![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 42. This is the beginning of the thread.
Posted by LouisianaSportsman on September 24, 2013, at 20:51:00
Current Psychiatric "Cocktail":
Abilify (aripiprazole)10mg.
Concerta (methylphenidate ER) 54mg
Lamictal (lamotrigine) 200mg.
Lyrica (pregabalin) #60 150mg. [300mg.]
Pristiq (desvenlafaxine) 50mg.Dx:
296.80 Bipolar Disorder NOS
314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type---
I would like to discontinue the Lyrica (pregabalin) in place of Trodenki XR (topiramate XR) which unlike Lyrica, is non-scheduled and not abusable. I do not want to be taking two medications (Abilify and Lyrica) that cause significant weight gain. I do not expect the topiramate to be a direct replacement for pregabalin, obviously. Like pregabalin, topiramate is an anti-convulsant but it works primarily on sodium channels whereas Lyrica acts exclusively on calcium channels. I believe topiramate, initiated in the form of Trokendi XR (approved August 2013 as the only controlled-release form of topiramate not combined with phentermine) at #60 100mg. topiramate extended-release capsules would be a great adjunct to my Lamictal. I will suggest prescription of #60 100mg. (the initial dose for bipolar disorders and the mean dose for bipolar disorders according to one study = 210.5 mg/day). If side effects are too much, I can drop down to 100mg. since I was prescribed 100mg. pills. I believe the controlled-release pills might be advantageous because they will give less side effects since the dose is released over time instead of all at once, and it eliminates any need for BID dosing due to a more consistent peak plasma concentration. Is there any advantage of using a controlled-release formulation of topiramate over the instant release? I am guessing there might be. Only a theory. Also, I have noticed in some literature that when lamotrigine was transferred to another anticonvulsant, it was automatically titrated at the target dose of the alternative anticonvulsant. I also have a high tolerance of all psychoactive medications which my pdoc and I both agree on, and we frequently begin titrating at the higher doses of medications; therfore, I think a fast titration is feasible.
I am, of course, looking for weight loss of aripiprazole/pregabalin weight; however, that is not the only intended goal at all. I have been having mood swings not treated with the lamotrigine. I believe augmentation of lamotrigine with a target dose of 200mg. topiramate (average dosage for bipolar according to another study was 245mg. QD) would be beneficial. I do not want to exceed the dosage that gets the job done as cognitive side effects are dose-dependent. I did not experience cognitive dulling from pregabalin nor any other psychoactive medication and hopefully it will be the same case with potential topiramate. Pregabalin works well and hopefully so will topiramate. Topiramate has been shown to help with anxiety and bipolar depression of which I am suffering and, like pregabalin, it antagonizes glutamate. I am hoping it will make my mood more stable due to its powerful mood stabilizing mechanism of action. It should also fatigue the ability of aripiprazoles weight-gaining mechanism. With these reasons in mind, I believe it is the most important medicine to negotiate with at the present time.
Additionally, I believe that the dosage of Pristiq should be increased to 100mg (300mg. venlafaxine). I am still having depressive episodes on the 50mg. dosage. Also, this dosage is where it starts to effect NE and even DA more potently and acts more as a true SNRI than simply a souped-up SSRI.
I have taken Nuvigil in the past and it has since been replaced by a gambit of ADHD stimulants. I believe that I would benefit from the substitution of Nuvigil (armodafinil) at #60 150mg. BID QAM QPM in replacement of Concerta 54mg. Nuvigil is safely taken at this dosage. Like Concerta, Nuvigil does not provide adequate all-day relief. A 150mg. tablet taken in the morning with a 150mg. booster dose is my recommendation. Because aripiprazole has such a high D2 occupancy rate (85% at 10mg.), it drastically reduces the effects of ADHD stimulant drugs such as methylphenidate ER. Nuvigil, with its unique mechanism of action, compliments the Abilify better, IMO. Its abuse-potential is also much, much lower. The Nuvigil is an absolute *must* combined with the Abilify as it causes me to want to sleep during the daytime, but this may be the Pristiq. Also, I believe the armodafinil may help with possible side effects of cognitive dulling arising from the use of topiramate.
New Suggestion for next visit:
Abilify 10mg.
Lamictal 200mg.
* Nuvigil #60 150mg. [300mg.] substituted for Concerta 54mg.
* Pristiq 100mg. increase from Pristiq 50mg.
