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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 5 to 29 of 30. Go back in thread:
Posted by Jack Smith on May 22, 2003, at 15:57:26
In reply to Drug that could change my life...if I can get it, posted by Snoozy on May 22, 2003, at 12:39:25
> I'm thinking of calling my pdoc and telling him about this find. I could also try my cardiologist, but that would probably take a while to get in, and I don't have much time to wait.
I would definitely call your pdoc, explain the situation, explain that you have no history of drug abuse (everything you noted in that other email) and say that if he wants to, just give you enough for a few weeks. I think that is more than reasonable. If that fails, you should start thinking about a new pdoc but that won't help you with your immediate concerns. I would consider going to a GP--I have found most GP's to be very open to prescribing meds when you explain the whole situation. They do not get all offended like PDocs do that you would dare question their grand authority.
Hope it works out,
JACK
Posted by stjames on May 22, 2003, at 17:01:26
In reply to Re: Drug that could change my life...if I can get » Snoozy, posted by Jack Smith on May 22, 2003, at 15:57:26
I would consider going to a GP--I have found most GP's to be very open to prescribing meds when you explain the whole situation. They do not get all offended like PDocs do that you would dare question their grand authority.
>
> Hope it works out,
>
> JACKGP's tend to not like to prescribe stims. Mine will in a pinch but made it clear the DEA does not like to see Schedule II meds prescribed by generalists.
Posted by Snoozy on May 22, 2003, at 17:27:43
In reply to Re: Drug that could change my life...if I can get, posted by stjames on May 22, 2003, at 17:01:26
I did call my pdoc, explained I've got this big thing going on, that I've found Ritalin can help with not just sleepiness but my bp, can I just try it for a few weeks. No.
My GP has been seeing me for over 10 years, and I asked him about Ritalin several years ago, and he didn't want to prescribe it, but my pdocs at the time did.
My cardiologist actually had an opening next Thursday, but he's only seen me for a year or two, so I'm concerned he won't want to prescribe it either.
I have this terrible sense that I'll just get caught in buck-passing, one doctor saying see the other doctor, etc, etc. I'm honestly despairing at this point. If there was any way to get out of this committment, I would have to do it.
Thanks.
> I would consider going to a GP--I have found most GP's to be very open to prescribing meds when you explain the whole situation. They do not get all offended like PDocs do that you would dare question their grand authority.
> >
> > Hope it works out,
> >
> > JACK
>
> GP's tend to not like to prescribe stims. Mine will in a pinch but made it clear the DEA does not like to see Schedule II meds prescribed by generalists.
>
>
Posted by Larry Hoover on May 22, 2003, at 17:51:12
In reply to Re: more details » Larry Hoover, posted by Snoozy on May 22, 2003, at 15:26:28
> I wanted to add that I have not had problems with drug abuse/addiction. I haven't increased my Xanax, ever. I was taking Darvocet (for headaches), and I stopped taking it on my own. There were other opiates I was prescribed years ago for migraine, and I never abused those either. Also I don't drink.
>
> My 2 previous psychiatrists did prescribe Ritalin for me, and I never abused it. Thought those might be important details.There is a structural similarity between amphetamine and ephedrine/pseudoephedrine. I won't bore you with the chemistry, but Ritalin (methylphenidate) is metabolized to amphetamine. I don't know about how available ephedrine is, where you are, but I'm sure you can get pseudoephedrine (Sudafed is one brand). Walmart has it as a generic (cheaper). All four of the positional isomers (d-amphetamine, l-amphetamine, ephedrine, pseudoephedrine) raise blood pressure and heart rate. You don't have to see a doctor to try the latter.
I'd seldom recommend self-medication, especially given that I don't know the details of your medical history, but the fact that you've previously used Ritalin without negative outcomes suggest that the others ought to be safe. Why don't ask your doctor about these OTC compounds?
Lar
Posted by stjames on May 22, 2003, at 18:24:08
In reply to Re: Strike one (Jack/stjames), posted by Snoozy on May 22, 2003, at 17:27:43
You seem to have a contest going with me, and I do not wish to be part of it.
