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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 20 of 20. This is the beginning of the thread.
Posted by Babak on July 25, 2015, at 13:59:09
Hi
I posted this on an ADD forum but apparently any advice from them could lead to legal claims!!!
So, I hope someone can help here assured that I would 1st confirm its viability through a doctor.
I was diagnosed almost three years ago after over 35 years of misdiagnosis. Going back to the beginning; I developed periodic depression around the age of 14, which kept recurring until 29 when I had a complete breakdown and was put SSRi that was only partially beneficial. I was on a mix of Venlafaxine and Mirtazapine in 2001 when I was referred to hospital for ECT. But following a reaction to the anesthetic, not helped by being forced to take 300mg of Effexor after coming around I developed severe tachycardia. As I was left unattended in hospital (the nurse who was supposed to call the doctor failed to do so), I developed heart murmur which quickly deteriorated and I was forced to have my aortic valve replaced (was never compensated for the damage, because the hospital claimed that they had lost my records!).
Then I was prescribed Olanzapine to which I showed a paradoxical reaction. The paradoxical reaction deepened my depression as well lots of other side effects and it became permanent and I was forced to give up on my complaint. But contrary to the manufacturers' recommendations I was not kept under proper monitoring while on Olanzapine and the paradoxical reaction was not detected for five years although my condition got so bad that I couldn't leave home to buy food and once I was found starving in my bedroom by social services who finally came around when I stopped answering the phone or collecting my post.
To alleviate some of the painful side effects that included severe stomach pains, I was prescribed stronger and stronger painkillers up to morphine sulphate which unsurprisingly not only stopped the pain also lifted my mood. So after few months I kept increasing my dose until my doctor refused to repeat my prescription. So, I started using heroin but even heroin couldn't deal with all the side effects and I started to develop a whole new set of neurological symptoms. It got to the point that I developed RLS at nights and on waking up I felt paralyzed for the 1st 15 minutes or so.
Meanwhile I watched an episode of Horizon where I learned that hyperactivity was not an essential symptom of ADHD and how it manifested itself in Adults. Except Hyperactivity, I recognized just about all the other symptoms so clearly that might have well been my own personal history: four failed career changes, many, many more failed relationships that include three marriages and two failed children, having tried to live in three different countries. I also remembered how often I used to (and still do) lose, things like gloves, pencils, expensive lighters, jackets, pullovers, etc.. and have been mocked for it all my life as well as having a lousy handwriting, losing focus on details, losing interest in all hobbies and sports that my mother try to get me to pick up. The only thing is that I was a good student as long as I didn't have to study, specially when it came to sciences where I could use analysis rather than memory. But unable to study efficiently became more and more difficult and by the time I got to University my disadvantages lead to much lower grade than expected.
So I went to substance misuse services where and as well as being put on Methadone, I was referred for psychiatric evaluation. I mentioned that I might have been a case of undiagnosed ADHD but by then I was categorized as a substance abuse patient and the possibility of prescribing a stimulant was totally out of the question, i.e.; my proposal was considered as a mundane case of just another junkie trick to get high even though I didn't drink alcohol and my opiate dependency was not even a year old.
Once I was stable on Methadone, I was capable to do my own research and this how I came across Olanzapine's potential for causing paradoxical reactions. The only thing was that Olanzapine made me sleep and for some one in my situation, sleep was the only respite. So I was hesitant to come off it but I had no choice. To my amazement, I started feeling better after only 5 days. I was so incredulous that after two weeks, I started taking it again and symptoms returned within 48 hours. So, it couldn't have been anything else but Olanzapine.
However unfortunately by then my depression had become permenant, my teeth damaged and I was physically addicted to opiates as well psychologically. Over the next two year, I kept trying to come off Methadone, but my depression became intolerable as soon as my dose went below 12mg. So my social worker suggested to go on Subutex. My social worker was the only person who really helped me and argued that I was not a typical substance abuse patient as drug seeking behaviour was never observed during all the time that I was monitored.
By then I had done several on line ADHD tests and I even contacted a specialist in US who assessed me over Skype. He said that although he couldn't give me a definitive diagnosis he strongly recommended that I be assessed by a specialist. So, I made a formal complaint against the psychiatric department to the local NHS trust who finally agreed to arrange an appointment with an ADHD specialist, probably because just then there was at last a clinic for adult ADHD in Brighton hospital (one day per week).