* Trodenki XR #60 50mg. [100mg. target] substituted for Lyrica which was indicated off-label primarily for bipolar depression and anxiety
(asterisk indicates a change)Augmentation Ideas, in order of most promising, for future visits if above regimen does not succeed:
Mirapex (pramipexole)
Namenda (memantine)
Gabatril (baclofen)Any thoughts? Ideas?
Thank you!!
Posted by Dr. Bob on September 26, 2013, at 1:08:54
In reply to Augmenting Bipolar 'Cocktail' with Trodenki XR, posted by LouisianaSportsman on September 24, 2013, at 20:51:00
Posted by doxogenic boy on September 26, 2013, at 11:50:18
In reply to Augmenting Bipolar 'Cocktail' with Trodenki XR, posted by LouisianaSportsman on September 24, 2013, at 20:51:00
I think it is worth trying the meds you mention. In my experience, when I have been dissatisfied with my medication, and I have thought of other meds to try, it is best to do that, so I don't need to ruminate about it.
My successfull cocktail is a result of trial and error. If I had given up that process, I wouldn't have reached where I am now.
Here is an article about psychiatric uses of topiramate:
http://www.ajol.info/index.php/sajpsyc/article/download/34431/6359- doxogenic
Posted by LouisianaSportsman on September 27, 2013, at 15:56:25
In reply to Augmenting Bipolar 'Cocktail' with Trodenki XR, posted by LouisianaSportsman on September 24, 2013, at 20:51:00
doxogenic boy,
Thank you for sharing your experiences as well as the informative article on topiramate! You're right, it's a rocky road to reach the right path-- but you can eventually find the cocktail that works for you!
Follow up:
After consultation with pdoc, we decided to change the Lyrica to Gabapentin 900mg. QID. We're hoping the slightly different metabolic processes of gabapentin and the augmentation of Nuvigil 250mg. would hopefully ease up the weight gain.
Next visit is in one week. We're going to observe my weight and likely add topiramate 50mg. BID and titrate up from there. She is fine with the Trodenki XL idea after I titrate up to the 200mg. dosage we both agreed on. She doesn't want to make too many changes at once; yet, she wants to get me stable as possible which is why she will likely add the topiramate next week.
We made two changes:
Abilify (aripiprazole)10mg.
REPLACED: Concerta (methylphenidate ER) 54mg
Lamictal (lamotrigine) 200mg.
REPLACED Lyrica (pregabalin) #60 150mg. [300mg.]
Pristiq (desvenlafaxine) 50mg.Therefore, I am now taking:
Current Psychiatric "Cocktail":
Abilify (aripiprazole)10mg.
Nuvigil (armodafinil) 250mg.
Lamictal (lamotrigine) 200mg.
Neurontin (gabapentin) 1,800mg. [400mg. QID]
Pristiq (desvenlafaxine) 50mg.As you can see, we replaced the Concerta with Nuvigil and the Lyrica with the Neurontin this visit.
One week till next visit. We will, assuming things don't change, --> Pristiq 100mg.; Topiramate titration to 200mg. Trodenki after one month.
One month until second visit. We will investigate the addition of:
Mirapex (pramipexole)
Namenda (memantine)
Gabatril (baclofen)If anyone has any thoughts (concerns?) on these medications or my cocktail, let me know!
I appreciate any input.
Thanks!!
Posted by doxogenic boy on September 27, 2013, at 16:19:50
In reply to Re: Augmenting Bipolar 'Cocktail' with Trodenki XR » LouisianaSportsman, posted by LouisianaSportsman on September 27, 2013, at 15:56:25
>She doesn't want to make too many changes at once; yet, she wants to get me stable as possible which is why she will likely add the topiramate next week.
One important reason not to make too many changes simultaneously, is that it will make it difficult to know which of the new drugs that cause effects and side effects, but it isn't always easy to do that if one suffers a lot and is impatient to change the mental state into something else.
I wish you good luck with your new combo, and I would appreciate hearing how it will be further.
- doxogenic
Posted by SLS on September 28, 2013, at 6:41:26
In reply to Augmenting Bipolar 'Cocktail' with Trodenki XR, posted by LouisianaSportsman on September 24, 2013, at 20:51:00
I don't have much to suggest. I think your proposed treatments merit exploration. I do think that the dosage of Pristiq can be increased. Do you have any idea why one would not want to raise the dosage of Pristiq to 300 mg/day?
