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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 18 of 18. This is the beginning of the thread.
Posted by Christ_empowered on April 10, 2014, at 16:54:55
I take 30mgs/Abilify. I'm thinking about an older AP. I have either schizoaffective of the manic persuasion or severe bipolar I. I also take 1200/Trileptal and up to 300/Neurontin (I dropped my Tofranil).
Are there any other older APs that are probably "better than the rest" ? I've heard loxapine, but it seems dosing is tricky.
Anyone out there take perphenazine? I'm thinking that if I get switched to perph, I might A) save the tax payers money (on disability) and b) get a lower level of overall neuroleptic exposure, while still maintaining results. Docs like to ramp up abilify when you're really mentally ill. Ugh.
So...yeah...I was thinking Perphenazine, Trileptal, PRN Neurontin, and a nightly dose of Remeron, maybe start around 30. What do you guys think>
Posted by baseball55 on April 10, 2014, at 20:13:44
In reply to replace Abilify with perphenazine?, posted by Christ_empowered on April 10, 2014, at 16:54:55
Perphenazine didn't do much for me, but haldol did. Even now, when I am mostly better, I take high dose haldol PRN for breakout episodes of depression.
Of course, you have different psychiatric issues (mine is only really bad episodes of depression), so maybe perphazine would help. Can't hurt to try. Side effects are minimal at moderate doses. At high doses, of course, extrapyramidal side effects can occur. But you know that.
Posted by Phillipa on April 10, 2014, at 20:47:25
In reply to Re: replace Abilify with perphenazine?, posted by baseball55 on April 10, 2014, at 20:13:44
Haldol can lower the blood pressure. Phillipa
Posted by Zyprexa on April 10, 2014, at 21:11:04
In reply to replace Abilify with perphenazine?, posted by Christ_empowered on April 10, 2014, at 16:54:55
Well I agree with perphenazine, but it's nothing like Abilify. I took Abilify and lost it. Perphenazine, I have been taking for years and find it helpful.
Posted by ed_uk2010 on April 11, 2014, at 13:50:08
In reply to replace Abilify with perphenazine?, posted by Christ_empowered on April 10, 2014, at 16:54:55
You respond to aripiprazole. Whether you'd respond to perphenazine is unknown. Perphenazine is more likely to cause TD. I cannot see any logical reason for you to switch.
Posted by phidippus on April 11, 2014, at 16:35:12
In reply to replace Abilify with perphenazine?, posted by Christ_empowered on April 10, 2014, at 16:54:55
Perphenazine is only going to antagonise Dopamine receptors, while Abilify targets dopamine and seratonin receptors.
You're likely to incur more side effects as well.
Eric
Posted by LouisianaSportsman on April 12, 2014, at 19:59:49
In reply to replace Abilify with perphenazine?, posted by Christ_empowered on April 10, 2014, at 16:54:55
Greet topic! I'll approach it as a theoretical topic like this is: What typical antipsychotic would be best if you were to choose one?
I would choose Pimozide (Orap). That and Perphenazine are your only true options IMO. Not sure why Orap isn't more popular. It's just missing perhenazine's very important more potent 5-HT2a affinity (5.6), but it still has some moderate affinity and you can't tell me it's not enough to make some sort of difference (48.4). Pimozide is also not likely going to cause much sedation because it does effect H1 as much as much (692 vs. 8) and it shares perphenazine's coolness with binding to the 5-HT7 Scott loves to rave about even stronger (0.5 vs. 23). And of course they're both antipsychotics so they're going to have dopamine antagonism.
I think pimozide is better because it shouldn't cause much sedation, has even more significant binding at 5-HT7 and even has moderate binding at 5-HT2A.
I always told myself it would be the typical I would choose for myself.
Well, let's look at our other typical antipsychotic choices, shall we? Many of these may be hard to get (including perphenazine and pimozide).
We have approved and not discontinued right now in the USA:
Not to Mess With:
Fluphenazine
Haloperidol
ChlorpromazineProchlorperazine: This is mostly for dizziness, migraines and vertigo. Etc.
Thiothixene: Didn't know much about this one coming, had a bad image but not any basis behind it, admittedly. Looks like you shouldn't mess with it. Lots of side effects and one conclusion on one study: "Patients with borderline and schizotypal disorder without the foregoing symptoms probably would not profit from thiothixene and might needlessly be placed at risk for adverse drug effects."
This leaves us with:
Loxapine (kinda sucks)I think you should still stick with an atypical, however.
Posted by LouisianaSportsman on April 12, 2014, at 20:07:06
In reply to Re: replace Abilify with perphenazine? » Christ_empowered, posted by phidippus on April 11, 2014, at 16:35:12
Pimozide also has a weak effect on glucose homeostasis. It tends to produce relatively little extrapyramidal side effects compared to the other typical antipsychotics.
