to Re: one more thing » ed_uk, posted by zeugma on February 7, 2005, at 12:45:55
I'm still going thru stim withdrawal, and now that I'm going to be d/c'ing Strattera, I decided to stay at 75 nortrip for the time being because I am so d*mmed anxious about the effect these drugs are having on me that I want to make as few changes as possible in the space of 24 hours. The strattera dysphoria is a peculiar, anhedonic feeling that should dissipate within a day or two independently of any antidepressant effect of other drugs. (I suppose that Ki of 95 nM is low enough in my case...) I wonder why the TCA's are so much more reliable than these new drugs. My own theory is that since we don't have a clue about the brain yet, relatively speaking, it is the serendipitious discoveries that yield better meds, because we literally don't know what we're aiming at and are more likely to produce favorable results by pure chance than by 'designing' a drug 'rationally.'
-z
Posted by ed_uk on February 8, 2005, at 10:08:07
In reply to still going thru stim w/d, posted by zeugma on February 7, 2005, at 18:05:34
Hi Z!
>I've come to expect a certain lack of reason from people in mental health professions. I'll derive what grim amusement I can from today from pondering that one :)
Lol :-)
>I wonder why the TCA's are so much more reliable than these new drugs. My own theory is that since we don't have a clue about the brain yet, relatively speaking, it is the serendipitious discoveries that yield better meds, because we literally don't know what we're aiming at and are more likely to produce favorable results by pure chance than by 'designing' a drug 'rationally.'
Perhaps Strattera and/or desipramine bind to numerous receptors that haven't even been discovered yet, that might explain some of the apparant differences between them. What do you think? New receptors are being discovered all the time. Most drugs won't have even been tested to find out whether they bind to these 'new' receptors. Anyway, the function of recently discovered receptors is generally poorly understood.
Ed.
Posted by banga on February 8, 2005, at 11:18:51
In reply to Re: still going thru stim w/d » zeugma, posted by ed_uk on February 8, 2005, at 10:08:07
RE Why tricyclics may be better:
I think the newer drugs are almost overengineered...they are SO specific that they initially right the problem--the imbalance--but then go too far and disrupt the imbalance because they act so powerfully on the target but not on anything else. Like letting in cold water in the bath to cool off the bathwater...but if you overdo it it all swings to the other extreme. People talk about brain fog and apathy etc. The older "dirtier"drugs may act more broadly and not overpush the whole system.
Posted by SLS on February 9, 2005, at 20:19:11
In reply to still going thru stim w/d, posted by zeugma on February 7, 2005, at 18:05:34
> I'm still going thru stim withdrawal, and now that I'm going to be d/c'ing Strattera, I decided to stay at 75 nortrip for the time being because I am so d*mmed anxious about the effect these drugs are having on me that I want to make as few changes as possible in the space of 24 hours. The strattera dysphoria is a peculiar, anhedonic feeling that should dissipate within a day or two independently of any antidepressant effect of other drugs. (I suppose that Ki of 95 nM is low enough in my case...) I wonder why the TCA's are so much more reliable than these new drugs. My own theory is that since we don't have a clue about the brain yet, relatively speaking, it is the serendipitious discoveries that yield better meds, because we literally don't know what we're aiming at and are more likely to produce favorable results by pure chance than by 'designing' a drug 'rationally.'
>
> -z
I wonder what would happen if you were to take an anticholinergic like Akineton...
- Scott
Posted by zeugma on February 10, 2005, at 16:30:00
In reply to Re: still going thru stim w/d, posted by SLS on February 9, 2005, at 20:19:11
I wonder what would happen if you were to take an anticholinergic like Akineton...
It seems like you're thinking what I'm thinking... that the cholinergic-aminergic imbalance is so pronounced that it produces movement-disorder- and akathasia- type symptoms (and it does, though my docs son't take these seriously- when younger I used to pace incessantly, now I can barely get myself out of my chair, though I am so tense that I would love to pace if given the energy...) I'm also thinking that a stim is out of the question, for several reasons. I wonder if protriptyline might be the answer.
-z
Posted by ed_uk on February 11, 2005, at 6:42:03
In reply to Re: still going thru stim w/d » SLS, posted by zeugma on February 10, 2005, at 16:30:00
Hi Z,
>I wonder if protriptyline might be the answer.
Protriptyline tends to cause a lot of side effects. Anyway, it doesn't have any clear advantages over desipramine. It is sometimes claimed that protriptyline is 'stimulating' in a way that desipramine is not- I am convinced that this is a myth. Protriptyline is potently anticholinergic, cardiovascular side effects such as hypotension are common and it sometimes causes a rash. Basically, I'd stay away from it!! There are better drugs available!