* Gabitril = tiagabine
Good luck.
- Scott
Posted by LouisianaSportsman on September 28, 2013, at 11:31:15
In reply to Re: Augmenting Bipolar 'Cocktail' with Trodenki XR » LouisianaSportsman, posted by SLS on September 28, 2013, at 6:41:26
Thanks, Scott. I was looking forward to your reply. It makes me feel good that you think I'm heading in the right direction. Thanks for the gabatril correction. I try not to make mistakes-- remaining as professional as I can get. Do you mean Pristiq 100 equivalent to 300 generic venlafaxine? Pristiq 300mg is equal to 900mg of venlafaxine! :O I know you made an error lol.
Like a lot of members on Babble, I know my stuff. I think you can tell from my posts; however, I want to address some issues in particular.
1. What do you y'all think about extended release topiramate over the classic instant release?
2. Right now, the gabapentin is PRN. Should it be taken at full dosage everyday to act as a proper adjunct mood stabilizer?
3. How bad is the cognitive side effects of topiramate? I was thinking about augmenting with #90 bupropion SR 75mg. One in the morning, one in the afternoon and one at bedtime to keep steady state concentration. I was also thinking about adding #90 Dexedrine (dextroamphetamine) 10mg. to go with it. Take 2 in the morning with the bupropion and one in the afternoon with the bupropion. Dexamphetamine can cause aniexty and I was thinking Xanax XR 1mg. would be a smooth ride; also, my gabapentin tolerance is out of control. I was thinking about another benzodiazepine to augment with the night-time dose of my bupropion such as Ativan 0.5mg. It has been shown to lower blood pressure and be good for the dextroamphetamine "crash"
Next Visit idea:
1. Begin titration of Topamax.
2 Increase Pristiq to 100mg3.
New Scheduling of Meds:
#90 75mg. bupropion SR.
#90 10mg. dexamphetamine
#30 1mg Xanax XR
#30 0.5mg. lorazepamTheoretical:
7:30 A.M
Psychostimulants:
75mg. bupropion SR
20mg. dexamphetamine
250mg. NuvigilAnti-Anxiety
1mg. Xanax XR
800mg. GabapentinMood Stabilizer
200mg. Trodenki XL (topiramate)
200mg lamotrigine
10mg. Abilify (aripiprazole)Anti-Depressant
100mg. Pristiq2:00 P.M.
10mg. dextroamphetamine
75mg. bupropion SR
400mg. gabapentin9:30 P.M.
75mg. bupropion SR
400mg gabapentin
0.5mg Ativan (lorazepam)^^^ What do you think about the above plan? Right now, I suffer from extreme ADHD, lethargy (hope the Nuvigil gets rid of that!) and constant mood swings. I want to take the gabapentin everyday for an adjunct mood stabilizer with Lamictal and Topamax. I also suffer from overwhelming anxiety which I believe calls for BZD maintenance. The increase in Pristiq should eliminate some of my down periods, and the Abilify helps me look at things more rationally and has alleviated my symptoms more than any psychiatric drug I've had. Just an idea.
Let me know what you think! I'd appreciate it. :D
Posted by LouisianaSportsman on September 28, 2013, at 13:41:45
In reply to Re: Augmenting Bipolar 'Cocktail' with Trodenki XR, posted by LouisianaSportsman on September 28, 2013, at 11:31:15
I am not so sure about my prior idea of BZD/stimulants. I've been learning a lot about different drugs.
There's a plethora of drugs out there I could try-- off-label, in a lot of cases.
Given what you know about my DX and current regimen, what would be some good "unique" drugs that I could add to my cocktail that would be most efficacious?
Buspar?
Trazadone?
Wellbutrin (as mentioned)
Baclofen?
Notriptyline? (known as California Rocket Fuel with Pristiq)
Other TCA's?
Requip?
Amantadine?I just want people to use their intuition to suggest things. Thanks!
Posted by LouisianaSportsman on September 28, 2013, at 13:44:06
In reply to Augmenting Bipolar 'Cocktail' with Trodenki XR, posted by LouisianaSportsman on September 24, 2013, at 20:51:00
What med do you think is best for SNRI sexual dysfunction and combating fatigue? Amantadine looks very interesting as well as Requip and Mirapex.
