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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 19 of 19. This is the beginning of the thread.
Posted by tonyz on April 27, 2010, at 14:11:43
I was taking various amounts of seroquel, nortriptyline, fluvoxamine (just recently), lithium, remeron, restoril, and clonazepam since mid January and have been having a tough time.
Current meds are fluvoxamine (50mg), nortriptyline 50mg, Lithium 600mg, seroquel 50mg, restoril and clonazepam as needed which seems to work out to 30mg of restoril and 1-1.5mg of clonazepam. I've had some pretty severe insomnia.
Doc gave me a choice of cymbalta and possibly remeron and benzos for sleep
or
Amitriptyline and clonazepam and restoril as needed.
He wants me to stop the seroquel and fluvoxamine and continue with the Lithium for now. Seroquel had been at 50mg for past 5 days on a taper
I opted for the amitriptyline. It should help with sleep and has worked for me before. The side effects are difficult to deal with, but I don't see it as a permanent solution.
Cymbalta could have been a good choice except for the fact that 11% of the people have problems with insomnia and that is a drug that I have not taken before.
He said just to take the clonazepam and restoril as needed. I'm going to try and cut back on these as the Amitriptyline level builds up. I think the clonazepam is making me fuzzy.
I've been on the clonazepam since February so I know I have somewhat of an addiction now. Doctors always seem to trivialize how easy it is to get off of these drugs.
So I guess my questions are
1) ok to stop the seroquel?
2) Given the length of time on the clonazepam since February - think it's ok to try and taper by 1/8 mg every 3-4 days.
Posted by mellow on April 27, 2010, at 15:21:27
In reply to Opinion on medication change, posted by tonyz on April 27, 2010, at 14:11:43
Maybe an objective perspective will help. I would try and adjust to your new cocktail for a few weeks may 4-6 before you start a full on clonzepam taper. That is a very potent drug and even if you are addicted that's a whole separate bowl of worms that you might not want to mess with right now.
You were taking 6 medications so maybe that was what was making you fuzzy. Getting down to just the Amitriptyline + Lithium + the Clonazepam and Restoril as needed could be a great step toward getting rid of some of the side effects of such a huge cocktail. You'd be cutting out 2 drugs. I'd focus on the seroquel taper (which may be hell for a few days) and push through to start your new cocktail as prescribed. Don't worry about the clonazepam. I you are stable 6 months from now then worry about it.
There have been a couple of times i freaked out and took matters into my own hands when i probably should have stayed on course and just pushed through to some clarity. In most cases its worth it to put up with a few bad days to see if a combo will work. You will never know if you don't do what the doc suggest. That's what you are paying him for after all. Just an opinion.
I bet you will do great with less med. Being on 6 meds just seems like too much! That Amitriptyline will help with sleep for sure.
Best of luck!
mellow
> I was taking various amounts of seroquel, nortriptyline, fluvoxamine (just recently), lithium, remeron, restoril, and clonazepam since mid January and have been having a tough time.
>
> Current meds are fluvoxamine (50mg), nortriptyline 50mg, Lithium 600mg, seroquel 50mg, restoril and clonazepam as needed which seems to work out to 30mg of restoril and 1-1.5mg of clonazepam. I've had some pretty severe insomnia.
>
> Doc gave me a choice of cymbalta and possibly remeron and benzos for sleep
>
> or
>
> Amitriptyline and clonazepam and restoril as needed.
>
> He wants me to stop the seroquel and fluvoxamine and continue with the Lithium for now. Seroquel had been at 50mg for past 5 days on a taper
>
> I opted for the amitriptyline. It should help with sleep and has worked for me before. The side effects are difficult to deal with, but I don't see it as a permanent solution.
>
> Cymbalta could have been a good choice except for the fact that 11% of the people have problems with insomnia and that is a drug that I have not taken before.
>
> He said just to take the clonazepam and restoril as needed. I'm going to try and cut back on these as the Amitriptyline level builds up. I think the clonazepam is making me fuzzy.
>
> I've been on the clonazepam since February so I know I have somewhat of an addiction now. Doctors always seem to trivialize how easy it is to get off of these drugs.
>
> So I guess my questions are
> 1) ok to stop the seroquel?
> 2) Given the length of time on the clonazepam since February - think it's ok to try and taper by 1/8 mg every 3-4 days.
>
>
Posted by tonyz on April 27, 2010, at 16:36:57
In reply to Re: Opinion on medication change, posted by mellow on April 27, 2010, at 15:21:27
Thanks for your comments mellow.
Seroquel had been as high as 400mg and now is at 50mg so the doc said to just stop it. I'm hoping it doesn't create a problem.
