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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by kadykat on April 10, 2014, at 1:07:56
Hey, everybody!
Right now, I guess you could say that I don't have an official dx as of now; however, if I were to guess:
MDD - anergic depression
Very minor anxiety "stressed out" feeling. I also get social anxiety pretty bad, but not in places I'm comfortable.I am in pain management; therefore, the only psychiatric medication I take is duloxetine 60mg. I mean, I suppose I responded OK to it, for it to take me this long to get to this point.
I have already tried and hated: Lexapro, Zoloft, Effexor, Wellbutrin, Gabapentin, Lyrica.
I have a very supportive husband, thank God. It's sad that I'm home nearly everyday yet still we have to hire a maid to clean the house. I own a small business that I micromanage as much as I possibly can.
I sleep anywhere from 12-16 hours a day. I am literally too tired to get out of bed. I have a very supportive son that takes care of me, and I try to do my best for him, but I feel like all I can do is feed him money since I'm hardly there in any many other ways.
Let's go ahead and take my health into account. I am slightly overweight (really, I don't look like an ogre and I'm my family is surprised I don't since I don't get out too much) and have type II diabetes that runs in the family. I don't think Zyprexa is a good idea for me.
I think it might be a good idea to double the Cymbalta to 120mg. and augment with an atypical antipsychotic? I was thinking Abilify, but I'm not sure if it is appropriate considering my health. I was thinking Latuda.
I also think that Nuvigil (I think Focalin would be better but I take medication for high blood pressure) makes sense as well to combat my constant fatigue.
I think I need something for my anxiety. Of course benzodiazepines pop up first, but I know about their reputation.
I'm not sure if I'd really like to even stay on Cymbalta. I'm not sure it's doing anything or not. My body is immune to the stuff, it's been so many years. I believe I stuck with it just because it helped with my fibro. I mean, I didn't like Effexor, after all?
I don't think the duloxetine helps my fibromyalgia.
I'm really liking the idea of the idea of this Latuda stuff more than anything I've read about about. (can't be on anything that will cause weight gain, but this looks like the most weith neutral AAP) Same thing with Nuvigil, I really like the sound of this drug. Would prefer Focalin, but I take blood pressure medication, so I'm not sure if the PDOC would want to prescribe this out. I feel like the stimulant would help my social anxiety in a way too.)
A good first visit?:
Cymbalta 60mg. --> 20mg. titration downwards
Lamictal titration
Latuda 40mg.
Nuvigil 150mg.Second visit: Find an AP that works assuming that lamictal/latuda/nuvigil doesn't work completely?
I think Lamictal would be great for mood stabilization (something I may have an issue with), apparently one of the best mood stabilizers for anxiety-- effects the N-type calcium channel just like Lyrica and gabapentin (the only other anticonvulsant I believe that does this is Keppra).I think it's an overall good robust antidepressant effect in terms of mood stabilizers as well.
Does anyone have any ideas? I feel like I like someone good ideas going into my target visit. I've been doing a lot of reading on here. ;)
Posted by kadykat on April 11, 2014, at 3:54:53
In reply to PDOC appointment Friday first time in years, posted by kadykat on April 10, 2014, at 1:07:56
Aww, I was hoping someone would have some advice for me by now.
I thought I should mention that I believe that my pain medication has been "blunting" out my life and making me content with sleeping so often.
I'm not sure how I even get enough juice to run my small business sometimes. It takes some very trusted employees who I actually split the profits with.
Fentantyl Patches 10 x 50mcg (Duragesic)
Hydromorphone Extended-Release 32mg. (Exalgo)
Oxymorphone 90 x 10mg. (Opana IR)
Oxymorphone 30 x 40mg. (Opana ER)
Atenolol 60 x 25mg. (Tenormin)
This is about equal to 318mg. hydrocodone daily using an opiate conversion calculator.My current pain management doctor has referred me to this PDOC and said that I could be described "anything within reason", including atypical AAPs if if was requires. He is quite sympathetic to both my emotional needs and my pain needs.