Posted by LouisianaSportsman on April 13, 2014, at 0:54:42
In reply to replace Abilify with perphenazine?, posted by Christ_empowered on April 10, 2014, at 16:54:55
Right now, youre only on 30mg. aripiprazole, 1,200mg. oxcarbamazepine, and up to 300mg. gabapentin PRN? Correct?
I find your gabapentin dosage to be significantly low, but you know I love gabapentin lol. Consider raising it. I found it useful for anxiety and depression. YMMV.
Youre contemplating Remeron, right? If so, 30mg. is a start-up dosage if looking to avoid sedation. I thought Ive read somewhere where you were afraid of getting fat before. Well, I have bad news about mirtazapine.
One of the things I notice is you're on Trileptal. I remember you might have tried Oxtellar XR which I think is better than Trileptal in terms of how oxcarbamazepine formulations go, but Ive come to the conclusion that no form carbamazepine beats Equetro (carbamazepine XR) 1. Carbarmazepine, not oxcarbamazepine, has the science and research backing it for bipolar. 2. Equetro is actually indicated for the disorder. 3. It is time-released.
I would look into #120 200mg. capsules of Equetro. (or #90 300mg. capsules to be easier, itd be a 150mg. increase this way; you multiply carbamazepine by 1.5 to obtain equivalency to oxcarbamazepine) Theres no quantity dispensed limit on my insurance so you should be good. But you seem to be good with Trileptal? I was just throwing Equetro out as an idea just in case you ever became unhappy. I would just stick with Trileptal if everything is working out.
What antipsychotics have you tried? You must have been around the AAP block if youre throwing out perph? I understand trying to save the taxpayers money, but thats the only reasoning I can understand. Basically, I assume 30mg. of Abilify is too much for you? Your PDOC wont lower it?
I guess if you have no choice in changing AAPs then you can try changing to Fanapt. Youre supposed to dose it twice a day, and this shouldnt be an issue if youre taking 600mg. of Trileptal morning and night. Just take 8mg. of Fanapt with those doses for about a 16mg. dose (max dose 24mg., lowest is 12mg.)Obviously, youre having some sort of issue with depression or you wouldnt want to be on mirtazapine. Why did you quit Tofranil? Obviously, you dont seem to mind taking a TCA or a sedating medication so my best suggestion to you is Oleptro (trazodone extended-release).
Trazodone typically needs to be dosed TID, but with this XR version, you have a much more stable plasma concentration than the IR dosing and it stays above the antidepressant concentration level. And you would likely develop a tolerance to the sedation. In fact, this new formulation of trazodone XR has been tested in depressed patients with a surprisingly low incidence of sedation.
Trazodone is a pretty proven antidepressant and here we have it in a form you dont have to dose TID and isnt as sedating. They only have 150mg. and 300mg. bisectable tablets and have 375mg. as a listed max dose in the PI sheet. Cant take no more than 400mg. trazodone.
Id consider something like this:
#75 150mg. Oleptro (375mg. max dose)
#60 8mg. Fanapt (16mg. as close to 18mg., the mid-range dose as you can get to replace your maxed-out Abilify which you don't seem to like)
1,200mg. Trileptal (consider Equetro)
Gabepentin PRN (consider more of it actually or changing to Lyrica if financially possible)
Posted by Christ_empowered on April 13, 2014, at 22:49:22
In reply to Re: replace Abilify with perphenazine?, posted by LouisianaSportsman on April 13, 2014, at 0:54:42
I'll just stick with Abilify. Truth is, the trileptal apparently reduces abilily blood levels, so my 30mgs dose isn't really a 30mgs dose. I don't know how much it is, but its not a full 30mgs, lol.
I may reduce the dosage, anyway, with the help of my doc. I was thinking 20mgs Rx'd plus 5mgs sample packs for 1-2+ weeks to ease the transition, get those D2 receptors back in shape, lol. I may also ask for an increase in Neurontin, at least during the downward dosing of the Abilify, to stay calm. Just a thought.
Posted by ed_uk2010 on April 14, 2014, at 15:23:21
In reply to Re: replace Abilify with perphenazine?, posted by LouisianaSportsman on April 13, 2014, at 0:54:42
>#120
Isn't the number of tabs/caps up to the prescriber? A smaller quantity may be useful initially to assess response.
Posted by Christ_empowered on April 14, 2014, at 15:57:07
In reply to Re: replace Abilify with perphenazine? » LouisianaSportsman, posted by ed_uk2010 on April 14, 2014, at 15:23:21
OK. Instead of *replacing* the Abilify with perphenazine, what about adding a low dose of...something...maybe loxapine (?)...top keep agitation and residual mild psychosis at bay?
