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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 18 to 42 of 42. Go back in thread:
Posted by phidippus on October 1, 2013, at 14:32:16
In reply to Savella, posted by LouisianaSportsman on October 1, 2013, at 14:08:13
No one needs NE. Its role in depression is not well understood, but it doesn't keep drug manufacturers from exploiting the marketing possibilities. If anything, NE helps more with reward paradigms, which makes it invaluable in treating executive disfunction.
If you want more NE, look no further than Reboxetine, a potent NRI (norepenephrine reuptake inhibitor). Strattera is another NRI worth checking out.
If you want a robust NE solution, try Wellbutrin.
Eric
Posted by LouisianaSportsman on October 1, 2013, at 14:53:51
In reply to Re: Savella » LouisianaSportsman, posted by phidippus on October 1, 2013, at 14:32:16
> No one needs NE. Its role in depression is not well understood, but it doesn't keep drug manufacturers from exploiting the marketing possibilities. If anything, NE helps more with reward paradigms, which makes it invaluable in treating executive disfunction.
>
> If you want more NE, look no further than Reboxetine, a potent NRI (norepenephrine reuptake inhibitor). Strattera is another NRI worth checking out.
>
> If you want a robust NE solution, try Wellbutrin.
>
> EricThanks for a speedy response! I was hoping to kill two birds with one stone by switching Pristiq to Savella to avoid adding bupropion as well. The thing is, I respond well to more NE, I assure you. That's why I have done better with Pristiq than another antidepressant.
It is a SNRI as well that approved for depression in the European Union (the same way Lyrica is approved for anxiety in the European Union). Savella has minimum withdrawal symptoms compared to Pristiq and may be more effective. It is approved in the United States for fibromyalgia pain similar to Cymbalta. I believe that NE helps my ADHD tremendously and at the lower dosage of Pristiq, there is little NE actionit mostly acts as a SSRI. Whereas, Savella is inhibits the reuptake of serotonin and norepinephrine in an approximately 1:3 ratio, respectively; in practical use this means a relatively balanced action upon both neurotransmitters. Increasing both neurotransmitters concentration simultaneously works synergistically to treat depression very effectively. It is still a powerful SSRI and increases serotonin in the brain similarly to venlafaxine while having a stronger effect on NE, which I strongly desire. You suggested Wellbutrin and it primarily works on NE (and dopamine to a lesser extent). Savella has actually been proven to be an anxiolytic, especially in terms of social anxiety anecdotally. I dont want to increase to Pristiq 100, even though I think it would help, due to the nasty discontinuation symptoms compared to Savellas milder one. Adult Attention-deficit/hyperactivity disorder alleviated by Milnacipran study has shown efficiency in treating ADHD. I havent wanted to mention this because its embarrassing, but Pristiq causes unwanted sexual side effects which are not severe. Savella is also used successfully at 50mg. twice a day for depression.
Id like to add the following excerpt about Savella:
In a pooled analysis of 7 comparative trials with imipramine,[1] milnacipran and imipramine were shown to have comparable efficacy while milnacipran was significantly better tolerated. A pooled analysis of studies comparing milnacipran and SSRIs [2] concluded a superior efficacy for milnacipran with similar tolerability for milnacipran and SSRIs. A more recent meta-analysis of 6 studies involving more than 1,000 patients showed no distinction between milnacipran and SSRIs in efficacy or discontinuation rates, including discontinuation for side effects or lack of efficacy.[3] A meta-analysis of a total of 16 randomized controlled trials with more than 2200 patients [4] concluded that there were was not a statistically significant difference in efficacy, acceptability and tolerability when comparing milnacipran with other antidepressant agents. Compared with TCAs, significantly fewer patients taking milnacipran dropped out due to adverse events. As with other antidepressants, 1 to 3 weeks may elapse before significant antidepressant action becomes clinically evident.This means that Savella is easy to handle and better than TCAs in this study. Another reason Id like to replace the Pristiq with Savella is because it actually causes weight loss which might be avoid to need to use Topamax. Also, Savella is proven to prevent migraines that I suffer from time to time according to literature. I do not understand why it is not approved for depression in the United States. I dont see how it would hurt to try Savella. As an SNRI, the transition from Pristiq to Savella would also be more smooth than transferring from Pristiq to a SSRI. I have some time of research examining the best antidepressant, and I have my intuition and want to give it a shot. The prescribing dose for depression is 50mg, BID. There is not an extended release version. I would take it at morning and at night
Posted by LouisianaSportsman on October 1, 2013, at 14:55:36
In reply to Re: Savella » LouisianaSportsman, posted by phidippus on October 1, 2013, at 14:32:16
Could you explain how riluzole works?