Posted by Christ_empowered on April 11, 2014, at 14:44:53
In reply to PDOC appointment Friday first time in years, posted by kadykat on April 10, 2014, at 1:07:56
hey! so sorry about your situation. Maybe Provigil or Nuvigil, plus a smaller dose of Focalin? I'm no expert, but maybe if you had both on board, you could take a lower dose of the stimulant, so fewer (potential) cardio side effects?
Sorry Wellbutrin was so terrible. I'm glad your husband is supportive and you have some employees you can trust. And a cleaning lady...that's a good thing.
Anyway, I hope things get better. I seem to recall reading that, back in the day, when they used Ritalin and/or amphetamines more routinely in people with long term pain issues, the stimulant could brighten your mood, lift the sedation, and (I think) help the pain a bit, too. Here's hoping, anyway...I think that was back in the 60s or something.
Good luck to you!
Posted by Tomatheus on April 11, 2014, at 14:52:30
In reply to PDOC appointment Friday first time in years, posted by kadykat on April 10, 2014, at 1:07:56
Kadykat,
Hello, and welcome to Psycho-Babble. I apologize for my rather delayed response. I don't think that I have the kind of expertise on medications that some of the other members here do, but as far as medications are concerned, I will say that trying Nuvigil or Provigil seems like it might make sense, given your fatigue and long sleep times. Generally speaking, I think that antipsychotics will only increase your fatigue and make you sleep more than you already are, although Abilify (especially at lower doses) seems like it could be an exception, along with Latuda and maybe one or two others. Remember that the term "major tranquilizers" is sometimes used to refer to the class of drugs that most of us call antipsychotics or neuroleptics.
Interestingly enough, your psychiatric symptoms sound a little similar to mine before the onset of my psychosis some seven years ago. I had the strong fatigue with long sleep times that you describe, and the only medication that seemed to help me for more than a few days at a time was Nardil -- and I think that taking it with the antihistamine sleep aid doxylamine succinate (Unisom) may have kept my Nardil response going for longer than it would have otherwise gone on for. Unfortunately, my responses to various versions of Nardil didn't last for more than a few months total, and I eventually stopped trying to get the medication to work for me after I received what may have been a bad batch of the medication from my pharmacy in June 2006. I don't know if Nardil will interact with your pain medications (although I suspect that it might), but I thought I'd mention that for me, Nardil was the best psychiatric medication for my symptoms prior to my psychosis.
What I'm doing for my fatigue and excessive sleep now is taking vitamin D3. A blood test that I had done a little more than a year ago came back with me having an insufficiency of vitamin D, and I've gone through a few vitamin D3 trials now, with my current one lasting a little more than two months. I'd say that it's still too early for me to say how well I'm responding to vitamin D3, although the way I feel at present energy wise is leaving me somewhat optimistic about my chances of responding in the long run.
Have you ever had your vitamin D level tested? If you haven't, asking your doctor about a test might not be such a bad idea. There is some evidence that vitamin D levels tend to be somewhat lower in individuals with depression than they are in the general population, although studies that have looked at the effectiveness of vitamin D supplementation for depression have yielded mixed results. There is also some thinking that some individuals diagnosed with fibromyalgia might actually have osteomalacia, a softening of the bones that could be caused by low vitamin D levels. I know that this suggestion might seem like it's a little out of place here on the Psycho-Babble medication board, but I think that asking about getting a vitamin D blood test done most definitely would not hurt. Maybe -- just maybe -- getting your vitamin D level up into the optimal range (if it's low) might even help you with more than one of your current health problems.
Well, I realize that you've probably already gone to the appointment that you have scheduled for today with your pdoc, so instead of wishing you luck, I'm going to say that I hope that your appointment went well. I hope that the medications that your pdoc will prescribe (or has prescribed) will bring you some relief from your symptoms, along with any other treatment approaches that you may be using. It's probably too late to ask your pdoc about a vitamin D blood test today (unless your appointment is still yet to come), but I'd recommend keeping it in mind for the future.
Take care,
Tomatheus
Posted by phidippus on April 11, 2014, at 16:23:35
In reply to PDOC appointment Friday first time in years, posted by kadykat on April 10, 2014, at 1:07:56
> I am in pain management; therefore, the only psychiatric medication I take is duloxetine 60mg. I mean, I suppose I responded OK to it, for it to take me this long to get to this point.If you feel you're only getting partial response to the Cymbalta, maybe its time to move on to another medication.