Posted by SLS on September 28, 2013, at 15:22:57
In reply to One More Thing, posted by LouisianaSportsman on September 28, 2013, at 13:44:06
You ask a lot of great questions! I know that this is not just an academic exercise for you, though. It is interesting that you should ask people for their suggestions base upon their intuition. Psychiatry is still not very strong as an evidence-based field of medicine.
I have espoused the use of topiramate for psychiatric disorders. I have seen it work in bipolar disorder. I felt a bit better on it myself. To avoid cognitive impairments, you might think about using the manufacturer's recommended titration schedule and divide the dosage in half. I like the idea of using an extended release form of topiramate. Intuitively, one would think that it would reduce cognitive side effects by reducing the peak blood level. Intuitive, I know. :-)
I asked you about Pristiq versus Effexor dosage equivalencies because I really don't know the answer. How much Pristiq would you need to take to equal 300 mg/day of Effexor?
- Scott
Posted by phidippus on October 1, 2013, at 8:57:15
In reply to Augmenting Bipolar 'Cocktail' with Trodenki XR, posted by LouisianaSportsman on September 24, 2013, at 20:51:00
> Current Psychiatric "Cocktail":
>
> Abilify (aripiprazole)10mg.
> Concerta (methylphenidate ER) 54mg
> Lamictal (lamotrigine) 200mg.
> Lyrica (pregabalin) #60 150mg. [300mg.]
> Pristiq (desvenlafaxine) 50mg.All good, but Lyrica may be overkill. Not sure you should be on Pristiq. That dose of Lamictal is on the low side.
> I would like to discontinue the Lyrica (pregabalin) in place of Trodenki XR (topiramate XR) which unlike Lyrica, is non-scheduled and not abusable.
What are you going to be taking the Topomax for? Anxiety?
>topiramate is an anti-convulsant but it works primarily on sodium channels whereas Lyrica acts exclusively on calcium channels.
Do you know what this means down the line?
>topiramate extended-release capsules would be a great adjunct to my Lamictal.
How so? As a mood stabilizer? Topiramate is fairly useless as a mood stabilizer. I would just go up on the Lamictal, or add something useful, like Trileptal.
>If side effects are too much, I can drop down to 100mg.
It ain't called dopamax for nothing. 100mg will be useless. Most meaningful studies start dosing at 300 mg.
>they will give less side effects since the dose is released over time instead of all at once
Looks good on paper, but in reality, you're going to get side effects at any relevant dose.
>Is there any advantage of using a controlled-release formulation of topiramate over the instant release?
Not having to take it many times a day?
> I am, of course, looking for weight loss of >aripiprazole/pregabalin weight; hownever, that is ot the only intended goal at all.Weight loss is something you need to address therapeutically. ACT comes to mind...
>I have been having mood swings not treated with >the lamotrigine.
Because you're dose is too low.
>I believe augmentation of lamotrigine with a >target dose of 200mg. topiramate
No, not really. Try something with a little better evidence supporting its efficacy, like Carbamazapine.
>Topiramate has been shown to help with anxiety >and bipolar depression of which I am suffering >and, like pregabalin, it antagonizes glutamate.
>I am hoping it will make my mood more stable due to its powerful mood stabilizing mechanism of action.
Powerful? Topiramate is like, 4th line treatment for bipolar disorder. Here's a list of mood stabilizers with proven track records:
Depakote, Trileptal, Carbamazapine, Lithium, Lamictal...Topiramate (Topamax) is not FDA approved for bipolar disorder, either; and a 2006 Cochrane review concluded that there is insufficient evidence on which to base any recommendations regarding the use of topiramate in any phase of bipolar illness.
>It should also fatigue the ability of aripiprazoles weight-gaining mechanism.
Mechanism? If it were only that easy.
>With these reasons in mind, I believe it is the most important medicine to negotiate with at the present time.
Yet, you just overlook...look there...There...Just up your dose of lamictal instead of adding a side-effect conducive medication which has no meaningful data supporting it as a mood stabilizer.
>I am still having depressive episodes on the 50mg.
Of course you are. That dose is as useful as the dopamax. Its not so easy treating bipolar depression. Its better to rely on AAPs and other novel treatments. Have you tried Riluzole? More data exists supporting its efficacy as a mood stabilizer than Dopemax.
>dosage. Also, this dosage is where it starts to effect NE and even DA more potently and acts more as a true SNRI than simply a souped-up SSRI.
Pristiq's effects on dopamine are negligible. The jusry is still out when it comes to norepenephrine and its role on depression.