I was diagnosed with ADHD with possible comorbidity of Asperger syndrome (I have repeatedly scored as borderline with Asperger Syndrome, something that the CPT therapist in the same hospital has ruled out.
Anyway having not responded well to Stratta, I was finally and reluctantly prescribed Concerta and hence I had the first six completely depression free months of my life since I had turned fourteen and a sense of permanent calm that I had never felt before. As time went on I felt as if everything was clearer and I didn't have to strain myself to observe things. I felt as if until then I had been swimming in a muddy water against the current but now I was in clear waters and there was no current to swim against. I continued to improve as my dose was increased to 56 mg. I felt a totally different person and everyone noticed it, even on the other side of the telephone, people told me that I sounded "much more with it". I did have a faster than usual heart rate and my blood pressure was 180s/80s but I was in such CONTINUOUSLY good mood (not euphoric) that I didn't want to change anything. My short term memory was much better. I no longer forgot where I parked the car and I stopped zoning out when I read important but boring documents. I also started feeling easily satisfied rather than continuously feeling as if something was missing in everything I did. Everything looked in focus and easily perceptible, if that makes sense.
However I reluctantly accepted that I needed to do something about my blood pressure. That is when things started going wrong again. The problem was that high doses of Ramipril although brought down my blood pressure it made my heart beat even faster and I also started loosing power in my muscles and my blood test showed abnormally low testosterone level. I must have tried a dozen different blood pressure medication (including clonidine) and they all had intolerable side effects and caused my heart to beat even faster, except beta blockers which unfortunately counteracted the beneficial effects of Concerta as well and I felt continously sleepy. But things got even worse when I tried to come off Subutex. My own theory is that because Subutex lowers breathing, it probably also lowers the heart rate.
While attending CBT group (useless) I spoke to another ADHD sufferer who told me that she had the same problem with concerta but it was resolved when she changed to lisdexamfetamine (vyvanase). I knew that it didn't make sense but in desperation I begged to try it against my psychiatrist's advice. But for once the psychiatrist was right. It was a nightmare. My heart rate wet to 110 per minute and I couldn't handle it at all. So, I returned medication just incase they thought I might have made up the story to get hold of some meta-amphetamine to get high. So, I am stuck now, I have reduced my Subutex to 1.5mg but I have also had to reduce my Concerta to 18mg which has meant the return of the symptoms. What I have noticed is that on 36mg, I am OK until around noon and then my heart beat gets intolerable until 7:00pm when it starts to calm down again. I have measured it and it is normally around 96-98bps at rest but it does creep beyond 100bps at times. Please bear in mind that this is at rest on a day with minimum physical activity.
So, please, if there is anyone out there who can suggest something viable I would be forever thankful.
Posted by linkadge on July 25, 2015, at 20:34:51
In reply to Help with Methylphenidate induced tachycardia,, posted by Babak on July 25, 2015, at 13:59:09
Sorry, can you reduce your question to 2 or 3 sentences (not to sound harsh)?
For Ritalin induced tachycardia, you could try atenolol (or another beta blocker). Alternatively, you could try augmenting with something like guanfacine or clonidine (alpha 2 agonists which are originally blood pressure drugs, but have independent effects of ADHD).
They may reduce the dose of Ritalin needed and/or treat tachycardia.
Linkadge
Posted by rjlockhart37 on July 26, 2015, at 1:14:40
In reply to Help with Methylphenidate induced tachycardia,, posted by Babak on July 25, 2015, at 13:59:09
a vary "vary" option is to add Tenex, or Clonodine......their not heart medications but they regulate blood pressure, and could help in some way with maybe the tachycardia.....
Posted by Babak on July 26, 2015, at 2:41:22
In reply to Re: Help with Methylphenidate induced tachycardia,, posted by linkadge on July 25, 2015, at 20:34:51
> Sorry, can you reduce your question to 2 or 3 sentences (not to sound harsh)?
>
> For Ritalin induced tachycardia, you could try atenolol (or another beta blocker). Alternatively, you could try augmenting with something like guanfacine or clonidine (alpha 2 agonists which are originally blood pressure drugs, but have independent effects of ADHD).