> I sleep anywhere from 12-16 hours a day. I am literally too tired to get out of bed.
I bet you'd do well on Nuvigil or Xyrem.
> I think it might be a good idea to double the Cymbalta to 120mg. and augment with an atypical antipsychotic?
I think this might be a good idea if you're bipolar, but you're not. I think Tramadol would be a better augmenter with the pain issues you have.
> I also think that Nuvigil (I think Focalin would be better but I take medication for high blood pressure) makes sense as well to combat my constant fatigue.
A better response to an antidepressant will help with the sleep issues, but if you're also fatigued, Nuvigil and Xyrem aren't bad options.
> I think I need something for my anxiety. Of course benzodiazepines pop up first, but I know about their reputation.If the antidepressant isn't helping you 100% with your anxiety as well, its time to look at a different antidepressant.
> I'm not sure if I'd really like to even stay on Cymbalta.
Then try something else.
> I don't think the duloxetine helps my fibromyalgia.
I don't see how it would.
> I'm really liking the idea of the idea of this Latuda stuff more than anything I've read about about.
Get on a more effective antidepressant and you won't need Latuda.
> A good first visit?:
>
> Cymbalta 60mg. --> 20mg. titration downwards
> Lamictal titration
> Latuda 40mg.
> Nuvigil 150mg.Stop Cymbalta
Start Mirtazapine 15mg
Start Nuvigil 150 mg
Start Tramadol XR 150 mg
Lamictal 50 mg> Does anyone have any ideas?
Switch from Cymbalta to Mirtazapine, or something else. Start Tramadol. Start Lamictal. Start Nuvigil or Xyrem.
Eric
Posted by kadykat on April 11, 2014, at 17:34:35
In reply to Re: PDOC appointment Friday first time in years, posted by Tomatheus on April 11, 2014, at 14:52:30
Here is what happened at the PDOC appointment. I really like the man, we got along great and he devoted an entire hour of his time to me which was awesome. I had to give him the list of pain medication I took which made him wary. My PDOC also asked me if I was open to taking more than one medication as he is apparently a "polypsychopharmacologist", whatever that means.
I am on this pain medication for fibromyalgia, and I believe that the pain medication is what has helped me be stable all these years without antidepressants. I feel like I'm about to be blasted on here for receiving quite possibly one of the strongest pain management regiments you can receive for what I'd consider very livable pain for someone else who has this kind of regimen. But my PMDOC does not know this.
I revealed this to my PDOC and he suggested a Suboxone program which I will strongly consider. I would be more open to a methadone program, but that is only prescribed for pain around here-- not addiction. I manage I could figure something out, however.
My PDOC wrote:
#30 Abilify 5mg.
#60 Wellbutrin SR 150mg.
#60 Provigil 100mg.
#75 Tranxene T-Tab 15mg.(Tranxene T-Tab is a benzodiazepine btw, 15mg. is equivalent to 0.5mg. Xanax. You can break it in half easily. (t-tab) )
He told me to take the Abilify at night.
He told me to take one tablet of Wellbutrin 150mg. for 3 days and then beginning taking it BID. He said one tablet in the morning and then wait at least 8 hours before taking the second tablet. His idea behind the instant release instead of the time-release is that it might provide more energy since it is all at once.
He told me that Nuvigil is popular to prescribe for fatigue, but many patients have told him that it doesn't last all day. He told me to dose 100mg. Provigil in the morning and another 100mg. 4-6 hours later depending on my schedule. He said that he didn't want to prescribe me the benzo without the Provigil because he doesn't want me to get fatigued with my pain medication. He also mentioned that if Provigil doesn't do the trick that "ADHD medications aren't just for kids".
I have high hopes for what I'm getting into!
Posted by LouisianaSportsman on April 11, 2014, at 22:26:46
In reply to Re: PDOC appointment Friday first time in years » kadykat, posted by phidippus on April 11, 2014, at 16:23:35
Everyone's advice meant to much to me!
I'd like to target in on Eric's advice. I think that I would to switch to a different antidepressant class, but I do know how there have developments.
I don't see what's so special about have a SNRI, especially such a weak one like Cymbalta. The PDOC advocated moving to Fetzima, but uiltimately he decided against based on some bad reviews.