>I believe that I would benefit from the substitution of Nuvigil (armodafinil) at #60 150mg. BID QAM QPM in replacement of Concerta 54mg.
NUVIGIL IS NOT A TREATMENT FOR ADHD. Really, only stimulants are the only way to treat ADHD effectively. Maybe you have a little depression masquerading as ADHD.
>booster dose is my recommendation. Because aripiprazole has such a high D2 occupancy rate (85% at 10mg.), it drastically reduces the effects of ADHD stimulant drugs such as methylphenidate ER
It doesn't quite work that way. Research on receptor subtypes has shown that the therapeutic effects of stimulants are strongest at D1 receptors. Stimulants are widely considered the first-line treatment recommendation for ADHD because of their high reported success rate. However, atypical antipsychotics have been shown to treat ADHD symptoms. Specifically, risperidone was shown to improve attention and hyperactivity,26 and aripiprazole has been shown to improve cognitive functioning. Basic Dopamine Theory suggests that stimulants and antipsychotics have activity at most DA receptor-subtypes and in most DA pathways. Basic science confirms this. Complex Dopamine Theory suggests possible new insights into mechanisms of action, but further research is needed. Studies on clinical risks and benefits of concurrent use appear promising but often show conflicting data, and significant kinetic side effects have been described. Most physicians are not concerned, but it can be dangerous to ignore potential receptor interactions. Physicians considering the concurrent use of stimulants and antipsychotics should appreciate the following guiding points:
Concurrent use of stimulants and antipsychotics should be accompanied with hesitation and caution because of both theoretical and empirical concerns.
When using a stimulant and a comorbid disorder indicates an antipsychotic, or vice versa, a trial with a non-DA-medication should be initiated first.
Treating side effects of a stimulant with an antipsychotic, or vice versa, may mask symptoms temporarily while worsening the underlying chemical imbalance over the long term.
If using stimulants and antipsychotics concurrently, special caution should be made to taper either class of medication slowly when the other class is being used or when switching from one class to another.
Stimulant-antipsychotic syndrome should be suspected when adverse reactions are seen in the setting of concurrent use, especially following a medication change.
When using stimulants and antipsychotics concurrently, all side effects should be viewed as the product of the interactions of both medications together at their respective doses.
Complex Dopamine Theory suggests that concurrent stimulant-antipsychotic use at low doses may decrease the risk of tolerance and side effects.
Most clinical research on concurrent stimulant-antipsychotic use has been done to assess safety and efficacy despite potential interactions. Studies assessing benefits from their interactions are lacking.
Guidelines for absolute or relative dosing of concurrent stimulant-antipsychotic regimens cannot currently be formulated because of lack of data.
Despite the appropriateness of conservatism with concurrent use, clinical data from aggressive prescribers will be educational.
>Nuvigil, with its unique mechanism of action, >compliments the Abilify better, IMO.How so? The exact mechanism of action is unknown.
>Also, I believe the armodafinil may help with possible side effects of cognitive dulling arising from the use of topiramate.
Not likely. You know what else helps witht cognitive dulling of Topamax? Not taking it.
> New Suggestion for next visit:
>
> Abilify 10mg.Good for mood and keeping your head straight. This can also be increased to improve mood.
> Lamictal 200mg.
A higher dose will improve your mood.
> * Nuvigil #60 150mg. [300mg.] substituted for Concerta 54mg.
Nuvigil is not a subsitute for Concerta.
> * Pristiq 100mg. increase from Pristiq 50mg.
I'd replace this with Rilutek, which shows to be very effective at treating bipolar depression.
> * Trodenki XR #60 50mg. [100mg. target] substituted for Lyrica which was indicated off-label primarily for bipolar depression and anxiety
Useless for bipolar disorder - great indications for anxiety, however.
> Mirapex (pramipexole)
Mood? Has been studied as a treatment for bipolar depression.
> Namenda (memantine)
May confer some mood benefits.
>Gabatril (baclofen)
Useless.
Here are my suggestions:
Abilify 20 mg
Lamotrogine 400 mg
Switch from Concerta to Vyvanse - dex confers mood benefits and helps with anxiety.
How about Wellbutrin instead of Pristiq-much better indications for bipolar depression.
Add Rilutek for depression.Eric
Posted by LouisianaSportsman on October 1, 2013, at 12:50:27
In reply to Re: Augmenting Bipolar 'Cocktail' with Trodenki XR » LouisianaSportsman, posted by phidippus on October 1, 2013, at 8:57:15
Eric, your response was amazing! I really appreciate it. This is *EXACTLY* what I've been looking for. I sincerely thank you giving up your time to make this response.