>
> They may reduce the dose of Ritalin needed and/or treat tachycardia.
>
> Linkadge
>
>
I apologise for my detailed post which must have been why you seem to have missed the following two points:
1) I did mention in my post that I have already tried Clonidine. It is a medication used for lowering blood pressure which it does but if anything exacerbates my tachycardia.
2) Beta blockers which again I mentioned in my post and I have also tried are adrenergic blocking agents and as such counteract the effects of an androgenic agent like methylphenidate, i.e. it is equivalent to reducing the dose which I hope you agree defeats the object.
Posted by Babak on July 26, 2015, at 3:11:48
In reply to Re: Help with Methylphenidate induced tachycardia,, posted by rjlockhart37 on July 26, 2015, at 1:14:40
> a vary "vary" option is to add Tenex, or Clonidine......their not heart medications but they regulate blood pressure, and could help in some way with maybe the tachycardia.....
>
>
I have tried Clonidine which although lowers my blood pressure it actually makes my tachycardia worse. Same as Ramipril and other blood pressure medications I have tried.I have talked about this to my doctor and it seems that the way they lower blood pressure is by relaxing the blood vessel whose contraction actually reduces heart beat as in a feedback system without which the heart keeps beating faster.
Statins work but the other side effects are intolerable which unfortunately in my case include depression, anger, headache, muscle pain and change in liver enzymes levels.
I have not tried Tenex because my previous Pdoc was of the opinion that in my case is not suitable but I am changing doctors as I have moved out of UK. So it may yet to be tried.
However it does sound that like clonidine it works again by regulating blood pressure although it affects the nervous system at a lower level which might be promising. Thank you.
Posted by SLS on July 26, 2015, at 4:06:00
In reply to Re: Help with Methylphenidate induced tachycardia, » rjlockhart37, posted by Babak on July 26, 2015, at 3:11:48
How do you define tachycardia?
- Scot
Posted by Babak on July 26, 2015, at 13:20:24
In reply to Re: Help with Methylphenidate induced tachycardia, » Babak, posted by SLS on July 26, 2015, at 4:06:00
> How do you define tachycardia?
>
>
> - ScotHeart beat of >100 bps at rest, although mine is usually 96-98 but I suggest that doesn't leave much room for manoeuvre, don't you agree?
Posted by SLS on July 26, 2015, at 22:15:43
In reply to Re: Help with Methylphenidate induced tachycardia,, posted by Babak on July 26, 2015, at 13:20:24
> > How do you define tachycardia?
> Heart beat of >100 bps at rest, although mine is usually 96-98 but I suggest that doesn't leave much room for manoeuvre, don't you agree?Not necessarily.
What is your HR usually?
I am not positive as to how methylphenidate is supposed to affect resting heart rate. It will raise it, but I don't know by how much. Tricyclic antidepressants bring my resting HR up to 100 bpm. This is normal. Not enough doctors educate their patients as to what to expect regarding HR. I've seen too many people discontinue a TCA prematurely because they see their HR reach 90 bpm. It is frustrating to watch. If you are concerned, speak to your doctor. You can have an ECG to check things out.
Is there any history of heart disease in your family? Dysrhytmia?
- Scott
Posted by Babak on July 27, 2015, at 9:49:11
In reply to Re: Help with Methylphenidate induced tachycardia, » Babak, posted by SLS on July 26, 2015, at 22:15:43
If you are asking about my HR before methylphenidate then it was just below 80 and I never had hypertension in my life even when I was on tricyclic antidepressants (amitriptyline) or SSRIs.
After my heart operation I did develop arrhythmia and was prescribed 2.5mg Ramipril for couple of years.
There is no history of heart disease in my family.
As to my current HR (prior to reduction of dose in Concerta), it was/is pretty uncomfortable and restricts physical activity as I quickly get breathless.
Increased bp and HR is a common side effect of Concerta and I have discussed it with my Pdoc as well as GP and a cardiologist.
Unfortunately GPs and cardiologists are pretty ignorant about ADHD.
The cardiologist suggested that I stop taking concerta assured that there must be something else that could deal with my ADHD. Prioritizing my heart over my ADHD.
My GP prescribed beta-blockers which my Pdoc told me to stop taking them as it counteracted the ADHD medication.