Posted by LouisianaSportsman on October 1, 2013, at 14:58:19
In reply to Re: Savella, posted by LouisianaSportsman on October 1, 2013, at 14:55:36
Nevermind. Did not see above post.
Posted by LouisianaSportsman on October 1, 2013, at 15:02:49
In reply to Re: Augmenting Bipolar 'Cocktail' with Trodenki XR » LouisianaSportsman, posted by phidippus on October 1, 2013, at 14:19:21
> I definitely would recommend Rilutek-it has helped me with both mood and anxiety. (DX: BP, OCD and ADHD).
>I'm strongly considering it. I'm about to read the PubMed article.
> >Maybe augment with something else?
>
> Depends on what you want to achieve.
>I really want to have less social anxiety, depressive episodes, and mood instability.
>
> Don't expect it to be a mood stabilizer, rather think of it is an efficacious glutamate antagonist which will impact your anxiety. An interesting bit of info on Topamax: studies show it improves social anxiety.
>See, I'm fond about how this sounds!
> There are other ways of losing weight as well which might be a better alternative: Gabitril is a medication you mentioned before-studies show it can support weight loss. You'll also find a lot more info about Gabitril with regards to mood stabilization.
>So Gabitril > Topamax in terms of stableness but not anxiety?
> Also...About the Neurontin. I would take Lyrica instead. I found it a better mood stabilizer than Topamax.
>I was taking Lyrica 150mg. x2 but just switched to gabapentin last visit hoping it would cause less weight gain for some reason.
> Here's my cocktail: Lithium 1200, Vyvanse 70, Invega 12, Rilutek 100, Viibryd 60
>
> Eric
>Very Interesting cocktail. Thanks for sharing!
Posted by LouisianaSportsman on October 1, 2013, at 15:16:31
In reply to Re: Augmenting Bipolar 'Cocktail' with Trodenki XR, posted by LouisianaSportsman on October 1, 2013, at 15:02:49
What do you think about replacing Gabapentin with Riluzole?
I really like what I'm reading about the article on PubMed, and I like the idea of taking one pill.
This medicine sounds like it's right up my alley, and it's a godsend you suggested it.
There is likely no doubt that I'm going to try to add it to my cocktail.
Posted by LouisianaSportsman on October 1, 2013, at 15:34:13
In reply to Replacing Gabapentin with Riluzole, posted by LouisianaSportsman on October 1, 2013, at 15:16:31
I want this to be my new regimen
:
Abilify 10mg. (keep this how it is since it seems to still be working and I have up to 30mg. in case it poops out)
Lamictal 400mg. (I will follow your advice on dosage increase)
Savella 100mg. (50mg. x 2)
Rilutek 100mg.
Vyvanse 60mg. (replacement for Nuvigil, may take both, but it depends on pdoc's discretion)
Klonopin 1mg. (0.5mg. x2) (just in case the Rilutek does not help with acute episodes
Posted by phidippus on October 1, 2013, at 15:40:33
In reply to Re: Augmenting Bipolar 'Cocktail' with Trodenki XR, posted by LouisianaSportsman on October 1, 2013, at 12:50:27
Hey,
>Pristiq was added to help out my "lows", but maybe more Lamictal will make the Pristiq useless.
I've been on Pristiq at a 100mg dose and all it did was trigger mania. What you want is an antidepressant that has little risk of 'switching' like Reboxetine or Wellbutrin (did it cause you anxiety?)
> WEIGHT-LOSS!! Abilify is causing severe weight loss.
Sometimes using Topomax to offset the weight gain of another drug is not the best strategy. The involvement of lowered blood glucose level, which may stimulate eating through an effect on the hypothalamus, constitutes one of the possible mechanisms. Lowered blood glucose levels may result from a competition between the binding of the drug and long chain fatty acids. An increased availability of the latter stimulates insulin production and lowers the serum glucose levels. Another possible explanation for lowered blood glucose may be a deficiency in carnitine directly caused by the drug, that would result in a reduction of fatty acid metabolism and an increase in glucose consumption. An enhancing effect of gamma-aminobutyric acid-mediated neurotransmission may increase appetite for carbohydrates and reduce energy expenditure.