Your thoughts? I see the doc next month. The last thing I want is to add in Haldol or any other public health standard rx.
Posted by Louisiana Sportsman on April 14, 2014, at 18:44:54
In reply to Re: replace Abilify with perphenazine? » LouisianaSportsman, posted by ed_uk2010 on April 14, 2014, at 15:23:21
> >#120
>
> Isn't the number of tabs/caps up to the prescriber? A smaller quantity may be useful initially to assess response.Well, that's a basic concept of psychopharmacology. I'm aware of that, ed_uk2010, but thanks for reminding me.
I was converting her oxcarbamazepine IR dosage to carbamazepine ER if she was to theoretically switch to Equetro which is a time-released carbamazepine that is indicated for the treatment of acute manic and mixed episodes associated with bipolar disorder.
She currently is taking the instant release metabolite of carbamazepine, oxcarbamazepine (Trileptal), which is indicated for seizures. An equipotent dosage of carbamazepine to her current dosage of 1,200mg. oxcarbamazepine is 800mg. of carbamazepine.
Equetro is only supplied in capsule formations of 100, 200 and 300mg., respectively. To receive a 800mg. dosage of Equetro equivalent to Trileptal, the lowest quantity dispensed equal to 800mg. is #120 200mg. capsules. (200mg. x 4 capsules = 800mg. x 30 days in a month = #120)
Yes, ed_uk2010, smaller quantities are useful in psychiatry, but in this case, I was just doing a conversion. I thought it was useful.
I'm not sure why she'd need a smaller dosage of a mood stabilizer that she has already assessed just in a different formation; essentially, why would she need to assess a smaller dosage if she has already responded to that equipotent dosage of the metabolite? I guess you may have a different opinion and that's OK.
Posted by Louisiana Sportsman on April 14, 2014, at 19:59:50
In reply to Re: replace Abilify with perphenazine?, posted by Christ_empowered on April 14, 2014, at 15:57:07
> OK. Instead of *replacing* the Abilify with perphenazine, what about adding a low dose of...something...maybe loxapine (?)...top keep agitation and residual mild psychosis at bay?
>
> Your thoughts? I see the doc next month. The last thing I want is to add in Haldol or any other public health standard rx.I forgot that your oxcarbamazepine would reduce blood levels of aripiprazole. I guess this is amateur hour lol.
Normally, I would suggest raising the dosage of your antipsychotic if you're still experiencing agitation and residual mild psychosis, but I believe your insurance may put a #30 quantity dispensed on Abilify.
Totally different story when you're augmenting and not replacing Abilify with another neuroleptic.
OK, I'm not really sure if I'm buying into adding in another neuroleptic, but let's say that I am.
I think the best choice is the perphenazine-amitriptyline combination. If you think you can mix in an atypical then I advise risperidone.
Why avoid Haldol? It is probably one of the best typicals. Too potent? You may not like perphenazine then.
I understand you're not wanting to have two atypicals combined, but you're thinking that's it OK to add a typical? That's what you're thinking?
Second choice would be loxapine then. If you're against Haldol, then every other typical is going to be too potent for you. Loxapine is the only typical without a ridiculous dopamine binding affinity and it still has 11.
Loxapine and Perphenazine(alone too)/amitriptyline are going to be sedating due to H1 affinity. If you can handle a strong dopaminergic typical then the one with the least sedation that maintains a little serotonergic action that I could suggest is fluphenazine. Trifluphenazine is slightly more sedating.
My favorite suggestion is the perphenazine-amitriptyline combo, but you can consider loxapine and maybe fluphenazine?
If you're having agitation, how about Klonopin? Obviously benzos aren't suggested/effective for this condition, especially with the mild psychosis, but it could help, short-term?
Posted by Louisiana Sportsman on April 14, 2014, at 20:18:34
In reply to Re: replace Abilify with perphenazine? » Christ_empowered, posted by Louisiana Sportsman on April 14, 2014, at 19:59:50
http://www.schizophrenia.com/sznews/archives/002424.html#
"Perphenazine (the older medication) equally as effective as the other three newer medications (risperidone, quetiapine, and ziprasidone) and was as well tolerated as the newer drugs. The three newer medications performed similarly to one another.
Contrary to expectations, movement side effects (rigidity, stiff movements, tremor, and muscle restlessness) primarily associated with the older medications were not seen more frequently with perphenazine than with the newer drugs. The advantages of olanzapine in symptom reduction and duration of treatment over perphenazine were modest and must be weighed against the increased side effects of olanzapine.
Thus, taken as a whole, the newer medications have no substantial advantage over the older medication used in this study. An important issue still to be considered is individual differences in patient response to these drugs."