> All good, but Lyrica may be overkill. Not sure you should be on Pristiq. That dose of Lamictal is on the low side.
>I do want to go up on the Lamictal, absolutely. I think I will go ahead and aim for 400mg., as you suggested. Pristiq was added to help out my "lows", but maybe more Lamictal will make the Pristiq useless. I was already on Wellbutrin in the form of Aplenzin (a different bupropion salt) at 522mg. But, I switched pdocs and she took me off of it saying that it increases anxiety.
> What are you going to be taking the Topomax for? Anxiety?
>WEIGHT-LOSS!! Abilify is causing severe weight loss.
> >topiramate extended-release capsules would be a great adjunct to my Lamictal.
How so? As a mood stabilizer? Topiramate is fairly useless as a mood stabilizer. I would just go up on the Lamictal, or add something useful, like Trileptal.
>I understand Trileptal is a better mood stabilizer, but I was wanting to add Topamax for its weight loss properties.
> It ain't called dopamax for nothing. 100mg will be useless. Most meaningful studies start dosing at 300 mg. [time-release] looks good on paper, but in reality, you're going to get side effects at any relevant dose.
>Thanks for the advice about the time-release. I still think I will go for the time-release knowing full well I will get the side effects.
> Weight loss is something you need to address therapeutically. ACT comes to mind...
>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.
>
> Because you're dose is too low. [Lamictal]
>I agree. It is too low.
> No, not really. Try something with a little better evidence supporting its efficacy, like Carbamazapine.
>Good suggestion as an adjunct mood stabilizer.
> Powerful? Topiramate is like, 4th line treatment for bipolar disorder. Here's a list of mood stabilizers with proven track records:
Depakote, Trileptal, Carbamazapine, Lithium, Lamictal...Topiramate (Topamax) is not FDA approved for bipolar disorder, either; and a 2006 Cochrane review concluded that there is insufficient evidence on which to base any recommendations regarding the use of topiramate in any phase of bipolar illness.
>I agree that Topamax is not the best mood stabilizer.
> Yet, you just overlook...look there...There...Just up your dose of lamictal instead of adding a side-effect conducive medication which has no meaningful data supporting it as a mood stabilizer.
>Yes, but didn't you see me wanting to lose weight?
> Of course you are. That dose is as useful as the dopamax. Its not so easy treating bipolar depression. Its better to rely on AAPs and other novel treatments. Have you tried Riluzole? More data exists supporting its efficacy as a mood stabilizer than Dopemax.
>I am definitely going on Pristiq 100mg. I actually have been taking that since I have an extra pill bottle from a source. It is actually kind of helping, I think. I feel more energy, but it might be the Nuvigil, of course. Most likely is.
> Pristiq's effects on dopamine are negligible. The jusry is still out when it comes to norepenephrine and its role on depression.
>I understand that; however, I do want the NE action as possibly treating my symptoms better.
> NUVIGIL IS NOT A TREATMENT FOR ADHD. Really, only stimulants are the only way to treat ADHD effectively. Maybe you have a little depression masquerading as ADHD.
>I might have depression masquerading as ADHD, but I assure you, as a college student, I have genuine ADHD and the Nuvigil is doing wonders at keeping awake during clas. It is not a substitute for a stimulant which is why I'm thinking about augmenting with Vyvanse-- not Topamax due to your great suggestions!
> It doesn't quite work that way. Research on receptor subtypes has shown that the therapeutic effects of stimulants are strongest at D1 receptors. Stimulants are widely considered the first-line treatment recommendation for ADHD because of their high reported success rate. However, atypical antipsychotics have been shown to treat ADHD symptoms. Specifically, risperidone was shown to improve attention and hyperactivity,26 and aripiprazole has been shown to improve cognitive functioning. Basic Dopamine Theory suggests that stimulants and antipsychotics have activity at most DA receptor-subtypes and in most DA pathways. Basic science confirms this. Complex Dopamine Theory suggests possible new insights into mechanisms of action, but further research is needed. Studies on clinical risks and benefits of concurrent use appear promising but often show conflicting data, and significant kinetic side effects have been described. Most physicians are not concerned, but it can be dangerous to ignore potential receptor interactions. Physicians considering the concurrent use of stimulants and antipsychotics should appreciate the following guiding points:
>Concurrent use of stimulants and antipsychotics should be accompanied with hesitation and caution because of both theoretical and empirical concerns. When using a stimulant and a comorbid disorder indicates an antipsychotic, or vice versa, a trial with a non-DA-medication should be initiated first. (... explanation on dopamine theory)I have tried non-DA medication with no success. I think I will be fine with a stimulant medication in conjunction with my Abilify. Very, very informative on dopamine theory. One of the best pieces of information I've read in a long time. Thank you!