I like the idea of a MAOI + modafinil + low-dose dexedrine/bupropion to get me out this funk.
Let's be real.
I'd like to see:
#30 Abilify 5mg.
#60 Wellbutrin SR 150mg.
#60 Provigil 100mg.
#75 Tranxene T-Tab 15mg.
--
#30 Cymbalta 60mg.Go to:
#45 Abilify 5mg.
#45 Lexapro 10mg.
#60 Wellbutrin SR 200mg.
#60 Provigil 200mg.
#90 Tranxene T-Tab 15mg.
#60 Dexedrine IR 10mg.
He also mentioned some "ADHD stimulants" and how I might have to start carrying around meds just like they do if I don't completely respond to the Provigil.
Posted by phidippus on April 12, 2014, at 4:41:43
In reply to Eric, What do you think about this PDOC?, posted by LouisianaSportsman on April 11, 2014, at 22:26:46
>I think that I would to switch to a different antidepressant class, but I do know how there have developments.
A drug's class is not so important as the studies the drug has undergone. For example, one might think all SSRIs are created equal in regards to treating panic disorder, but one SSRI stands out as being short of data, namely Luvox. Its a good idea to survey the data available on any given antidepressant before switching to it. The class of a drug just indicates a general quality of the drug.
> I don't see what's so special about have a SNRI, especially such a weak one like Cymbalta.I wouldn't say Cymbalta is weak.
"Duloxetine potently inhibited binding to the human 5-HT transporters with a Ki value of 0.8 nM, whereas venlafaxine was 106 times less potent. Duloxetine also potently inhibited binding to the human NE transporter with a Ki value of 7.5 nM and venlafaxine inhibited binding to the human NE transporter with a Ki value of 2480 nM. Thus, venlafaxine inhibited binding to the NE transporter with 331 times lower affinity than duloxetine. " - http://www.nature.com/npp/journal/v2.../1395741a.html"
>The PDOC advocated moving to Fetzima, but uiltimately he decided against based on some bad reviews.
Fetzima is a young drug. I wouldn't place much weight on "reviews" given it. I would take the position of intrepid explorer if taking this drug.
More than 1700 adults with depression took part in clinical studies that evaluated Fetzima. In these studies, about half of the people had already used a depression medication, and about a quarter of the people in the studies were not helped by their previous depression medication. The patients in the studies included men and women who ranged in age from 18-80.
In these clinical studies, participants taking Fetzima had significant improvement in their overall depressive symptoms. Fetzima was also associated with a significant improvement in the overall ability of participants to function in their everyday lives.
> I like the idea of a MAOI + modafinil
Why do people value Modafanil as an antidepressant agent? One of its possible side effects is depression. Alas, one study does not agree with my position: http://www.sciencedaily.com/releases/2013/11/131127115355.htm.
>+ low-dose dexedrine/bupropion to get me out this funk.
Dexedrine and bupropion may share some qualities, but overall they are very different drugs that can produce very different results. So which one? Or do you want to take both?
> #30 Abilify 5mg.
> #60 Wellbutrin SR 150mg.
> #60 Provigil 100mg.
> #75 Tranxene T-Tab 15mg.I like this combination of drugs, but please be careful with Tranxene. Tranxene is Clorazepate and Clorazepate produces the active metabolite desmethyl-diazepam, which is a partial agonist of the GABA A receptor and has a half life of 20 179 hours; a small amount of desmethyldiazepam is further metabolised into oxazepam. That's right a half life of up to 179 hours!
> #30 Cymbalta 60mg.
You're not really reaping the benefit of NE reuptake until you go above 60 mg dosages of Cymbalta.
> #45 Abilify 5mg.
> #45 Lexapro 10mg.
> #60 Wellbutrin SR 200mg.
> #60 Provigil 200mg.
> #90 Tranxene T-Tab 15mg.
> #60 Dexedrine IR 10mg.Again, careful with the Tranxene.
Why only 10 mg of Lexapro?
> He also mentioned some "ADHD stimulants" and how I might have to start carrying around meds just like they do if I don't completely respond to the Provigil.I have no idea what this means.