My Pdoc who was concerned about my PB and HR proposed Clonidine after all the other hypertension medications proved either ineffective to deal with my HR or had intolerable side effects as was the case with Statins.
But as I mentioned before while Clonidine reduces my blood pressure, it actually exacerbates my tachycardia pretty much like other hypertension medications I have tried.
This I believe is because of the way they relax the veins and arteries rather than slowing down the heart rate which in the absence feedback from high blood pressure beats even faster under the androgenic effects.
I have had to relocate and I therefore had to discontinue seeing my Pdoc now.
Posted by Babak on July 28, 2015, at 3:01:25
In reply to Re: Help with Methylphenidate induced tachycardia, » SLS, posted by Babak on July 27, 2015, at 9:49:11
I just like to mention that non-stimulant ADHD approved medication such as Clonidine and Intuniv (except atomoxetine which is really just a weaker stimulant) act more like sedatives which might be useful where hyperactivity is a symptom but are actually detrimental with ADD symptoms.
In view of the above and considering:
1) ADD being more prevalent in adults ADHD patients; i.e. without hyperactivity.
2) Large number of reported cases of Tachycardia/Tachyarrhythmia associated with methylphenidate as well as dangers of stroke and/or sudden death syndrome,
Isn't it amazing that there has been no strategy developed to deal with the issue?
Posted by SLS on July 28, 2015, at 7:16:55
In reply to Re: Help with Methylphenidate induced tachycardia, » Babak, posted by Babak on July 28, 2015, at 3:01:25
> I just like to mention that non-stimulant ADHD approved medication such as Clonidine and Intuniv (except atomoxetine which is really just a weaker stimulant)
Atomoxetine is more like an antidepressant than it is a stimulant. It just hits the brain in the right place (PFC) and helps to reduce dopamine clearance there. This should increase PFC activity and output, thus reducing ADD symptomatology.
If my resting heart rate were to become uncomfortably high, I might ask my doctor about taking atenolol. It is a beta-blocker that does not cross the blood-brain barrier. It should slow down the heart.
Clonodine can produce symptoms of depression, even in otherwise healthy individuals. I would be hesitant to take it. Guanfacine might be a better choice here. It does not stimulate all of the NE alpha-2 receptor subtypes as does clonidine. Guanfacine is selective for the alpa-2a subtype and is more stimulant-like than depressant-like. It thus strengthens PFC activity via postsynaptic receptor stimulation rather than more globally inhibiting NE release via presynaptic receptor stimulation.
When I first combined Parnate + desipramine, my resting heart rate was often over 100 bpm. I had no history of heart disease, though. My worry over increased HR was mitigated by my doctor telling me that this was often the case, and that it did not represent a threat. The "100" bpm value is arbitrary, anyway. I know of no studies demonstrating the safety of 100 and the danger of 105. I think real trouble starts at 120 bpm, but my perceptions are biased for having had to take trycyclics for 33 years.
If your doctor specializes in the use of methylphenidate, I would take his advice regarding accelerated heart rate. I would be curious to know his opinion of the use of atenolol to reduce HR.
Good luck.
- Scott
Posted by linkadge on July 28, 2015, at 16:42:10
In reply to Re: Help with Methylphenidate induced tachycardia, » linkadge, posted by Babak on July 26, 2015, at 2:41:22
The effects of methylphenidate include modulation of serotonergic, dopaminergic and noradrenergic mechanisms. A beta blocker will not block all the effects of Ritalin.
Linkadge
Posted by linkadge on July 28, 2015, at 16:59:03
In reply to Re: Help with Methylphenidate induced tachycardia,, posted by linkadge on July 28, 2015, at 16:42:10
Also, some beta blockers are more "cardioselective" meaning they block adrenaline in the periphery but less so in the brain.
Posted by Babak on July 29, 2015, at 3:08:38
In reply to Re: Help with Methylphenidate induced tachycardia, » Babak, posted by SLS on July 28, 2015, at 7:16:55
Thank you very much for your response.
I didn't know about hydrophilic and lipophilic beta-blockers and more worryingly it seems that neither did my GP, Pdoc and nor the cardiologist that I was referred to by UK's NHS.