It would be better to replace the drug causing the weight gain.
> I disagree. I really want a medication to help with the weight-loss, but I might decide to forgo topiramate if I decide to get Vyvanse.
There is no miracle pill for weight loss.
> Yes, but didn't you see me wanting to lose weight?
Yes, I get that. I just don't think adding another chemical to your regime is going to benefit you. I would remove the offending agent, namely the abilify. Try Latuda instead.
> I am definitely going on Pristiq 100mg.
Have you tried Mirtazapine or (there's a new one I can't remember the name-starts with a B)? Antidepressants I've used with no 'switching'-Clomipramine, Mirtazapine, Viibryd and Luvox.
> I understand that; however, I do want the NE action as possibly treating my symptoms better.
I recommend Reboxetine.
>I think I will be fine with a stimulant medication in conjunction with my Abilify.
I think you will be too. I've been on all the atypicals and none have impeded my ADHD medications, except for Seroquel.
> I believe it increases histamine, oxerin, and dopamine to some extent, but you're right-- it's still a mystery.Oxerin is the main neurotransmitter affected by by Nuvigil.
> So it is good to increase it since it does improve my mood? I notice you suggest 20. What about 15?I would go for the %100 increase, although 15 mg isn't a bad target dose either. Remember, Abilify is a dopamine partial agonist AND a 5ht1a agonist, both actions help to treat depression.
> It is not, but it does help with my fatigue. And, it has helped my stay awake in class.
Working as well as it should. Have you heard of Xyrem?
>I actually prefer to Concerta for ADHD. I swear.
I believe you!
> I need the anxiety relief and weight loss which is why I still think the topiramate is beneficial
I'm sure it will help with your anxiety.
>, and I may stay with Nuvigil for my ADHD since it sincerely helps with that.
Vyvanse and Nuvigil is a good one-two punch.
> I was also hoping for cognitive benefits as well?
Memantine can provide some cognitive boosting, but if you really want improve your thinking, I would have to recommend Keppra-studies show it enhances cognitive function. In fact, you could take it instead of Topomax-it has more data supporting its use as a mood stabilizer than does Topomax.
> Augment with Riluzole. This is the exact sort of medication advice I was thinking of! What dosage?100 mg, up to 200 mg a day.
> I still want to augment with topiramate for weight-loss and anxiety relief...since I'm already taking Lamictal, and I want it to be an add-on.
Good way to look at it.
> Therefore, in conclusion, I'm aiming for:
>
> Abilify (aripiprazole)20mg.Trade for Latuda to reduce weight gain issues.
> Nuvigil (armodafinil) 300mg.(150mg.x 2)
Will work best as augmentation to Vyvanse.
> Vyvanse (lisdextroamphetamine) 60mg.
Might as well just do 70 mg
> Lamictal (lamotrigine) 400mg.
Perfect.
> Neurontin (gabapentin) 1,800mg. [400mg. QID]
I would exchange this for Lyrica-it will provide better mood stabilization and stronger relief from anxiety.
> Pristiq (desvenlafaxine) 100mg.Doesn't seem to be that effective for you.
> Bupropion XL 450mg. (522mg. Aplenzin)
Will help with sexual side effects of Pristiq. Good antidepressant for bipolar folk.
> Trodenki XL 200mg.
300 mg.
> Mirapex ER 2mg.
Be careful with compulsive behaviors! Really don't need it if you're taking Wellbutrin.
> Memantine 20mg.
eh,why not?
> Riluzole 150mg.
Up to 200 mg.
>Which should I add first?
Well, up your Lamictal first. Then add Topamax. Then add back the Wellbutrin. Vyvanse, Wellbutrin and nuvigil can all be added at the same time...
>I really want the topiramate for weight loss and anxiety.
Very realistic expectations.
>
> What do you think, Eric, about mirtazapine with the Pristiq? It's nicknamed "California Rocket Fuel". >>Another question I have for you-- in the past when I took Wellbutrin (Aplenzin) alone, I needed a secondary antidepressant to help with my constant lows.
Its not unusual to experience lows when taking antidepressants as bipolar person-it usually means the antidepressant may be causing some cycling. It is moi important to stabilize your mood first then treat remaining depression. For that reason I recommend you stop the Pristiq until you are up on your Lamictal.