Posted by Phillipa on April 27, 2010, at 17:23:07
In reply to Re: Opinion on medication change, posted by tonyz on April 27, 2010, at 16:36:57
What about the fluvoxamine or luvox? Can be taken up to 300mg I once took 250 and worked well till doc took me off for a trial. Phillipa
Posted by bleauberry on April 27, 2010, at 18:35:56
In reply to Opinion on medication change, posted by tonyz on April 27, 2010, at 14:11:43
I can't really offer any suggestions on what to do about the meds. I just wanted to comment that it really gets me heated when doctors do what they have done with you. That is, pile one drug not helping much on top of another on top of another, to the point that it is impossible to know what is doing what or if it is the drugs themselves causing the problems.
I do not see a cohesive high power strategy in this cocktail. It looks to me like someone is "winging it" and doesn't really have a gameplan. I could be wrong. Like I said, I hate to see so many drugs and the person is no better for it. It doesn't speak well for the choice of those particular drugs.
Posted by linkadge on April 27, 2010, at 19:05:37
In reply to Opinion on medication change, posted by tonyz on April 27, 2010, at 14:11:43
what about cymbalata and amitriptyline for sleep?
Linkadge
Posted by tonyz on April 27, 2010, at 20:49:28
In reply to Re: Opinion on medication change, posted by bleauberry on April 27, 2010, at 18:35:56
I agree that less is better.
The side effects are difficult w/ amitriptyline but manageable. The benzos are for sleep until the amitriptyline kicks in - although I hate them. Lithium is a good augmentation strategy. If it were up to me I would ditch the Lithium right away, but I don't want to make too many changes and the doc didn't want me to do that.
I had raised concerns about the fluvoxamine in combination with a tricyclic that drug levels of the tricyclic can be vastly increased.
The reason for introducing fluvoxamine was to get some serotonin action. I have never gotten out of a depressed state w/o a tricyclic.
So with the amitriptyline the number of drugs are getting reduced.
The goal is to get my depression lifted and my sleep cycle stable and then figure out one drug to use for maintenance. It has been 4 torturous months, but hopefully things will start to get better.
I always appreciate your comments, thanks.
Posted by tonyz on April 27, 2010, at 21:01:24
In reply to Re: Opinion on medication change, posted by linkadge on April 27, 2010, at 19:05:37
Cymbalta would be a new drug for me. New stuff always gives me some anxiety, doc gave me a choice a or b. a was amitriptyline w/ benzos for sleep and b was cymbalta and benzos for sleep.
Combination of cymbalta and amitriptyline wasn't given as an option. Not sure why.
Remeron was also suggested as a potential for sleep. Remeron which has worked wonderfully for me in the past does nothing in my current state, and I would have to check on how it interacts with amitriptyline.
So the more sedating the better. Other problem w/ cymbalta is that 11% of people experience insomnia.
5 mg of lexapro was a disaster for me in terms of anxiety and sleep and I believe that has similar statistics. Not to say that the cymbalta would effect me the same way, but at this point in time I need something that will hopefully stabilize me.So that's the reason, I'm sure cymbalta works great for some people, but I can't afford to try something new at this point. I've been through enough of a runaround with drugs.
Posted by tonyz on April 27, 2010, at 21:09:19
In reply to Re: Opinion on medication change » tonyz, posted by Phillipa on April 27, 2010, at 17:23:07
SSRIs don't seem to work well for me. Maybe for maintenance they would be ok, but right now sleep is too much of an issue.
The other issue is how fluvoxamine affects tricyclic drug levels. So it would become problematic as which drug to raise. The original intent was to get some serotonin action which was why the fluvoxamine was added, but it is best to go back to an old standby and just tough out the side effects and then figure out something for maintenance.
I've never gotten well w/o a tricyclic, this way fewer drugs fewer potential interactions.
Once I'm stable hopefully I can take something else.
Posted by Phillipa on April 27, 2010, at 21:24:28
In reply to Re: Opinion on medication change, posted by tonyz on April 27, 2010, at 21:09:19
I see TCA's are your meds. Know that it also raises levels of benzos. Phillipa
Posted by Laney on April 27, 2010, at 23:57:51
In reply to Re: Opinion on medication change » tonyz, posted by Phillipa on April 27, 2010, at 21:24:28
Hi there,
You mentioned not liking the benzos. Why? What do they do to you? I have been taking .5mg once per day of clonazepam for 17 years. Haven't even attempted to go off of it.
Laney
Posted by tonyz on April 28, 2010, at 10:44:33
In reply to Re: Opinion on medication change » tonyz, posted by Phillipa on April 27, 2010, at 21:24:28
Thanks Phillipa, I did not know that.
Posted by tonyz on April 28, 2010, at 10:48:16
In reply to Re: Opinion on medication change, posted by Laney on April 27, 2010, at 23:57:51
Well for me I think they tend to make me a bit fuzzy. They can disrupt sleep architecture a bit, but I suppose everyone reacts differently.