Posted by stjames on May 22, 2003, at 19:42:37
In reply to Re: more details, posted by Larry Hoover on May 22, 2003, at 17:51:12
> There is a structural similarity between amphetamine and ephedrine/pseudoephedrine. I won't bore you with the chemistry, but Ritalin (methylphenidate) is metabolized to amphetamine.Seems to me I remember one of the MAOI's is
metabolized to an amphetamine
Posted by Jack Smith on May 22, 2003, at 20:03:03
In reply to Re: Strike one (Jack/stjames), posted by stjames on May 22, 2003, at 18:24:08
> You seem to have a contest going with me, and I do not wish to be part of it.
If you are referring to me, I think you ought to reread those posts, I didn't write anything regarding you, you responded to me.
JACK
Posted by Snoozy on May 22, 2003, at 20:50:56
In reply to Re: Strike one (Jack/stjames), posted by stjames on May 22, 2003, at 18:24:08
Hi stjames -
I'm sorry if you thought I was trying to make this a contest, I certainly did not intend anything like that. I really value and appreciate all of the responses I receive.
I don't know much about baseball, other than 3 strikes and you're out, and the expression just came to me. I was thinking of the fact that I have 3 doctors to ask, and one of them said no. I put your name and Jack's on the subject line, as I felt I was responding to the posts from both of you.
I was very upset when I did that post, and perhaps I wasn't thinking it through clearly enough. I apologize if you thought I was trying to have a contest.
> You seem to have a contest going with me, and I do not wish to be part of it.
Posted by Larry Hoover on May 22, 2003, at 20:51:47
In reply to Re: more details, posted by stjames on May 22, 2003, at 19:42:37
>
> > There is a structural similarity between amphetamine and ephedrine/pseudoephedrine. I won't bore you with the chemistry, but Ritalin (methylphenidate) is metabolized to amphetamine.
>
> Seems to me I remember one of the MAOI's is
> metabolized to an amphetamineOoops. My bad. Methylphenidate does not metabolize to amphetamine. It is nearly completely de-esterified to ritalinic acid, which is excreted in urine.
There is an MAOI that metabolizes to amphetamine, and amphetamine is an MAOI.
Thanks for catching my mistake.
Lar
Posted by Snoozy on May 22, 2003, at 21:07:13
In reply to Re: more details, posted by Larry Hoover on May 22, 2003, at 17:51:12
Actually, I did start using Sudafed (just one or two) a few days ago. It helps some with the sleepiness. Interestingly, I get an increased appetite from any kind of stimulant, which I actually appreciate. I seem to have no desire to eat, especially in hot weather. It certainly doesn't help to feel good if I'm not eating right.
Thanks.
> There is a structural similarity between amphetamine and ephedrine/pseudoephedrine. I won't bore you with the chemistry, but Ritalin (methylphenidate) is metabolized to amphetamine. I don't know about how available ephedrine is, where you are, but I'm sure you can get pseudoephedrine (Sudafed is one brand). Walmart has it as a generic (cheaper). All four of the positional isomers (d-amphetamine, l-amphetamine, ephedrine, pseudoephedrine) raise blood pressure and heart rate. You don't have to see a doctor to try the latter.
>
> I'd seldom recommend self-medication, especially given that I don't know the details of your medical history, but the fact that you've previously used Ritalin without negative outcomes suggest that the others ought to be safe. Why don't ask your doctor about these OTC compounds?
>
> Lar
Posted by Ritch on May 22, 2003, at 22:28:56
In reply to Drug that could change my life...if I can get it, posted by Snoozy on May 22, 2003, at 12:39:25
> In addition to the extreme sleepiness and depression, I also have a low blood pressure condition - basically, if I have to stand without moving, within a few minutes my bp drops and I get very sick, woozy and faint. I haven't actually passed out, but that does happen with this condition. I've tried several medications for this, and either they didn't work or the side effects were too bad. I've also tried many non-drug treatments.
>
> It may not sound bad, but I have to avoid situations where there's a possibility I would have to stand for more than 5 minutes. I pretty much never shop, and when I have to it's miserable. It restricts my life considerably.
>
> This morning I was doing some research, thinking of trying one of these drugs again - I'm so desperate. And I find that stimulants (Ritalin and Dexedrine) are used as treatments. Not just end-of-the-line, everything else under the sun has been tried and failed treatments, but primary treatment.