The dosage of perphenazine used in the CATIE study http://www.nejm.org/doi/full/10.1056/NEJMoa051688#t=articleResults was 20.8mg.
The perphenazine/amitriptyline combo comes in:
- Tablets 2 mg perphenazine/10 mg amitriptyline
- Tablets 2 mg perphenazine/25 mg amitriptyline
- Tablets 4 mg perphenazine/10 mg amitriptyline
- Tablets 4 mg perphenazine/25 mg amitriptyline
- Tablets 4 mg perphenazine/50 mg amitriptylineMaintenance dose for amitriptyline is 25 to 150 mg per day in single or 3 to 4 divided doses.
You could try #150 4 mg perphenazine/25 mg amitriptyline?
Posted by ed_uk2010 on April 15, 2014, at 13:32:44
In reply to Re: replace Abilify with perphenazine?, posted by Louisiana Sportsman on April 14, 2014, at 18:44:54
>....why would she need to assess a smaller dosage if she has already responded to that equipotent dosage of the metabolite? I guess you may have a different opinion and that's OK.
Hi,
Oxcarbazepine isn't a metabolite of carbamazepine, but it is structurally closely related, and appears to have a similar mechanism of action. Carbamazepine is metabolised to carbamazepine-10,11-epoxide. Oxcarbazepine is metabolised to eslicarbazepine.
I understand the reasoning behind suggesting a particular drug, but (most) people are not in a position to tell their doctor to prescribe a specific quantity :)
Posted by LouisianaSportsman on April 17, 2014, at 3:10:26
In reply to Re: replace Abilify with perphenazine? » Louisiana Sportsman, posted by ed_uk2010 on April 15, 2014, at 13:32:44
> >....why would she need to assess a smaller dosage if she has already responded to that equipotent dosage of the metabolite? I guess you may have a different opinion and that's OK.
>
> Hi,
>
> Oxcarbazepine isn't a metabolite of carbamazepine, but it is structurally closely related, and appears to have a similar mechanism of action. Carbamazepine is metabolised to carbamazepine-10,11-epoxide. Oxcarbazepine is metabolised to eslicarbazepine.
>
> I understand the reasoning behind suggesting a particular drug, but (most) people are not in a position to tell their doctor to prescribe a specific quantity :)Tell? I'm pretty sure everything I say is my opinion and a suggestion. God help people if I tell doctors what to do.
The metabolite of oxcarbamazepine isn't an epoxide so I guess that explains where they reason it has better side effects and why you can't directly convert necessarily. Mentioning Aptom, I wonder if it might be OK for fibromyalgia patients? Pretty new and this derivative of carbamazepine has the most potential.
Regardless, I can't suggest a quantity even though they're both benzo-fluorinated 10,11's and there are existing professional guidelines regarding conversion factors for both drugs, including Aptom. I'm sure the PDOC doesn't know the conversion in head, and why would he not directly convert also? Sounds like she would save him a step.
Posted by ed_uk2010 on April 18, 2014, at 11:02:18
In reply to Re: replace Abilify with perphenazine?, posted by LouisianaSportsman on April 17, 2014, at 3:10:26
> > >....why would she need to assess a smaller dosage if she has already responded to that equipotent dosage of the metabolite? I guess you may have a different opinion and that's OK.
> >
> > Hi,
> >
> > Oxcarbazepine isn't a metabolite of carbamazepine, but it is structurally closely related, and appears to have a similar mechanism of action. Carbamazepine is metabolised to carbamazepine-10,11-epoxide. Oxcarbazepine is metabolised to eslicarbazepine.
> >
> > I understand the reasoning behind suggesting a particular drug, but (most) people are not in a position to tell their doctor to prescribe a specific quantity :)
>
>Mentioning Aptom, I wonder if it might be OK for fibromyalgia patients? Pretty new and this derivative of carbamazepine has the most potential.I think the main benefit of eslicarbazepine acetate (Aptiom, Zebinix) over oxcarbazepine (Trileptal) is convenience ie. once daily dosing and simple titration. In terms of efficacy and tolerability, there two meds are probably very similar. I wouldn't be surprised if the cost of Aptiom was prohibitive in some cases.
Carbamazepine and oxcarbazepine haven't been used a great deal in fibromyalgia - I don't think eslicarbazepine offers much promise here either. Eslicarbazepine might potentially be useful in bipolar disorder but I'd like to see some major trials comparing it with established meds such as Depakote and lithium. It might also be useful in trigeminal neuralgia.
Conversion from carbamazepine to oxcarbazepine may depend on the dose of carbamazepine which was taken, due to auto-induction of hepatic enzymes. It may also depend on which formulation of carbamazepine was taken eg. standard release or sustained release.
This is the end of the thread.
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