Best Regards,
Ed.
Posted by ed_uk on February 11, 2005, at 7:24:57
In reply to Re: still going thru stim w/d » zeugma, posted by ed_uk on February 11, 2005, at 6:42:03
Hi Z,
Wow, my last post was a bit negative wasn't it?! Sorry about that, I was in a bad mood :-S
Ed.
Posted by zeugma on February 11, 2005, at 15:24:29
In reply to Re: still going thru stim w/d » zeugma, posted by ed_uk on February 11, 2005, at 6:42:03
Hi Ed.
I haven't read much that is good about protriptyline. The one place I did read a positive comment was on a chat board for narcolepsy in which a woman claimed to take 15 mg a day with no side effects and great efficacy. Everything else was negative, so you are simply affirming the consensus on this one. The thing that concerns me is its lack of antihistaminic effect- yes, that might make for a 'stimulating' experience (and it would truly be interesting to see if its being more stimulating than DMI is a myth or not) but I am skeletal, and that it was I was put on nortriptyline, and not DMI, in the first place. I can't tell you how much better I feel, physically and emotionally, to have the strattera out of my system. The stuff truly was poisonous to my emotions.
So now I'm on just three drugs- 100 mg nortriptyline, 30 mg buspirone, 1 mg clonazepam. Now I am down to nearly zero side effects. And I have an appetite- not a large one, but the thought of food does not fill me with dismay. And the combination is good for my nerves. Oh, and tons, TONS of caffeine. Why is caffeine the only tolerable stimulant I can take?
It's amazing how three drugs has basically zero side effects, and then when I add a fourth, my system seems to become overwhelmed. I'm filled with fatigue, but at least I don't feel the anxiogenic roller coaster of Ritalin or the dysphoric alertness of strattera. Just the normal, everyday, dead-on-my-feet exhaustion that seems resistant to everything. It's better than what I felt on ritalin.
-z
Posted by SLS on February 12, 2005, at 9:20:38
In reply to Re: still going thru stim w/d » SLS, posted by zeugma on February 10, 2005, at 16:30:00
> I wonder what would happen if you were to take an anticholinergic like Akineton...
>
>
>
> It seems like you're thinking what I'm thinking... that the cholinergic-aminergic imbalance is so pronounced that it produces movement-disorder- and akathasia- type symptoms (and it does, though my docs son't take these seriously- when younger I used to pace incessantly, now I can barely get myself out of my chair, though I am so tense that I would love to pace if given the energy...) I'm also thinking that a stim is out of the question, for several reasons. I wonder if protriptyline might be the answer.
>
> -zI would give Akineton a quick trial. You know, there is a balance between muscarinic and dopaminergic systems. It might possibly be involved in your presentations - even the narcolepsy, although I would have to look into that more. It might be nice to try a pure antimuscarinic and not confound any results with what protripyline does.
- Scott
Posted by ed_uk on February 12, 2005, at 9:58:42
In reply to Re: still going thru stim w/d » ed_uk, posted by zeugma on February 11, 2005, at 15:24:29
Hi Z!
Glad you're feeling better :-)
>The thing that concerns me is its lack of antihistaminic effect- yes, that might make for a 'stimulating' experience
Desipramine has very little anti-histamine activity.
>I can't tell you how much better I feel, physically and emotionally, to have the strattera out of my system. The stuff truly was poisonous to my emotions.
:-) Strattera is a strange drug!
>Why is caffeine the only tolerable stimulant I can take?
You haven't tried all the stimulants yet!
Best,
Ed.
Posted by zeugma on February 13, 2005, at 16:47:54
In reply to Re: still going thru stim w/d » zeugma, posted by ed_uk on February 12, 2005, at 9:58:42
I'm not eager to try another stimulant. for one thing three drugs feels like enough, four and the s/e start to become noticeable. Nortriptyline is a very 'natural' feeling drug, if you know what I mean. It makes me a little more emotional than I ordinarily would be, and it stops the REM problems at 100 mg pretty efficiently. Clonazepam makes it possible to stand on supermarket lines without going through agony. Buspirone... well, there is the theoretical rationale of alpha-2 antagonists potentiating noradrenergic AD's, and that seems to be true in my case.
if I do try another stim, it's going to have to be with atenolol, after an EKG, under the auspices of someone who knows what they're doing. right now I have only limited trust in any pdoc to know what they're doing.