Another strategy that works well with lamictal is to add Lithium-lithium can do wonders for bipolar depression.
> What would be a good antidepressant to switch Pristiq out for? I was thinking Savella milnacipran)Read a great review of it here: http://www.dr-bob.org/babble/20110630/msgs/990711.html
It is not approved for the clinical treatment of major depressive disorder in the USA, but it is in other countries.
Also it causes major sexual side effects.
I'd recommend Mirtazapine or Viibryd. Also, there's new one that starts with a B.
Eric
Posted by phidippus on October 1, 2013, at 15:52:25
In reply to Re: Augmenting Bipolar 'Cocktail' with Trodenki XR, posted by LouisianaSportsman on October 1, 2013, at 15:02:49
Hey,
> I really want to have less social anxiety, depressive episodes, and mood instability.
Topamax has great indications forsocial anxiety. Mood instability and depression go hand in hand with bipolar disorder-upping the lamictal will help on both accounts.
> So Gabitril > Topamax in terms of stableness but not anxiety?
Gabitril has been studied as a treatment for panic disorder.
Eric
Posted by phidippus on October 1, 2013, at 15:55:30
In reply to Re: Savella, posted by LouisianaSportsman on October 1, 2013, at 14:55:36
Riluzole inhibits the release of glutamic acid from cultured neurons, from brain slices, and from corticostriatal neurons in vivo. It is thought these effects may be partly due to inactivation of voltage-dependent sodium channels on glutamatergic nerve terminals, as well as activation of a G-protein-dependent signal transduction process. Riluzole also blocks some of the postsynaptic effects of glutamic acid by noncompetitive blockade of N-methyl-D-aspartate (NMDA) receptors.
Eric
Posted by phidippus on October 1, 2013, at 15:56:57
In reply to Replacing Gabapentin with Riluzole, posted by LouisianaSportsman on October 1, 2013, at 15:16:31
Gabapentin never did much for me. Rilutek, however, has had great impact on my moodand anxiety.
Eric
Posted by LouisianaSportsman on October 1, 2013, at 16:06:18
In reply to Re: Augmenting Bipolar 'Cocktail' with Trodenki XR » LouisianaSportsman, posted by phidippus on October 1, 2013, at 15:40:33
> I've been on Pristiq at a 100mg dose and all it did was trigger mania. What you want is an antidepressant that has little risk of 'switching' like Reboxetine or Wellbutrin (did it cause you anxiety?)
>Pristiq at 50mg. has not made me manic and I have taken it for almost two months now. I did not experience anxiety on Wellbutrin.
> Sometimes using Topomax to offset the weight gain of another drug is not the best strategy.
>I loved your scientific explanation to death!
> It would be better to replace the drug causing the weight gain.
>Maybe I will consider transferring to Latuda later on. I can't be making too many changes at once. I just like the partial agonist effects of the Abilify. I'm afraid of a full-blown antipsychotic. Would it do the same benefits as Abilify does for me?
> There is no miracle pill for weight loss.
Yes, I get that. I just don't think adding another chemical to your regime is going to benefit you. I would remove the offending agent, namely the abilify. Try Latuda instead.
>I understand. But, I assure you, Vyvanse has helped me lose weight in the past.
>
> Have you tried Mirtazapine or (there's a new one I can't remember the name-starts with a B)? Antidepressants I've used with no 'switching'-Clomipramine, Mirtazapine, Viibryd and Luvox.
>Interesting AD choices! I'll look into them. Does Latuda do the same thing at that 5-HT1A thing that Abilify does (same 5-HT1A things Buspar does?)
> I recommend Reboxetine.
>Do you think it's better than Wellbutrin?
> I would go for the %100 increase, although 15 mg isn't a bad target dose either. Remember, Abilify is a dopamine partial agonist AND a 5ht1a agonist, both actions help to treat depression.
>I just don't see my pdoc doing a 100% increase, and I don't see why it is needed?
> Working as well as it should. Have you heard of Xyrem?
>Yes, I have heard of GHB. I don't think my pdoc is *that* open even though she is progressive.
>
> I'm sure it will help with your anxiety.
>Well, yeah, and weight-loss too, so it sounds like a nice idea, actually, still.
>
> Vyvanse and Nuvigil is a good one-two punch.
>
I will try to get my pdoc to let me have both.