> How so? The exact mechanism of action is unknown.
>I believe it increases histamine, oxerin, and dopamine to some extent, but you're right-- it's still a mystery.
> Not likely. You know what else helps witht cognitive dulling of Topamax? Not taking it.
>You're right. I might not need the Topamax is my doctor puts me back on Vyvanse 60mg.
Abilify 10mg.
>
> Good for mood and keeping your head straight. This can also be increased to improve mood.
>So it is good to increase it since it does improve my mood? I notice you suggest 20. What about 15?
> > Lamictal 200mg.
>
> A higher dose will improve your mood.
>I will definitely move to a higher dosage.
> > * Nuvigil #60 150mg. [300mg.] substituted for Concerta 54mg.
>
> Nuvigil is not a subsitute for Concerta.It is not, but it does help with my fatigue. And, it has helped my stay awake in class. I actually prefer to Concerta for ADHD. I swear. But, not Vyvanse, per se. I switched to Concerta because I wanted to try something different, and it worked OK.
> > * Pristiq 100mg. increase from Pristiq 50mg.
>
> I'd replace this with Rilutek, which shows to be very effective at treating bipolar depression.
>I will definitely look into it seriously since I trust your advice.
> [topiramate] Useless for bipolar disorder - great indications for anxiety, however.
>I need the anxiety relief and weight loss which is why I still think the topiramate is beneficial, and I may stay with Nuvigil for my ADHD since it sincerely helps with that. I might be a special case when it comes to this.
> > Mirapex (pramipexole)
>
> Mood? Has been studied as a treatment for bipolar depression.
>I will consider it also for some slight sexual dysfunction from Pristiq as well as for mood.
> > Namenda (memantine)
>
> May confer some mood benefits.
>I was also hoping for cognitive benefits as well?
> >Gabatril (baclofen)
>
> Useless.
>Good to know.
> Here are my suggestions:
>
> Abilify 20 mg
> Lamotrogine 400 mg
> Switch from Concerta to Vyvanse - dex confers mood benefits and helps with anxiety.
> How about Wellbutrin instead of Pristiq-much better indications for bipolar depression.
> Add Rilutek for depression.Thanks so much for your suggestions. I'm not sure if you read my recap. Here's what I'm on now:
Abilify (aripiprazole)10mg.
Nuvigil (armodafinil) 250mg.
Lamictal (lamotrigine) 200mg.
Neurontin (gabapentin) 1,800mg. [400mg. QID]
Pristiq (desvenlafaxine) 50mg.I'm thinking, based on your advice:
I will stick with this, notice the increase in Abilify, Lamictal and Pristiq:
Abilify (aripiprazole)20mg.
Nuvigil (armodafinil) 300mg.(150mg.x 2)
Lamictal (lamotrigine) 400mg.
Neurontin (gabapentin) 1,800mg. [400mg. QID]
Pristiq (desvenlafaxine) 100mg.I don't think the gabapentin is overkill. It is my primary anti-anxiety med. I found it more effective than my previous clonazepam 0.5mg. TID
I want to add, based on your suggestions:
Aplenzin 522mg. again. I think the Pristiq is minorly effective now, and I'd like to augment with the Wellbutrin in the form of Aplenzin.
Vyvanse 60mg. in conjuction with the Nuvigil.
Augment with Riluzole. This is the exact sort of medication advice I was thinking of! What dosage?
I still want to augment with topiramate for weight-loss and anxiety relief, however. I did not experience cognitive swelling with gabapentin/pregabalin so I'm hoping I can avoid that. I still want to shoot for 200mg. since I'm already taking Lamictal, and I want it to be an add-on.
Therefore, in conclusion, I'm aiming for:
Abilify (aripiprazole)20mg.
Nuvigil (armodafinil) 300mg.(150mg.x 2)
Vyvanse (lisdextroamphetamine) 60mg.