>
> I had asked my pdoc if I could try Ritalin, for the sleepiness, and he didn't want to prescribe it. (My 2 previous pdocs had given it to me, for fatigue, several years earlier).
>
> The thing is that I'm committed to this huge project for the next 5-6 weeks, and I can't get out of it. I've been in tears wondering how I'm going to get through this given the way I feel.
>
> I'm thinking of calling my pdoc and telling him about this find. I could also try my cardiologist, but that would probably take a while to get in, and I don't have much time to wait.
>
> If I could feel awake, and be able to stand on my own two feet (literally) for more than 5 minutes, life would be so much better.
>
> Does anyone have any thoughts? Thanks.
Get a blood pressure machine. Take a reading when you first get up in the morning and chart your BP and HR (in the same way) every hour all day long eating/drinking coffee/whatever. Next to the readings write down ANY medications you take and at what dosage. Do a diary. See if your BP/HR taken sitting at a table in the proper position is different from a reading standing up (have somebody hold the machine if necessary). This is the kind of thing that happens when you go to the ER with a stomach flu and have postural hypotension (dehydration). Look to see if your heart rate increases substantially when you stand up for awhile (in association with the BP drop). IF so, you are having postural hypotension troubles for some reason. This is way out there, but if you can't get stims for this-you might want to consider other meds that can boost BP and help depression like Effexor.
Posted by Caleb462 on May 22, 2003, at 22:45:24
In reply to Re: more details » stjames, posted by Larry Hoover on May 22, 2003, at 20:51:47
> >
> > > There is a structural similarity between amphetamine and ephedrine/pseudoephedrine. I won't bore you with the chemistry, but Ritalin (methylphenidate) is metabolized to amphetamine.
> >
> > Seems to me I remember one of the MAOI's is
> > metabolized to an amphetamine
>
> Ooops. My bad. Methylphenidate does not metabolize to amphetamine. It is nearly completely de-esterified to ritalinic acid, which is excreted in urine.
>
> There is an MAOI that metabolizes to amphetamine, and amphetamine is an MAOI.
>
> Thanks for catching my mistake.
>
> Lar
>
>It has been suggested that tranylcypromine (Parnate) metabolizes into methamphetamine, but this has been proved false. It is structurally related to amphetamine though.
Amphetamine is an MAOI? I would assume a very weak one then?
Posted by Snoozy on May 22, 2003, at 23:05:09
In reply to Re: Drug that could change my life...if I can get it » Snoozy, posted by Ritch on May 22, 2003, at 22:28:56
I do have one of those wrist cuff bp machines. I tried to chart it a few months ago, but was just so discouraged, I guess, that I didn't really do a good job.
I was able to get an appt with my cardiologist next week, so this diary would be a great thing to have. I'll start tonight and try to be disciplined about it! Thanks so much for the suggestion.
>
> Get a blood pressure machine. Take a reading when you first get up in the morning and chart your BP and HR (in the same way) every hour all day long eating/drinking coffee/whatever. Next to the readings write down ANY medications you take and at what dosage. Do a diary. See if your BP/HR taken sitting at a table in the proper position is different from a reading standing up (have somebody hold the machine if necessary). This is the kind of thing that happens when you go to the ER with a stomach flu and have postural hypotension (dehydration). Look to see if your heart rate increases substantially when you stand up for awhile (in association with the BP drop). IF so, you are having postural hypotension troubles for some reason. This is way out there, but if you can't get stims for this-you might want to consider other meds that can boost BP and help depression like Effexor.
Posted by stjames on May 23, 2003, at 0:39:22
In reply to Re: more details, posted by Caleb462 on May 22, 2003, at 22:45:24
> Amphetamine is an MAOI? I would assume a very weak one then?
Yep. Not sure of strength, relative to the
the better known MAOI's.Honestly, I would never see a pdoc if they would not prescribe stims, as I have taken them for years. If I have to switch I call first and ask
"Does the doc prescribe Dex, or other stims", so I have not ever had problems getting them. That plus well documented need and sucessful treatment
for years.
Posted by Caleb462 on May 23, 2003, at 2:23:43
In reply to Re: more details, posted by stjames on May 23, 2003, at 0:39:22
> > Amphetamine is an MAOI? I would assume a very weak one then?