Eric
Posted by LostBoyinNC45 on April 12, 2014, at 17:04:03
In reply to Eric, What do you think about this PDOC?, posted by LouisianaSportsman on April 11, 2014, at 22:26:46
I think you need to be in the hospital on that much psych meds. Is there an ER near you? If I was on that much stuff I'd probably be dead.
Eric AKA "LostBoyinNC"
> Everyone's advice meant to much to me!
>
> I'd like to target in on Eric's advice. I think that I would to switch to a different antidepressant class, but I do know how there have developments.
>
> I don't see what's so special about have a SNRI, especially such a weak one like Cymbalta. The PDOC advocated moving to Fetzima, but uiltimately he decided against based on some bad reviews.
>
> I like the idea of a MAOI + modafinil + low-dose dexedrine/bupropion to get me out this funk.
>
> Let's be real.
>
> I'd like to see:
>
> #30 Abilify 5mg.
> #60 Wellbutrin SR 150mg.
> #60 Provigil 100mg.
> #75 Tranxene T-Tab 15mg.
> --
> #30 Cymbalta 60mg.
>
> Go to:
>
> #45 Abilify 5mg.
> #45 Lexapro 10mg.
> #60 Wellbutrin SR 200mg.
> #60 Provigil 200mg.
> #90 Tranxene T-Tab 15mg.
> #60 Dexedrine IR 10mg.
>
> He also mentioned some "ADHD stimulants" and how I might have to start carrying around meds just like they do if I don't completely respond to the Provigil.
Posted by SLS on April 12, 2014, at 17:15:14
In reply to Re: Death is in your future, posted by LostBoyinNC45 on April 12, 2014, at 17:04:03
Posted by LostBoyinNC45 on April 12, 2014, at 17:23:23
In reply to Please don't do that. (nm) » LostBoyinNC45, posted by SLS on April 12, 2014, at 17:15:14
???
Posted by ed_uk2010 on April 14, 2014, at 15:09:13
In reply to I think I should mention my pain medication, posted by kadykat on April 11, 2014, at 3:54:53
>Fentantyl Patches 10 x 50mcg (Duragesic)
> Hydromorphone Extended-Release 32mg. (Exalgo)
> Oxymorphone 90 x 10mg. (Opana IR)
> Oxymorphone 30 x 40mg. (Opana ER)Why 3 potent opioids at once? It's very unusual. As I'm sure you know, it's standard practice just to use one potent opioid at an appropriately titrated dose, except where a different drug is needed for breakthrough pain (most common when fentanyl patches are used + an oral agent).
I'm also surprised that your pdoc added so many drugs all at once. I find this rather reckless. In general, only one medication should be adjusted at a time. If not, you are left with no idea how each medication is affecting you individually and there is a risk of multiple adverse effects.
Due to your fatigue and excessive sleep, I think you should consider reducing your pain medication. I do not think that adding additional medication such as Provigil is a particularly good idea until this has been tried, assuming you haven't already. Fatigue may worsen initially as a withdrawal effect but should then improve. I don't think you need to look at Suboxone unless you have abused your current meds. A structured and supported dose reduction regimen would be more logical.
I do not understand the reason for prescribing Tranxene. Benzos should be reserved for severe anxiety, panic or severe insomnia. It does not seem that you have any of these conditions?
I am not judging you in any way, by your doctors prescribing is rather worrying. They are virtually throwing medication at you, and you are currently so tired it's hard to get out of bed. There has been lot of talk of multiple complex regimens on this thread. A sensible regimen should only been achieved by careful adjustment of one medication at a time, assessing the response to each change individually. You cannot find the best regimen by starting so many meds all at once based on what sounds good on paper. And why does everyone seem to want you on the highest possible doses? Not everyone needs the maximum dose. The best dose to take is the lowest dose which is effective for you personally.
Take care.
Posted by ed_uk2010 on April 14, 2014, at 15:41:09
In reply to Re: Death is in your future, posted by LostBoyinNC45 on April 12, 2014, at 17:04:03
PS.
You also need to be careful due to the risk of oversedation on the benzo (Tranxene) and high dose opioid combination. Tranxene accumulates on repeated dosing, and there is a possible risk of respiratory depression.
This is the end of the thread.
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