>
> Memantine can provide some cognitive boosting, but if you really want improve your thinking, I would have to recommend Keppra-studies show it enhances cognitive function. In fact, you could take it instead of Topomax-it has more data supporting its use as a mood stabilizer than does Topomax.
>That's awesome to hear! Does it have the same anxiety reduction as topiramate? If so, I will go with Keppra over topiramate.
><
> 100 mg, up to 200 mg a day.
>I got you.
>
> Good way to look at it.
>Yeah, but Keppra is a good way to look at it too. If it has anxiolytic effects.
> > Therefore, in conclusion, I'm aiming for:
> >
> > Abilify (aripiprazole)20mg.
>
> Trade for Latuda to reduce weight gain issues.
>
> > Nuvigil (armodafinil) 300mg.(150mg.x 2)
>
> Will work best as augmentation to Vyvanse.
>
> > Vyvanse (lisdextroamphetamine) 60mg.
>
> Might as well just do 70 mg
>
> > Lamictal (lamotrigine) 400mg.
>
> Perfect.
>
> > Neurontin (gabapentin) 1,800mg. [400mg. QID]
>
> I would exchange this for Lyrica-it will provide better mood stabilization and stronger relief from anxiety.
>
> > Pristiq (desvenlafaxine) 100mg.
>
> Doesn't seem to be that effective for you.
>That's why I'm thinking about a different AD like Savella. But, I'm going to put more research into the ones you just suggested.
> > Bupropion XL 450mg. (522mg. Aplenzin)
>
> Will help with sexual side effects of Pristiq. Good antidepressant for bipolar folk.
>Sounds good!
> > Trodenki XL 200mg.
>
> 300 mg.
>Yes Sir. The pdoc says 200mg., but that's what she takes-- so she's biased.
> > Mirapex ER 2mg.
>
> Be careful with compulsive behaviors! Really don't need it if you're taking Wellbutrin.
>
I read about that. I won't take it in conjunction with Wellbutrin> > Memantine 20mg.
>
> eh,why not?
>Sounds good.
> > Riluzole 150mg.
>
> Up to 200 mg.
>Gotcha.
> >Which should I add first?
>
> Well, up your Lamictal first. Then add Topamax. Then add back the Wellbutrin. Vyvanse, Wellbutrin and nuvigil can all be added at the same time...
>I got you.
> >I really want the topiramate for weight loss and anxiety.
>
> Very realistic expectations.
>This is what I want.
>
> Its not unusual to experience lows when taking antidepressants as bipolar person-it usually means the antidepressant may be causing some cycling. It is moi important to stabilize your mood first then treat remaining depression. For that reason I recommend you stop the Pristiq until you are up on your Lamictal.
>
Good advice, Eric. Solid.> Another strategy that works well with lamictal is to add Lithium-lithium can do wonders for bipolar depression.
>I will consider that. I've always had something against it, idk why...
> It is not approved for the clinical treatment of major depressive disorder in the USA, but it is in other countries.
>
> Also it causes major sexual side effects.
>
> I'd recommend Mirtazapine or Viibryd. Also, there's new one that starts with a B.I'm scared of weight gain with mirtazapine. I know Viibyrd also hits the Buspar/Abilify 5-HT1A receptor. I may consider Viibyrd if Latuda doesn't hit that receptor.
> Eric
>
>
Thank you!
Posted by LouisianaSportsman on October 1, 2013, at 16:18:52
In reply to Re: Replacing Gabapentin with Riluzole » LouisianaSportsman, posted by phidippus on October 1, 2013, at 15:56:57
I'm considering another AD, but I wanted to post my theory on the Savella and you let me know what you think:
It is a SNRI as well that approved for depression in the European Union (the same way Lyrica is approved for anxiety in the European Union). Savella has minimum withdrawal symptoms compared to Pristiq and may be more effective. It is approved in the United States for fibromyalgia pain similar to Cymbalta. I believe that NE helps my ADHD tremendously and at the lower dosage of Pristiq, there is little NE actionit mostly acts as a SSRI. Whereas, Savella is inhibits the reuptake of serotonin and norepinephrine in an approximately 1:3 ratio, respectively; in practical use this means a relatively balanced action upon both neurotransmitters. Increasing both neurotransmitters concentration simultaneously works synergistically to treat depression very effectively. It is still a powerful SSRI and increases serotonin in the brain similarly to venlafaxine while having a much stronger effect on NE, which I strongly desire. You suggested Wellbutrin and it primarily works on NE (and dopamine to a lesser extent). I feel like I'm killing two birds with one stone with Savella Savella has actually been proven to be an anxiolytic, especially in terms of social anxiety, anecdotal. I dont want to increase to Pristiq 100, even though I think it would help, due to the nasty discontinuation symptoms compared to Savellas milder one. Adult Attention-deficit/hyperactivity disorder alleviated by Milnacipran study has shown efficiency in treating ADHD superior to Effexor. I havent wanted to mention this because its embarrassing, but Pristiq causes unwanted sexual side effects which are not severe. Savella is also used successfully at 50mg. twice a day for depression.