-z
Posted by Maxime on February 13, 2005, at 19:56:04
In reply to Re: Stimulant withdrawal » zeugma, posted by CareBear04 on February 3, 2005, at 13:18:59
Has anyone gone through the same withdrawal symptoms I had? I was dizzy and throwing up for several days and had the cold sweats. Is this normal if you quit something like Adderall or I am a freak?
Maxime
Posted by zeugma on February 13, 2005, at 20:04:41
In reply to Re: Stimulant withdrawal, posted by Maxime on February 13, 2005, at 19:56:04
I had dizziness, and a general feeling of weakness for a good while after d/c'ing Ritalin abruptly. Of course, I added on strattera quickly as a replacement, so that could have contributed to these symptoms, then Strattera brought on an intense dysphoria of its own.
Extreme anergia, beyond my already anergic baseline, and a feeling of being in slow motion (which I am, my reflexes are in their usual dysfunctional state- with a reaction time like mine, driving a car is impossible). Withdrawal from a stim is very unpleasant.
-z
Posted by ed_uk on February 15, 2005, at 8:15:26
In reply to Re: still going thru stim w/d » ed_uk, posted by zeugma on February 13, 2005, at 16:47:54
Hi Z :-)
How are you doing?
>for one thing three drugs feels like enough, four and the s/e start to become noticeable.
Lol Z, I think that was due to which drugs you were taking, not how many.
>if I do try another stim, it's going to have to be with atenolol, after an EKG, under the auspices of someone who knows what they're doing.
Yes, you might need to see a cardiologist.
Best,
Ed.
Posted by zeugma on February 15, 2005, at 16:38:44
In reply to Re: still going thru stim w/d » zeugma, posted by ed_uk on February 15, 2005, at 8:15:26
> Hi Z :-)
>
> How are you doing?
>
> >for one thing three drugs feels like enough, four and the s/e start to become noticeable.
>
> Lol Z, I think that was due to which drugs you were taking, not how many.well there's the nortriptyline, 100 mg. i think it's a good drug BUT doesn't cover all my symptoms (it isn't all that stimulating, and doesn't calm me down much either: the paradox i've been grappling with is that i needed to be simultaneously calmed and stimulated); there's buspirone, 30 mg, which has negligible s/e but which i would be happy to dispose of if given a reason to do so; there's clonazepam 1 mg, which keeps a lid on the anxiety but which adds to the asthenia, so i keep the dose as low as possible.
i spoke to my pdoc just now, and he wants me to retry Provigil at 50 mg tomorrow am. Now there is something crazy about retrying failed meds, but the Provigil failed because of weird side effects; it actually calmed me down and stimulated me, and I could swear the drug works on 5-HT (while taking it I felt no need to augment with buspirone). I'm trying to get thru the next few days at work in a functional state, because I have BAD ADDD, like I'm watching a reel of film sputter inside my head as I frantically struggle with the projector. What are your thoughts on Provigil?it's the first line med these days for narcolepsy. i know it concentrates in the hypothalamus, and i'm convinced (for some very simple reasons) that i have hypothalamus problems. the drug worked, it just caused bizarre but subjective side effects, unlike the ritalin, which caused objective s/e, like temper tantrums when it wore off and tachycardia. it is only in the last day or two that the chest pains have wholly dissipated.
i am convinced Provigil has some 5-HT effect that has not been elucidated yet. the drug calmed me the way SSRI's calm some people. how else can you explain a drug that gives a hypochondriac like the bizarre s/e I experienced (like feeling hot and cold simultaneously, and having swollen neck glands [ok, that's objective, I've got to have my pdoc look at my neck if I get that again]) without causing me to ramp up the klonopin? the ritalin had me so tense that some days I would take 2 mg of clonazepam and f*ck up my sleep completely.
i suppose this is only a stopgap until i can try dexedrine or something. But unfortunately, I am trying to hold down a job, and the caffeine pills aren't cutting it.
-z
>
> >if I do try another stim, it's going to have to be with atenolol, after an EKG, under the auspices of someone who knows what they're doing.
>
> Yes, you might need to see a cardiologist.
>
> Best,
> Ed.
>
>
Posted by zeugma on February 15, 2005, at 16:58:49
In reply to Re: still going thru stim w/d » ed_uk, posted by zeugma on February 15, 2005, at 16:38:44
I know it's a long shot, but I suppose it's just possible that the weird s/e I experienced on provigil were specific to nortriptyline, and that switching to desipramine might alleviate them. It's just a thought. Provigil was actually anxiolytic or at least neutral for me in that department, which as you know is a huge concern of mine. And provigil, unlike d-amphetamine, would not send me to the cardiologist (at least if my past experience, relatively extensive, with the drug is any indication). I really want to find a workable combination. If Provigil doesn't work out again, I am going to have to find something- an AP, an SSRI, a mood stabilizer, SOMETHING- to ease the terrible inner tension I constantly feel, and that comes out on stims in bursts of irritability. Of course, if it's something like akathisia, an SSRI or an AP would be a very bad idea...
thanks for listening to all this,
z
Posted by ed_uk on February 16, 2005, at 7:06:14
In reply to ed- your opinion please, posted by zeugma on February 15, 2005, at 16:58:49
Hi Zeugma!