Posted by Phillipa on April 28, 2010, at 20:09:21
In reply to Re: Opinion on medication change, posted by tonyz on April 28, 2010, at 10:44:33
Tony was referring to fluvoxamine and benzos didn't sound clear when reread. Phillipa
Posted by tonyz on April 28, 2010, at 20:21:05
In reply to Re: Opinion on medication change » tonyz, posted by Phillipa on April 28, 2010, at 20:09:21
Phillipa I understand, I had not heard that about TCAs so was surprised. With Luvox it appears to depend on which benzo
Here's an excerpt from a link:
Benzodiazepines: Benzodiazepines metabolized by hepatic oxidation (e.g., alprazolam, midazolam, triazolam elc.) should be used with caution because the clearance of these drugs is likely to be reduced by fluvoxamine. The clearance of benzodiazepines metabolized by glucuronidation (e. g., lorazepam, oxazepam, temazepam) is unlikely to be affected by fluvoxamine.and here's the link if you want to read the whole thing
http://www.flexyx.com/L/Luvox.html
Posted by Phillipa on April 28, 2010, at 22:14:50
In reply to Re: Opinion on medication change, posted by tonyz on April 28, 2010, at 20:21:05
Tony that's so sweet of you thanks. I do know when first on luvox pdoc had me on ativan seems this pdoc doesn't care. I even have 2mg ativan she just prescribed for me. Now idiot me is afraid to switch over. How dumb right?. And will definitely read the link. Thanks again Phillipa
Posted by Phillipa on April 28, 2010, at 22:24:17
In reply to Re: Opinion on medication change, posted by tonyz on April 28, 2010, at 20:21:05
Tony seriously thanks I seriously need to switch to ativan or cut the luvox even the 50mg as will be having surgery and I wonder if effects the general anesthesia as before I didn't want to wake up and kept stopping breathing? What do you suggests? Seriously? When I previously was taken off the 50mg by pdoc and was given 6mg first then 6mg of ativan didn't sleep for two weeks. Phillipa
Posted by tonyz on April 29, 2010, at 11:51:34
In reply to Re: Opinion on medication change, posted by Phillipa on April 28, 2010, at 22:24:17
I'm not in the medical field and have a limited understanding of how these things work. Maybe blueberry can add some comments - he seems to be very up on this stuff.
50mg is a not a very high dosage of luvox. I would talk to the anesthesiologist and ask what he thinks. I don't know if the problem you had before when you had surgery was just something unique to you or a result of the combination of things that you were taking.
For some people a small dose of remeron 7.5mg will help with sleep but may leave you with a hangover feeling the next day.
From what I understand ativan is the most potent or one of the more potent benzos.
From your prior postings it sounds like you really need the luvox, and it also appears that interferes with the anesthesia. Maybe there is a similar drug that they can switch to (similar to Luvox) that wouldn't interfere with anesthesia. I'm not sure if this is possible. Maybe doing a gradual conversion from one drug to the other and use the ativan of some other benzo or remeron to manage anxiety during the switch. (This may not work based on what's below). I think you really need to engage your pdoc and anesthesiologist on this one..
I'm just throwing out some ideas here, I really don't know that much about this. I hope someone with more experience (hint blueberry) would chime in.
When I was on luvox very briefly, from what I was reading it appeared to have more interactions with other drugs, but I was primarily looking at tricyclics.
It does say if you are planning on having surgery/general anesthesia within the next few months to inform your doctor.
Special Medication Alerts!
If you are on anti-depressants, please advise your doctor. Some monoamine oxidase (MAO) inhibitors (also known as MAOI) intensify the effects of the anesthesia, especially general anesthesia. This could be quite dangerous in the operating room if your doctor is unaware of your medication usage. If you advise your doctor, he or she can make adjustments for your anesthesia or at least will watch for the slightest decrease in heart or breathing rate.
These medications are used for the treatment of depression, obsessive-compulsive disorder, eating disorders, essential hypertension, chronic pain syndromes and migraine headaches: Isocarboxazid, Marplan, phenelzine (Nardil, Nardelzine) tranylcypromine (Parnate, Sicoton), Deprenyl, selegiline hydrochloride, 5 HTP, Amitriptyline, Prozac, Wellbutrin, Buropion, Buropion HCL, Fluoxetin, EFFEXOR® XR, etc.
They work by inhibiting nerve transmissions in brain that may cause depression.
It is reported that drug interactions can occur even weeks after discontinued use of an MAOI. Therefore, in patients undergoing general anesthesia, usage is normally banned for several weeks prior to surgery to avoid possible cardiovascular effects. However, it may be more important and more risky to cease the MAOI than to keep taking it. Discuss this with your surgeon and/or anesthesiologist.
Sorry I couldn't be more helpful
Posted by Phillipa on April 29, 2010, at 20:35:08
In reply to Re: Opinion on medication change, posted by tonyz on April 29, 2010, at 11:51:34
Tony your're a sweety pie. I met with the surgical RN today and listed my meds, told of what happened in past, she said day of surgery to discuss with anesthesiologist and told her I wanted the minimal amount. Hate being under. Surgery two weeks away. She said stay with the meds as they are. I do have that bottle of 2mg ativans keep thinking of trying them instead but then it would be 4mg right? I was an RN but never worked in surgery except post op. Phillipa
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