Id like to add the following excerpt about Savella:
In a pooled analysis of 7 comparative trials with imipramine,[1] milnacipran and imipramine were shown to have comparable efficacy while milnacipran was significantly better tolerated. A pooled analysis of studies comparing milnacipran and SSRIs [2] concluded a superior efficacy for milnacipran with similar tolerability for milnacipran and SSRIs. A more recent meta-analysis of 6 studies involving more than 1,000 patients showed no distinction between milnacipran and SSRIs in efficacy or discontinuation rates, including discontinuation for side effects or lack of efficacy.[3] A meta-analysis of a total of 16 randomized controlled trials with more than 2200 patients [4] concluded that there were was a statistically significant difference in efficacy, acceptability and tolerability when comparing milnacipran with other antidepressant agents. Compared with TCAs, significantly fewer patients taking milnacipran dropped out due to adverse events. As with other antidepressants, 1 to 3 weeks may elapse before significant antidepressant action becomes clinically evident.
This means that Savella is easy to handle and better than TCAs in this study. Another reason Id like to replace the Pristiq with Savella is because it actually causes weight loss which might be avoid to need to use Topamax. Also, Savella is proven to prevent migraines that I suffer from time to time better than Cymbalta according to literature. I do not understand why it is not approved for depression in the United States. I dont see how it would hurt to try Savella. As an SNRI, the transition from Pristiq to Savella would also be more smooth than transferring from Pristiq to a SSRI. I have spent hours of research examining the best antidepressant, and I truly hope you could trust my intuition and give it a shot. The prescribing dose for depression is 50mg, BID. There is not an extended release version. I would take it at morning and at night. Remember, the increased NE is more than that of Cymbalta and Pristiq and has shown to be more effective at treating ADHD it is also potent at serotonin, which I believe I need as well. Additionally, Savella has been shown to improve sleep architecture.
Posted by LouisianaSportsman on October 1, 2013, at 16:20:03
In reply to In Defense of Savella, posted by LouisianaSportsman on October 1, 2013, at 16:18:52
Wait, have I posted that already? I can't remember.
Posted by LouisianaSportsman on October 1, 2013, at 16:27:32
In reply to Re: In Defense of Savella, posted by LouisianaSportsman on October 1, 2013, at 16:20:03
Hang on, I can't find where you gave me what you think you would do if you were me in my shoes. On the condition you add topamax and not remove abilify.
Can you create a make-believe regimen as a guideline for me to follow?
Posted by LouisianaSportsman on October 1, 2013, at 16:29:41
In reply to Re: In Defense of Savella, posted by LouisianaSportsman on October 1, 2013, at 16:27:32
I'm thinking:
Abilify 10mg. (keep this how it is since it seems to still be working and I have up to 30mg. in case it poops out)
Lamictal 400mg.
Topamax 300mg. (I want it for social anxiety and weight-loss. A must have for me.)
**NEW ANTIDEPRESSANT GIVE ME YOUR NUMBER ONE CHOICE**
Rilutek 100mg.
Vyvanse 60mg.
Nuvigil 250mg.
Posted by LouisianaSportsman on October 1, 2013, at 17:42:44
In reply to Re: In Defense of Savella, posted by LouisianaSportsman on October 1, 2013, at 16:29:41
I called the pdoc. Yes, we are that close. She wants to do a dose increase of the Pristiq to 100mg. on Friday and begin titrating Topamax. She says she is open to any augmentation ideas I might have.
Therefore, it's going to look like this:
The Abilify is going to remain the same. Don't want to change what works. Will consider changing to Latuda if I keep gaining weight.
I'm also not going to do the Topamax. I want to raise the Lamictal and see if that helps.
