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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by LouisianaSportsman on April 5, 2014, at 21:24:24
I feel like I can use this place a diary for my med changes, but I get a lot of benefit from this place.
I had my last PDOC appointment Monday and my current medication regiment is now the following:
Adderall IR (amphetamine salts) 60mg.;
Aplenzin (bupropion hydrobromide) 174mg.;
Brintellix (vortioxetine) 20mg.;
Lamictal (lamotrigine) 200mg.;
Latuda (lurasidone) 60mg.;
Nuvigil (armodafinil) 250mg.;
Neurontin (gabapentin) 1,200mg.;
Trokendi XR (topiramate) 200mg.
Xanax XR (alprazolam) 1.5mg.We increased the Brintellix dosage to 20mg. from 10mg. and she reduced Aplenzin down to 174mg. from 522mg. with instructions for me to go off of it cold turkey this month. We added Xanax XR.
We thought that it'd be best to remove bupropion from the regiment. Bupropion is a strong CYP2D6 inhibitor that interferes with Brintellix. Also, I believe that bupropion makes my amphetamine salts weaker due to reuptake inhibition vs. releaser and I've read literature that supports that bupropion does indeed make the effects amphetamine weaker and vice versa-- that amphetamine blocks the positive effects of bupropion. I think it's best to cease bupropion.
My PDOC said that she'd be open to any ideas I might have to replace the Aplenzin so I was thinking about nortriptyline or desipramine. I am also open to adding another mood stabilizer such as Oxtellar XR.
Other ideas?
Also still having some trouble with anxiety. My PDOC is hesistant to increase my gabapentin dosage because she knows of my abuse of gabapentinoids. Xanax XR is working OK, but I can see myself having some problems with abuse, just like I had a problem with abusing Lyrica. Lyrica, however, was much more abusable. I don't see myself paying people to go to the doctor to get Xanax for me like I did with the Lyrica. I just don't want to have the temptation around every single month. Thoughts on:
Gabitril
Prazosin
Baclofen
Pindolol ?
Posted by LouisianaSportsman on April 5, 2014, at 21:31:25
In reply to Making a few med changes; I would like some input, posted by LouisianaSportsman on April 5, 2014, at 21:24:24
How could I forget!
I am thinking about going from Latuda back to Abilify. Yes, I know I've bragged about how awesome Latuda has been for me, but I've done some serious soul-searching and thinking and I have come to the conclusion that Abilify was slightly better. It just packed on the pounds.
What do you think about switching the Latuda back to Abilify and adding Metformin at the same time?
Latuda has more of a blunting effect on my life if that makes sense. I felt like I had more motivation on Abilify. It's still a tough call to make the switch back.
My blood pressure was high last visit too and I forgot to ask her to switch me back to Dexedrine from Adderall. I'm going to miss the "kick" Adderall provides over Dexedrine.
Posted by ed_uk2010 on April 6, 2014, at 10:12:09
In reply to Making a few med changes; I would like some input, posted by LouisianaSportsman on April 5, 2014, at 21:24:24
Looking at your meds, I expect that simplification and reduction would be more useful than adding anything at all. If any of your meds have not proved *clearly beneficial*, I would taper and discontinue them. Nothing should be taken just for the sake of it... I believe you mentioned before that you were unclear about the benefits of some of your meds, but continued them in case they might be helping? I think this is the route to adverse reactions and excessively complex expensive combinations.
Posted by Christ_empowered on April 6, 2014, at 21:22:42
In reply to Re: Making a few med changes; I would like some input, posted by ed_uk2010 on April 6, 2014, at 10:12:09
I kinda agree. With this many psych meds, it seems like you're pulling yourself in multiple directions. What are your core issues? Have you tried some kinda talk therapy, like cbt, dbt, that sort of thing?
Posted by SLS on April 6, 2014, at 21:53:43
In reply to Making a few med changes; I would like some input, posted by LouisianaSportsman on April 5, 2014, at 21:24:24
As a refresher - what conditions are you treating?
What do you think would happen if you were to discontinue the Nuvigil and Neurontin?
Adding nortriptyline or desipramine to Brintellix is an interesting idea.
Personally, I find Focalin much more helpful than Adderall for treating my bipolar depression.
I'm having good luck with prazosin.
Pindolol never quite made it as an augmentor of SSRIs. At most, it is an "accelerator" of SSRIs and helps produce an improvement earlier in treatment. I would be surprised if it were to be helpful in the long-term. It would be great if you were to surprise me. :-)
You might be able to reduce the dosage of topiramate to 100 mg/day. It will help prevent metabolic acidosis, decreased concentrations of blood bicarbonate, and kidney stones. Does topiramate help prevent mixed-state hypomania or depression?