>i needed to be simultaneously calmed and stimulated
Me too!!! I don't like caffeine either, it does nothing for me, I still feel tired.
>there's clonazepam 1 mg, which keeps a lid on the anxiety but which adds to the asthenia, so i keep the dose as low as possible.
Do you think it's worth trying a different benzo? I think I've asked you that before but I don't remember what you said. You could try a low dose of chlordiazepoxide or something like that? For whatever reason, some people find certain benzos more fatiguing than others. I have a friend who found chlordiazepoxide made him more tired than clonazepam but other people seem to find the opposite.
>he wants me to retry Provigil at 50 mg tomorrow am.
Perhaps it could be worth one last try. I'm a bit concerned that what you experienced before was some kind of unusual allergic/hypersensitivity reaction. The swollen lymph nodes (lymphadenopathy) reminded me of 'serum sickness'. It's probably way off but here's a link, may drugs can cause serum sickness but I've never heard of a case with modafinil......
http://www.emedicine.com/EMERG/topic526.htm>I know it's a long shot, but I suppose it's just possible that the weird s/e I experienced on provigil were specific to nortriptyline, and that switching to desipramine might alleviate them.
It's possible, that's all I can say really. Your Provigil side effects were quite unique, I really don't know what caused them.
>And provigil, unlike d-amphetamine, would not send me to the cardiologist
I wonder whether a cardiologist might suggest bisoprolol, it's more beta1 selective than atenolol- I think it penetrates the blood brain barrier to a greater extent though.
>if it's something like akathisia, an SSRI or an AP would be a very bad idea
What makes you think it was akathisia?
Best Regards,
Ed.
Posted by zeugma on February 16, 2005, at 16:22:44
In reply to Re: ed- your opinion please » zeugma, posted by ed_uk on February 16, 2005, at 7:06:14
> Hi Zeugma!
Hi Ed!
>
> >i needed to be simultaneously calmed and stimulated
>
> Me too!!! I don't like caffeine either, it does nothing for me, I still feel tired.
>
> >there's clonazepam 1 mg, which keeps a lid on the anxiety but which adds to the asthenia, so i keep the dose as low as possible.
>
> Do you think it's worth trying a different benzo? I think I've asked you that before but I don't remember what you said. You could try a low dose of chlordiazepoxide or something like that? For whatever reason, some people find certain benzos more fatiguing than others. I have a friend who found chlordiazepoxide made him more tired than clonazepam but other people seem to find the opposite.
>Don't you think ALL benzos have, as a consequence of GABA potentiation, a degree of sedative activity? In my case, atomoxetine had more fatiguing/depressogenic activity than clonazepam, although clonazepam is a natural suspect. I also differentiate between the sedative activity of nortriptyline, which is antihistaminic in nature, and the unusual fatigue that atomoxetine induced. I find myself fairly tolerant of antihistamines, and they do help me sleep (another paradox: I am sleepy all day, but sometimes feel too agitated to sleep at night. My circadian rhythms have been totally off since childhood!)
> >he wants me to retry Provigil at 50 mg tomorrow am.
>
> Perhaps it could be worth one last try. I'm a bit concerned that what you experienced before was some kind of unusual allergic/hypersensitivity reaction. The swollen lymph nodes (lymphadenopathy) reminded me of 'serum sickness'. It's probably way off but here's a link, may drugs can cause serum sickness but I've never heard of a case with modafinil......
> http://www.emedicine.com/EMERG/topic526.htm
>Thanks for the link. It is obviously a major concern. It was frustrating because I did not discontinue Provigil because of lack of efficacy, and I stayed on it as long as I could because I was clearly getting a lot of benefit from it. So far no swollen lymph nodes or other weird reactions :) But of course, I am going to be careful, and I'm glad my pdoc app't is next week. At the time, I didn't know that the lymph node problem could have been serum sickness or allergic reaction. I do have a multitude of allergies, and certain drugs have caused potentially life-threatening reactions, and I am hugely concerned that this will happen with provigil again too. At the same time I have been falling asleep at work, so you can see my dilemma. And the caffeine pills I was taking every three hours were more effective at causing anxiety than having any kind of therapeutic effect.