So, for sure, it will be:
Abilify 10mg.
Lamictal 400mg.
Pristiq 100mg.
Nuvigil 250mg.
Vyvanse 60mg.
Rilutek 100mg.What would be best to augment besides Wellbutrin?
Posted by LouisianaSportsman on October 1, 2013, at 17:44:19
In reply to Re: In Defense of Savella, posted by LouisianaSportsman on October 1, 2013, at 17:42:44
I meant to say "not start titrating"
Posted by phidippus on October 1, 2013, at 18:20:27
In reply to Re: In Defense of Savella, posted by LouisianaSportsman on October 1, 2013, at 16:27:32
Lamictal 400 mg
Topomax 300 mg
Vortioxetine
Vyvanse 70 mg
Nuvigil
Rilutek 200 mg
Lyrica 600 mgGabitril or Keppra instead of Topomax
Eric
Posted by phidippus on October 1, 2013, at 18:22:33
In reply to Re: In Defense of Savella, posted by LouisianaSportsman on October 1, 2013, at 17:42:44
Vortioxetine instead of Wellbutrin.
Eric
Posted by LouisianaSportsman on October 1, 2013, at 19:20:35
In reply to Re: In Defense of Savella » LouisianaSportsman, posted by phidippus on October 1, 2013, at 18:22:33
> Vortioxetine instead of Wellbutrin.
>
> EricWow, a drug just approved! Brintillex. That's the b-one you meant. Bro, I might just let your combo pan out IRL.
Posted by LouisianaSportsman on October 1, 2013, at 19:24:44
In reply to Re: In Defense of Savella » LouisianaSportsman, posted by phidippus on October 1, 2013, at 18:22:33
> Vortioxetine instead of Wellbutrin.
>
> EricUgh, it is not available yet. Just approved today.
Posted by LouisianaSportsman on October 1, 2013, at 19:30:07
In reply to Re: In Defense of Savella, posted by LouisianaSportsman on October 1, 2013, at 19:26:02
Do you know of an alternative to Wellbutrin that is in pharmacies?
Posted by LouisianaSportsman on October 1, 2013, at 22:49:31
In reply to Re: In Defense of Savella, posted by LouisianaSportsman on October 1, 2013, at 19:30:07
Hi Eric,
Thanks so much for helping me out.
This is what I wrote to print out to bring to the PDOC. It might sound a bit biased to get what I want out of her.
------------------I want to leave the Abilify where it is at for now, and I only want to increase when its necessary so it will be a long-lasting part of my medication regimen. We can go up to 30mg., of course.
The Nuvigil works well, when it is working. I have done research and some narcoleptic patients are prescribed 2 250mg. tablets a day. Im asking for 150mg. twice a day. It simply does not last that long. I want to take one 150mg. tablet in the morning and one 150mg. tablet later in the afternoon. This is a net increase of a mere 50mg. It is nowhere close to be as effective as Vyvanse 60 which I have had in the past and I would like to replace it with Vyvanse 60. I think having Nuvigil and Vyvanse conjointly would be therapeutic.
I am interested in Topamax; however, I dont think I need it if Im able to get Vyvanse. If Im able to get Vyvanse, I want to try to increase my dosage of Lamictal to 400mg. to see if this works to stabilize my mood better before beginning Topamax. It is a perfectly normal increase according to literature Ive read and does not lead to an increased risk of severe rash, e.g. dosages are commonly doubled, e.g. Pristiq 50 to 100, Abilify 5 to 10, etc. I see no reason why prescribing #60 200mg. tablets of Lamictal would be an issue. Dr. Williams had me at 400mg. from 200mg. before going down when I started taking the Abilify. The PI sheet suggests 400mg but then also says 500mg may be used. Some bipolar patients even take 600mg. I really would like to try 400mg. again. It worked well for awhile and then the Abilify was added and I didnt need that dose. But now, the Lamictal is starting to poop out on me. If I do have a problem, and I likely wont I can split the scored tablet. I have an extra bottle of Lamictal and have already begun taking 400mg. lately in an attempt to control my mood, and it is really working for my mood swings. If I am unable to get the Vyvanse and youre not willing to go up to 400mg. on the Lamictal, then I would like to begin titrating on the Topamax.