Lamictal (lamotrigine) 400mg.
Neurontin (gabapentin) 1,800mg. [400mg. QID]
Pristiq (desvenlafaxine) 100mg.
Bupropion XL 450mg. (522mg. Aplenzin)
Trodenki XL 200mg.
Mirapex ER 2mg.
Memantine 20mg.
Riluzole 150mg.My pdoc told me she allows a maximum of ten medications and has no problem prescribing that many, if needed. ^^^ the regimen above will be a slow process to reach and may not be needed if symptoms improve. Which should I add first?
I don't expect this to happen all at once, perhaps in a month or two. I've been seeing the pdoc once weekly so I can make faster changes to see results faster. I really want the topiramate for weight loss and anxiety.
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. 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
Please share further thoughts, Eric. Your post was beyond informative and useful to me. I really, really look forward to your response. I know the above regimen is overkill as well.
Thanks!!
------------
To SLS, 50mg. Pristiq = 300mg. venlafaxine. And, I appreciate your comment, it was a good one!
Posted by LouisianaSportsman on October 1, 2013, at 12:55:08
In reply to Re: Augmenting Bipolar 'Cocktail' with Trodenki XR, posted by LouisianaSportsman on October 1, 2013, at 12:50:27
To be honest, I want to keep these, Eric.
Abilify (aripiprazole) 20mg.
Nuvigil (armodafinil) 300mg.(150mg.x 2)
Vyvanse (lisdextroamphetamine) 60mg.
Lamictal (lamotrigine) 400mg.
Neurontin (gabapentin) 1,800mg. [400mg. QID]So, should I augment with riluzole and add Vyvanse 60 and call it a day? Maybe augment with something else?
I believe the pdoc will only add two or one more medications this Friday. I'm thinking about asking for dosage increases and the addition of one med since that's all she'll likely allow. I really want to add the topiramate next since that's what we already discussed and I need to lose weight. But, what do you think I should add first? Anybody? (Eric)
Posted by LouisianaSportsman on October 1, 2013, at 13:49:53
In reply to Re: Augmenting Bipolar 'Cocktail' with Trodenki XR » LouisianaSportsman, posted by phidippus on October 1, 2013, at 8:57:15
Eric, do you have any studies or anecdotal/personal experience with Rilutek that I could share with my pdoc? She's very, very open about prescribing what I suggest as long as I have sources to back it up.
I've never heard of it! Which is rare. Looks super interesting.
Could you explain its pharmacology?
What are some other medicines you'd suggest like this?
Thanks!
Posted by LouisianaSportsman on October 1, 2013, at 14:08:13
In reply to Re: Augmenting Bipolar 'Cocktail' with Trodenki XR, posted by LouisianaSportsman on October 1, 2013, at 12:55:08
I am considering transferring from Pristiq to Savella. I have not been on Pristiq long enough for their to be severe discontinuation symptoms. I've read a lot of good things about Savella, and I feel like I need NE. Thoughts?
Posted by phidippus on October 1, 2013, at 14:19:21
In reply to Re: Augmenting Bipolar 'Cocktail' with Trodenki XR, posted by LouisianaSportsman on October 1, 2013, at 12:55:08
>So, should I augment with riluzole and add Vyvanse 60 and call it a day?
I definitely would recommend Rilutek-it has helped me with both mood and anxiety. (DX: BP, OCD and ADHD).
I think you'll find adding Vyvanse beneficial. I take it alongside Invega and do not experience any diminishment in efficacy. Augmenting the Vyvanse with Nuvigil will improve mental alertness, though I don't believe basic executive function will be enhanced.
>Maybe augment with something else?
Depends on what you want to achieve.
>I really want to add the topiramate next since >that's what we already discussed and I need to >lose weight.
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.
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.
Also...About the Neurontin. I would take Lyrica instead. I found it a better mood stabilizer than Topamax.
Here's my cocktail: Lithium 1200, Vyvanse 70, Invega 12, Rilutek 100, Viibryd 60
Eric
Posted by phidippus on October 1, 2013, at 14:24:16
In reply to Re: Augmenting Bipolar 'Cocktail' with Trodenki XR, posted by LouisianaSportsman on October 1, 2013, at 13:49:53
Read:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2587133/
Other medications like Riluzole would be Tramadol, Memantine and Ketamine.
Eric
ps. I take Rilutek for both mood and anxiety and it works really well.
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
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