>
> Yep. Not sure of strength, relative to the
> the better known MAOI's.
>Well... I just assume amphetamine's MAOI action is relatively weak, or otherwise it's cathecolamine-releasing action + MAOI action could easily create a hypertensive reaction.
Posted by Larry Hoover on May 23, 2003, at 7:26:11
In reply to Re: more details, posted by Caleb462 on May 22, 2003, at 22:45:24
> Amphetamine is an MAOI? I would assume a very weak one then?
It is a reversible inhibitor, meaning it doesn't disable the enzyme. It inhibits MAO only while there is a (relatively) significant concentration of amphetamine in the brain.
Actually, there are many inhibitors of MAO, some of which are quite common. Few, however, have a lasting impact.
Lar
Posted by Ritch on May 23, 2003, at 9:39:37
In reply to Re: great idea, thanks » Ritch, posted by Snoozy on May 22, 2003, at 23:05:09
Posted by jemma on May 23, 2003, at 12:04:29
In reply to Drug that could change my life...if I can get it, posted by Snoozy on May 22, 2003, at 12:39:25
Have you considered modafinil (brand name provigil or alertec). It's used to treat narcolepsy and has little abuse potential, so your pdoc might be receptive. I take it, and I feel more awake than I've ever felt in my life. Plus it increased my energy and motivation. I find that stimulants are okay, but they wear off and the rebound is hard to take.
- Jemma
Posted by Snoozy on May 23, 2003, at 14:26:45
In reply to Re: Drug that could change my life...if I can get it » Snoozy, posted by jemma on May 23, 2003, at 12:04:29
Thanks, I have tried Provigil. I was on it for about 3 weeks, and it did help with the sleepiness without any major crashing. Unfortunately, my insurance denied coverage and I can't afford to pay for it out-of-pocket (already on the hook for the stuff I did get). I don't know how long it will take to go through the appeals, but based on previous experience, I am not at all encouraged! If I didn't have this big thing going on this month, I could handle the waiting. My pdoc said he would try to get some samples for me.
Thanks for sharing your experience. May I ask what dose you take and how long you've been on it?
> Have you considered modafinil (brand name provigil or alertec). It's used to treat narcolepsy and has little abuse potential, so your pdoc might be receptive. I take it, and I feel more awake than I've ever felt in my life. Plus it increased my energy and motivation. I find that stimulants are okay, but they wear off and the rebound is hard to take.
>
> - Jemma
Posted by medlib on May 23, 2003, at 18:10:53
In reply to Drug that could change my life...if I can get it, posted by Snoozy on May 22, 2003, at 12:39:25
Hi Snoozy--
I'm sorry that the medical community is giving you such a hard time; wish I thought that your experience is at all unusual. If your difficulty in getting Ritalin seems a tad illogical, it may be because 1 or more of your docs don't have licenses to prescribe Schedule II meds. Most GPs don't, and a surprising number of specialists, including pdocs and cardiologists, decline to pony up the extra cost or bother with the triplicate forms hassle if their practices don't include many likely candidates for stims. Often, this state of affairs is presented as "conservative medical judgement", when "conservative" is just a euphemism for "more convenient" or "cheaper".
From what you've described, it does sound like you may be vasovagaling. If that's the case, it's important to determine if, when you stand, your heart rate rises sharply before it drops. As Mitch suggested, take your pulse lying down, sitting and standing. It's a good idea to wait 10+ seconds after changing positions before beginning the count. People with low bp sometimes have some difficulty finding and "holding onto" their pulse long enough to count it. Some of us who've taken a lot of vital signs may be able to offer a tip or 2 on technique, if needed.