- Scott
Posted by LouisianaSportsman on April 7, 2014, at 0:10:44
In reply to Re: Making a few med changes; I would like some input, posted by SLS on April 6, 2014, at 21:53:43
Finally some real advice from someone who understands! I knew I could count on you, Scott!
"As a refresher - what conditions are you treating?"
My Dx is ADHD-PI and BP2. She also has an opinion of MDD and GAD. I also suffer from personality disorders. I have partial remission from ICD-10: F48.1 and atypical F60.1 with narcissistic features (elitism about place in society that leads to anxiety).
It is Day 35 of vortioxetine administration and I am now at 20mg. I must say that I notice a dramatically improved effect superior to sertraline.
What I am trying to treat right now is this "weird, anxious, nervous" feeling I get from time to time where I feel like I'm about to ride a roller coaster when I'm just doing normal activities like cleaning the kitchen.
I am also trying to treat battling thinking of every negative life decision I have made sitting down on the toilet.
I am also trying to be happier and show people that I am in good spirits. People still say that I seem down, but that I am getting better. I feel lackluster motivation to do daily tasks.
Sometimes, I think about life and have moments where I feel so alive and it's almost sickening and scary. I'd like to treat that.
BUT!!!
The main symptom I want to treat is anxiety.
>
> What do you think would happen if you were to discontinue the Nuvigil and Neurontin?
>I think about it. I've gotten to where I don't even want to include them in my list of meds anymore since I don't take them like I should. I want to continue to fill the scripts because I enjoy them PRN.
> Adding nortriptyline or desipramine to Brintellix is an interesting idea.
>Yes! Exactly what I was thinking. What dosage would suggest be the target? At what point should I have a blood test and what concentration should it be?
> Personally, I find Focalin much more helpful than Adderall for treating my bipolar depression.
>Focalin was going to be my second choice after amphetamine salts. What dosage of Focalin would be equipotent to 60mg. of amphetamine salts? About equal right? #180 10mg. Focalin IR would suffice. My script for Adderall IR is #180 10mg. right now anyway so it wouldn't be a big deal to replace it with Focalin for a month to see how I like it. I like having the dosage control with the pills. I'm going to try it based on your suggestion.
> I'm having good luck with prazosin.
>What dosage and what time do you take it?
> Pindolol never quite made it as an augmentor of SSRIs. At most, it is an "accelerator" of SSRIs and helps produce an improvement earlier in treatment. I would be surprised if it were to be helpful in the long-term. It would be great if you were to surprise me. :-)
>I probably won't give it a go.
> You might be able to reduce the dosage of topiramate to 100 mg/day. It will help prevent metabolic acidosis, decreased concentrations of blood bicarbonate, and kidney stones. Does topiramate help prevent mixed-state hypomania or depression?
>
>It's been helpful for mood and I am hoping the 200mg. will help with the Latuda weight and especially the weight if I do switch back to Abilify.
-----------
I was thinking about Oleptro (trazodone extended release).Take a look at this article: http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=2373
It would have the serotonergic action as nortriptyline except at 5-Ht6. But, it would lack the NET effects, of course.
From the article:
"These various pharmacological mechanisms which suggest the way in which 5-HT2A/2C antagonists could be antidepressants in themselves, and especially the possibility that these mechanisms could exert synergistic antidepressant actions along with simultaneous SERT inhibition are still just theoretical considerations. No clinical trials prove that adding 5-HT2A/2C antagonism to SSRI/SNRI action potentiates antidepressant effects in depressed patients. Nevertheless, this notion is consistent with observations that atypical antipsychotics, which have 5-HT2A antagonist effects as a prominent property, do potentiate the actions of SSRIs/SNRIs in certain depressed patients,9,23 especially those who have treatment resistant depression,23 and the observation that several agents with 5-HT2C antagonist actions are approved antidepressants.4,9,12 "
High doses recruit the critical SERT inhibition to make trazodone an antidepressant, and high doses also recruit 5-HT2C antagonism, which combined with 5-HT2A antagonism has multiple theoretical mechanisms by which the antidepressant actions and tolerability of SERT inhibition could be enhanced.
Generally, for an antidepressant effect-- trazodone needs to be dosed TID. This can be very sedating but according to the article:
"trazodone XR at 300 mg should provide sufficient and constant blood levels of trazodone for antidepressant actions, yet might theoretically be no more sedating than 100 mg of trazodone IR. Furthermore, the sustained blood levels generated by trazodone XR are theoretically ideal for causing tolerance to the side effect of sedation, as opposed to short term pulsatile delivery with trazodone IR where no tolerance to the therapeutic effect of sedation would be desired." "In fact, this new formulation of trazodone XR has been tested in depressed patients with a surprisingly low incidence of sedation."