I'm terrified of the amphetamines ,too. It seems like I run into big problems when I go below 75 mg nortriptyline, so I can't really take any drug that has substantial sympathomimetic activity without seeing a cardiologist.
As far as I recall, the adverse reactions to Provigil began with the first dose, and were not dose-dependent. So maybe the fact that so far I've gotten through unscathed is a good sign. On the other hand, I am going to have my pdoc look at my lymph nodes regardless of how I feel just to be sure.
> >I know it's a long shot, but I suppose it's just possible that the weird s/e I experienced on provigil were specific to nortriptyline, and that switching to desipramine might alleviate them.
>
> It's possible, that's all I can say really. Your Provigil side effects were quite unique, I really don't know what caused them.
>
> >And provigil, unlike d-amphetamine, would not send me to the cardiologist
>
> I wonder whether a cardiologist might suggest bisoprolol, it's more beta1 selective than atenolol- I think it penetrates the blood brain barrier to a greater extent though.
>
> >if it's something like akathisia, an SSRI or an AP would be a very bad idea
>
> What makes you think it was akathisia?
>I have terrible difficulty initiating movements. I constantly feel this 'resistance'to actual physical movement though I am simulataneously tense within. It has been improved by nortriptyline, which is mildly antimuscarinic, and is specifically mitigated by provigil, which appears to act on circuits intimately tied to movement:http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9774168
you can see that provigil is under investigation for Parkinsonian disorders. There is a very close connection between Parkinson's disease, depression, and sleep disorders. I am afraid that if I don't treat my various sleep/attentional./affective disorders properly, I'll wind up with Parkinson's soon (this also is what terrifies me about the atypical AP's).
Best,
z
> Best Regards,
> Ed.
Posted by zeugma on February 16, 2005, at 17:18:43
In reply to Re: ed- your opinion please » ed_uk, posted by zeugma on February 16, 2005, at 16:22:44
I see that Provigil causes neck pain as a relatively common s/e. It can also cause eosoniphilia (sp.), which could have been responsible for why I always felt 'sick' on the drug.
I need to get myself to a GP asap. I'm on too many meds to take my health for granted.
-z
Posted by ed_uk on February 18, 2005, at 9:37:40
In reply to Re: ed- your opinion please » ed_uk, posted by zeugma on February 16, 2005, at 16:22:44
Hi Z!
>Don't you think ALL benzos have, as a consequence of GABA potentiation, a degree of sedative activity?
Yes, but some people seem to find certain benzos less sedative than others. There's no science to this, it's just a matter of experimenting and finding out which you prefer.
>So far no swollen lymph nodes or other weird reactions :)
Have you already restarted Provigil?
>certain drugs have caused potentially life-threatening reactions
Which drugs? How do you react?
Regards,
Ed.
Posted by zeugma on February 18, 2005, at 18:46:55
In reply to Re: ed- your opinion please » zeugma, posted by ed_uk on February 18, 2005, at 9:37:40
hey there Ed!
> >
>
> Have you already restarted Provigil?Yes, several days ago. On my third day.
>
> >certain drugs have caused potentially life-threatening reactions
>
> Which drugs? How do you react?
>I'm allergic to penicillin, and was told that if I didn't make that 5 am emergency app't with my local doctor, that I could have died. I was covered from head to toe in spots.
I suppose I'm guilty of some exaggeration, since that was the only drug that elicited a reaction termed 'life-threatening.' I had a lot of problems with psych meds. Wellbutrin didn't go over well with me. SSRI's caused panic attacks, secondary to intense nausea.
I am wondering if the response I had to Provigil was allergic, and if I'm in for more swollen nodes. So far nothing. If I'm due for them, that would be frustrating. Provigil works much better for my symptoms than Ritalin, and is not anxiogenic.I think the benzo is going to stay the same for a while. I have terrible social anxiety. Clonazepam has the best track record among the benzos for this particular type of anxiety. It does not make me more outgoing- I'm as introverted as ever. Unlike some others, I don't really want a 'pro-social' effect- my fatigue is so intense, anyway, that it precludes most socializing. (You can see the dilemma here. I need a stimulant to keep me awake enough to socialize- but most stims are anxiogenic! So it's kind of a vicious circle there. By all accounts, including yours, d-amphetamine is less anxiogenic than ritalin, but it's frowned upon in the US- although the recent controversy over Adderall may change that.) Also, its pharmacokinetics are better than alprazolam's for my purposes.
By the way, what do you think of buspirone? It is useless for social anxiety, but seems to have value as an antidepressant.
-z
> Regards,
> Ed.
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