My Pdoc told me not to take beta blockers prescribed by my GP and the cardiologist told me to stop taking my Concerta.
None of them ever even considered trying a selective beta blocker. Just goes to show the dangers we face when we need "doctors".
I am currently in Italy but last night I, managed to get hold of 100mg Atenolol tablets through a friendly pharmacy.
I had already taken 10mg diazepam and 300mg Gabapentine but I still have palpitation and my blood pressure was 187/99.
So in almost desperation I took half a tablet and then my heart rate dropped to 75 and my blood pressure came down to 135/87 within half an hour.
Obviously late at night with all the medication in me, I couldn't tell if my focus or concentration had been affected by Atenolol as well. However, it still took me three hours to fall asleep (ADHD does cause chaotic sleep patterns).
I have taken 36mg of Concerta today which means that I should start having palpitation within six hours.
I know that Atenolol has short life time but my blood pressure by this time would be high into 180s is still in the 130s/70s and my HR is still 69. I feel a bit dizzy but other than that I feel fine!
I know that it is too early to make any definitive conclusions but WHY this was not considered by the doctors?
Posted by Babak on July 29, 2015, at 3:38:16
In reply to Re: Help with Methylphenidate induced tachycardia,, posted by linkadge on July 28, 2015, at 16:59:03
> Also, some beta blockers are more "cardioselective" meaning they block adrenaline in the periphery but less so in the brain.
Thank you for your help. I have elaborated on this in my earlier response to SLS.
While we are on the subject;
1) does anyone know which of the two Bisoprolol and Atenolol are more suitable in terms of crossing the blood brain barrier?
2) What are the differences between the two?I have read the Atenolol must not be prescribed in case stimulant overdose because its lack of affect on alpha androgenic receptors, not that I would consider overdosing on Concerta but then overdosing is relative, isn't it?
Posted by phidippus on August 5, 2015, at 11:22:53
In reply to Help with Methylphenidate induced tachycardia,, posted by Babak on July 25, 2015, at 13:59:09
Straterra is the obvious choice. It is not a stimulant.
Eric
Posted by Babak on August 8, 2015, at 13:50:18
In reply to Re: Help with Methylphenidate induced tachycardia, » Babak, posted by phidippus on August 5, 2015, at 11:22:53
I have tried Straterra as well all other non-stimulants without any success.
However 50mg or even 25mg of Atenolol has been working very well except that it has worsened my insomnia of all things.
It doesn't make me sleepy or lessen the stimulants effects by much anyway.
I feel a lot better now since I have moved from 18 to 36mg of Concerta with the help of Atenolol.
I am thinking of increasing my dose back to 54mg which what it was before palpitation developed into tachycardia.
Posted by Babak on August 8, 2015, at 14:00:25
In reply to Re: Help with Methylphenidate induced tachycardia, » phidippus, posted by Babak on August 8, 2015, at 13:50:18
I am not sure but it could be that it was the palpitation that was also making me tired too quickly during the day and hence I fell asleep easier at night because I don't feel tired anymore although I do feel the effect of Concerta wearing off at around 8:00pm as I get restless, having taken it around 7:00 am in the morning.
They are all pretty blunt instruments to resynch the brain to something like "normal" if you think about it. So you just don't know what is the effect and what is the side effect.
We are decades aways from finding out exactly why ADHD symptoms manifest themselves as such and all the psychological as opposed to neurological arguments around the subject only divert resources from the necessary research.
Posted by phidippus on August 11, 2015, at 17:32:16
In reply to Re: Help with Methylphenidate induced tachycardia, » phidippus, posted by Babak on August 8, 2015, at 13:50:18
If atenelol is causing insomnia, try another beta blocker - Propanalol is often prescribed for insomnia.
Eric
Posted by Babak on August 12, 2015, at 2:25:11
In reply to Re: Help with Methylphenidate induced tachycardia, » Babak, posted by phidippus on August 11, 2015, at 17:32:16
I am limited to Beta blockers that don't cross the blood brain barrier which otherwise would counteract the sought after androgenic effects of Concerta.
Although it has been difficult to find a list of those that have this characteristic.
However it seems to me that any beta blocker helps insomnia is likely to cross the blood brain barrier which of course does the leave one open question: why or how does atenolol can cause insomnia?
This is the end of the thread.
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