A stray factoid escaped from my Swiss cheese memory when I read your posts. I recalled scenes from GI labs and tilt table tests and a drug often prescribed that begins and ends with an "f". When my mental efforts to retrieve the med name produced only more familiar "f" words, like "futile" and f..., I got irritated enough to go look it up--it's Floricef. In the process, I found a web site you may find useful. I admit that I'm a sucker for flow charts (often termed algorithms in medicalese); but, if I were you, I'd print it out and take it to your cardiologist. It will probably irritate him to be presented with it, since it's a four year old article from the American Journal of Cardiology which he's presumably read. But, it *may* convince him that you (and your condition) are too serious to just brush off. If so, you may find that Floricef or midodrine works better than Ritalin (and is easier to obtain).
http://www.aafp.org/afp/20000401/tips/9.html
BTW, when you say you feel "sick", do you possibly mean that you feel slightly nauseated? Do you crave salty snacks? This notion is no doubt worth even less than my usual 2 cents, but have you been checked for adrenal insufficiency? It occurred to me when I noticed "depression, no appetite (under weight?), fatigue, and low bp/orthostatic hypotension" mentioned together.
Being on the receiving end of crummy medical care when you're feeling too crummy to do anything about it is the pits. I wish for you better help and health.---medlib
Posted by Snoozy on May 23, 2003, at 19:20:40
In reply to Re: Drug that could change my life...if I can get it » Snoozy, posted by medlib on May 23, 2003, at 18:10:53
Hi medlib -
I had no idea that a doc needs a license to prescribe Schedule II drugs. I just assumed if you were an M.D. you could prescribe anything, with the DEA watching everything. That's very interesting, and good to know. Part of what's so frustrating now is that I've had Ritalin before, from 2 different pdocs. And those 2 were judicious in their prescribing overall.
I did have a tilt table test some years ago. I didn't pass out, but I did have an abnormal response. I don't remember if the heart rate was abnormal, but I can check it out at home. I tried propranolol, Florninef, and midodrine, and they either didn't work enough or the side effects were too bad. I've also tried non-drug treatments: support hose, drinking extra fluids, increasing salt, sleeping with head elevated.
I do get nauseated when I'm standing and my bp drops. I also get very hot and sweaty. I become nearly oblivious to what's going on around me, my mind is just so intently focused on not passing out. I've always unconsciously done all of the shifting around and sitting positions that they recommend. I can clearly remember many episodes of this in childhood.
I do love pretzels, which I discovered generally have a much larger sodium content than potato chips. And I am underweight (I haven't had a huge weight loss though - I've always been thin. At least I got one socially desirable gene!)
Would the adrenal function be tested by bloodwork? I'm scheduled for a complete physical next month, and I'm supposed to come in for labs a week before. I'm thinking perhaps I should call and make sure they do adrenal testing.
Thanks so much for the info!!
> Hi Snoozy--
>
> I'm sorry that the medical community is giving you such a hard time; wish I thought that your experience is at all unusual. If your difficulty in getting Ritalin seems a tad illogical, it may be because 1 or more of your docs don't have licenses to prescribe Schedule II meds. Most GPs don't, and a surprising number of specialists, including pdocs and cardiologists, decline to pony up the extra cost or bother with the triplicate forms hassle if their practices don't include many likely candidates for stims. Often, this state of affairs is presented as "conservative medical judgement", when "conservative" is just a euphemism for "more convenient" or "cheaper".
>
> From what you've described, it does sound like you may be vasovagaling. If that's the case, it's important to determine if, when you stand, your heart rate rises sharply before it drops. As Mitch suggested, take your pulse lying down, sitting and standing. It's a good idea to wait 10+ seconds after changing positions before beginning the count. People with low bp sometimes have some difficulty finding and "holding onto" their pulse long enough to count it. Some of us who've taken a lot of vital signs may be able to offer a tip or 2 on technique, if needed.
>
> A stray factoid escaped from my Swiss cheese memory when I read your posts. I recalled scenes from GI labs and tilt table tests and a drug often prescribed that begins and ends with an "f". When my mental efforts to retrieve the med name produced only more familiar "f" words, like "futile" and f..., I got irritated enough to go look it up--it's Floricef. In the process, I found a web site you may find useful. I admit that I'm a sucker for flow charts (often termed algorithms in medicalese); but, if I were you, I'd print it out and take it to your cardiologist. It will probably irritate him to be presented with it, since it's a four year old article from the American Journal of Cardiology which he's presumably read. But, it *may* convince him that you (and your condition) are too serious to just brush off. If so, you may find that Floricef or midodrine works better than Ritalin (and is easier to obtain).