I have an alternative suggestion to gabapentin to help my anxiety in the form of Rilutek. Riluzole possesses both glutamatergic modulating, antiepileptic, and neuroprotective properties, all of which make it a promising candidate for the treatment of mood and anxiety disorders. Clinical use and clinical investigations support riluzoles antidepressant and anxiety properties. These reports comprise either case series or open-label studies in patients with treatment-resistant conditions, especially bipolar depression and generalized anxiety disorders. The anti-anxiety effects of riluzole have been postulated to be the result of postsynaptic GABAA receptor function potentiation in hippocampal neurons. This is the exact same thing that gabapentin does! Recently, Mathew and colleagues (2008) found, in an eight-week open-label study, that riluzole 100 mg/day was effective in treating anxiety symptoms in patients with GAD. In this study, 80% of completers responded to riluzole, and 53% met remission criteria at eight weeks. One unique aspect of riluzole is that it does not require dose titration and the suggested initial dosage of 100mg. is indicated as effective in all-day anxiety treatment. It is taken 50mg. every 12 hours, morning and night.
The Nuvigil works well, when it is working. I have done research and some narcoleptic patients are prescribed 2 250mg. tablets a day. Im asking for 150mg. twice a day. It simply does not last that long. I want to take one 150mg. tablet in the morning and one 150mg. tablet later in the afternoon. This is a net increase of a mere 50mg. It is nowhere close to be as effective as Vyvanse 60 which I have had in the past and I would like to replace it or use with Vyvanse 60mg. I think having Nuvigil and Vyvanse conjointly would be as I have in the past would be extremely therapeutic and almost result in complete remission of ADHD symptoms. I also read that it is OK to begin adding Vyvanse and Wellbutrin (Aplenzin) at the same time, but I really want to try out Rilutek if you let me.
Remember, I guess we are being slightly experimental with the Rilutek, but I have spent six-seven hours researching what I think would be best for me. I will add more on Rilutek. I dont see why it would hurt to try Rilutek. If it works well, then I would be taking a single pill everyday instead of many.
My Goal:
Abilify 10mg.
Lamictal 400mg.
Pristiq 100mg.
Nuvigil 250mg.
Vyvanse 60mg. or Topamax Titration
Rilutek 100mg. (hopeful replacement for gabapentin)
Aplenzin (Wellbutrin 450mg. XL) 522mg.If you want to be conservative:
Keep Abilify, Gabapentin, Lamictal, Nuvigil and Pristiq the same. And, I want to do the Topamax and Wellbutrin like we discussed last time.
Abilify 10mg.
Lamictal 200mg. (raise it though?)
Pristiq 100mg. (increase like we talked about)
Gabapentin 400mg. QID
Nuvigil 250mg.
Topamax Titration
Aplenzin (Wellbutrin) 522mg. as I had with my previous doctor. (Yes, Im aware of seizure, but Im on Lamictal, but there is a reason why I was on such a high dosage I didnt respond to Wellbutrin 300mg. XL until this Aplenzin 522mg. It would be pointless to give me a lower dose. Also, I had zero side effects from any dose, even when I started it.) Once again, I had four extra Aplenzin 522s I have been taking the best four days before my visit to see how my body would adjust. I see no reason not to go ahead and go on this dosage. It works best for me. With the ER formulation, the rate is 0.4% (4/1000) at doses of 300 to 450 mg/day; however, the rate increases substantially at doses above this level. Also, if you allow me to try Rilutek, it is an additional anticonvulsant to the Lamictal. Please use the dosage that works best for me.All, in all, I hope you consider my suggestions.
---------------------------------------------I sorta lied when I told her I've been on 400mg. before and I've been taking 522mg. tablets the past few days, but I know how she is-- she'd never dose me that high. I know it's not right to lie, however.
I will definitely recap you on what happens, Eric! Thanks for caring!
Posted by LouisianaSportsman on October 1, 2013, at 22:54:22
In reply to Conclusionary: What I'm Bringing To The PDOC, posted by LouisianaSportsman on October 1, 2013, at 22:49:31
I wrote that a bit early. Where it says:
My Goal:
Abilify 10mg.
Lamictal 400mg.
Pristiq 100mg.
Nuvigil 250mg.
Vyvanse 60mg.
*****Keppra or Gabitril Titration******
Rilutek 100mg. (hopeful replacement for gabapentin)
Aplenzin (Wellbutrin 450mg. XL) 522mg.I changed this part. I'm doing research on which is best for me. Which one you think? About equal?
This is the end of the thread.
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