Also, on the graph, the XR version has a bunch more stable plasma concentration than the IR dosing and stays above the antidepressant concentration level.
This means I would likely develop a tolerance to the sedation and may not experience it especially since I take Adderall and Nuvigil.
I also take Latuda which is also a partial agonist at 5-HT1a along with trazodone so the potentiation would be interesting.
I would dose Oleptro QHS and I think the relaxation effects may be very nice and perhaps give me some anxiety relief. My target dosage would be 375mg. which is the max on the PI sheet. This would be #75 150mg. The tablets are bisectable. The tablets are only available in 150mg. and 300mg. so they have to be able to be able to be broken in half. If I added Oleptro (and switched to Lamictal XR), my "real" regimen, e.g. psychotropics I take correctly everyday would be:
vortioxetine 20mg., trazadone ER 375mg., lurasidone 60mg., lamotrigine XR 200mg., topiramate ER 200mg.
Here we have Brintellix as my primary antidepressant which I believe is a quality antidepressant that I would suggest over Paxil, Luvox, Pristiq, Cymbalta and Celexa-- but I'm not sure if I could honestly suggest it over Prozac, Zoloft, Effexor or Lexapro as a first-line treatment.
We have a quality, proven augmentation to this antidepressant in the form of trazadone that may be anxiolytic.
As part of BP2 treatment with depressive features, we have an official FDA approved medication for bipolar depression on board in the form of Latuda.
We have the quintessential mood stabilizer Lamictal as well as a very beneficial augmentation agent, Topamax that has done more good than bad. The other meds (neurontin, adderall, nuvigil) are mostly taken everyday, but not everyday and I don't consider them apart of my essential treatment.
I'm thinking about doing something with lamotrigine. I've been on it for forever and I'm not really sure what it does. I'm thinking about switching to brand name Lamictal XR to see if it does anything; I also thinking about raising my dosage to 300mg. to see if I can get some benefit.
Any input on Gabitril or Baclofen? Perhaps I could add it as an anxiety PRN when I possibly get prescribed Oleptro?
Any input from anyone?
Thanks!
Posted by phidippus on April 7, 2014, at 0:51:54
In reply to Making a few med changes; I would like some input, posted by LouisianaSportsman on April 5, 2014, at 21:24:24
> Gabitril
> Prazosin
> Baclofen
> PindololI'd say Gabitril, but it can make you feel really wonky.
Try Keppra. It does a great job of treating anxiety.
Eric
Posted by LouisianaSportsman on April 7, 2014, at 1:58:47
In reply to Re: Making a few med changes; I would like some input » LouisianaSportsman, posted by phidippus on April 7, 2014, at 0:51:54
> > Gabitril
> > Prazosin
> > Baclofen
> > Pindolol
>
> I'd say Gabitril, but it can make you feel really wonky.
>
> Try Keppra. It does a great job of treating anxiety.
>
> Eric
>
>Yeah, Gabitril was the most interesting to me. And I don't mind the wonky-ness; after all, I loved that effect from Lyrica. ;)
I've been interested in Keppra myself, just not much information out there. I might suggest it over Oleptro just based on what you suggest.
What do you think about my Oleptro suggestion?
Haha, it looks like I was spot on earlier when I suggested a carbamazepine for your mood stabilizer and mentioned Keppra in an earlier thread.
Posted by ed_uk2010 on April 8, 2014, at 14:31:47
In reply to Making a few med changes; I would like some input, posted by LouisianaSportsman on April 7, 2014, at 0:10:44
>Finally some real advice from someone who understands!
Other people do understand. It's important to appreciate that adding more medication doesn't always help. Meds can easily make people feel worse as well as better. As an example, some people find that stimulants aggravate anxiety.
Posted by LouisianaSportsman on April 9, 2014, at 19:51:27
In reply to Re: Making a few med changes; I would like some input, posted by ed_uk2010 on April 8, 2014, at 14:31:47
> Other people do understand. It's important to appreciate that adding more medication doesn't always help. Meds can easily make people feel worse as well as better. As an example, some people find that stimulants aggravate anxiety.
I know you understand.
I think you'll find that tinkering with my medication is more of a hobby of mine than anything else.
(shhhh)
Posted by phidippus on April 11, 2014, at 17:13:36
In reply to Re: Making a few med changes; I would like some input, posted by LouisianaSportsman on April 7, 2014, at 1:58:47
I'd do Oleptro if Trazadone had some data backing it in the treatment of OCD, but there's not much.
Eric
ps. the carbamazapine is treating me well :)
This is the end of the thread.
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