>
> http://www.aafp.org/afp/20000401/tips/9.html
>
> BTW, when you say you feel "sick", do you possibly mean that you feel slightly nauseated? Do you crave salty snacks? This notion is no doubt worth even less than my usual 2 cents, but have you been checked for adrenal insufficiency? It occurred to me when I noticed "depression, no appetite (under weight?), fatigue, and low bp/orthostatic hypotension" mentioned together.
>
> Being on the receiving end of crummy medical care when you're feeling too crummy to do anything about it is the pits. I wish for you better help and health.---medlib
>
>
>
>
Posted by medlib on May 23, 2003, at 21:00:27
In reply to Re: thanks!! » medlib, posted by Snoozy on May 23, 2003, at 19:20:40
Hi Snoozy--
I was thinking of Addison's Disease when I saw your sxs; but, if this is a longstanding med problem, that's bound to have been ruled out. Addison's isn't the only adrenal deficiency, but it's the best known because President Kennedy had it. It's a rare autoimmune disorder, and a doc wouldn't order special tests unless your skin pigmentation looks abnormally tanned, your CBC differential came back with eosinophilia or other white cell abnormalities and your blood chemistry showed below normal sodium (Na) and above normal potassium (K) levels.
Put my stray musing down to a current endocrinology fixation; I go in for blood tests next week which will likely reveal my insulin and thyroid glands racing each to extinction.
Good luck!---medlib
Posted by Ritch on May 23, 2003, at 21:00:33
In reply to Re: thanks!! » medlib, posted by Snoozy on May 23, 2003, at 19:20:40
Snoozy, what meds are you taking? It is interesting reading your symptoms of orthostatic hypotension. I used to have MAJOR problems similar to yours when I was on high dose doxepin (TCA). It got to a near emergency situation once when I was taking high-dose doxepin AND some thorazine together AND took one dose of codeine cough syrup (scripted for a bad cold from my GP), and fainted at work. It took about two hours before I could stand up without getting TV snow in my brain.
Posted by Snoozy on May 24, 2003, at 0:04:43
In reply to Meds you are on? » Snoozy, posted by Ritch on May 23, 2003, at 21:00:33
Hi Ritch -
I'm currently taking Synthroid, Wellbutrin (400) and Imitrex. (That's the shortest my daily med list has been since I can't remember when!) I occasionally take Benadryl or Zyretc, and I've been taking Sudafed for a few days to try and stay awake (only slept 12 hours today so far).
I can relate to your problem with the TCA. I was on a couple of them (imimpramine, despiramine and amitriptyline - maybe others that my mind is blocking out!) This was years before I knew that there was something wrong with my blood pressure. You can imagine how truly horrible I felt. I didn't know how on earth it was possible people could take this stuff - I couldn't tolerate even small amounts. I remember one time walking to work, only 4 blocks, and I really thought I was going to die before I got there. Another time I had to drive to the other side of town to pick up a prescription (for a TCA) because I couldn't walk the few blocks to my neighborhood pharmacy. At the same time I was on TCA's, I also took Tylenol w/codeine occasionally for migraine. It's likely I had both at some point, maybe I didn't notice a really bad interaction because I was stuck in bed with the migraine and not moving around at all.
When you fainted, did you or the doctors put it together that it was from the 3 drugs? It seems I figure out all these things years later. Time machine, please :)
> Snoozy, what meds are you taking? It is interesting reading your symptoms of orthostatic hypotension. I used to have MAJOR problems similar to yours when I was on high dose doxepin (TCA). It got to a near emergency situation once when I was taking high-dose doxepin AND some thorazine together AND took one dose of codeine cough syrup (scripted for a bad cold from my GP), and fainted at work. It took about two hours before I could stand up without getting TV snow in my brain.
Posted by Ritch on May 24, 2003, at 11:34:22
In reply to Re: Meds you are on? » Ritch, posted by Snoozy on May 24, 2003, at 0:04:43
> When you fainted, did you or the doctors put it together that it was from the 3 drugs? It seems I figure out all these things years later. Time machine, please :)
I told my pdoc about it later, and found out that on top of the trouble I was already having with the doxepin, Thorazine is used to lower blood pressure, so it was already depressed to start with, adding the codeine interacted in some way with one or both of them dropping it much further causing the spell. I can't remember specifically how it interacted, but I definitely noticed!
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