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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 23 of 23. This is the beginning of the thread.
Posted by linkadge on October 19, 2011, at 17:46:36
I don't know what to do. I am completely helpless and hopeless.
I can't get more than about 3 hours of sleep a night. This is with some of the best sleeping medications.
I feel like am going to accidently end up like Michael Jackson.
Posted by Phillipa on October 19, 2011, at 18:01:03
In reply to chronic unremitting insomnia - I can't take it!!!, posted by linkadge on October 19, 2011, at 17:46:36
Link what are you taking for sleep? Did you withdraw from anything too fast? Seriously as once I didn't sleep for two weeks when a doc took a med away from me and added really high dose benzos? Phillipa
Posted by Chairman_MAO on October 19, 2011, at 18:16:44
In reply to chronic unremitting insomnia - I can't take it!!!, posted by linkadge on October 19, 2011, at 17:46:36
> I don't know what to do. I am completely helpless and hopeless.
>Have you ever tried Xyrem (GHB)?
Posted by jono_in_adelaide on October 19, 2011, at 18:46:51
In reply to Re: chronic unremitting insomnia - I can't take it!!! » linkadge, posted by Chairman_MAO on October 19, 2011, at 18:16:44
What are your current meds (sleeping meds and others?)
Posted by rjlockhart04-08 on October 19, 2011, at 19:00:06
In reply to Re: chronic unremitting insomnia - I can't take it!!!, posted by jono_in_adelaide on October 19, 2011, at 18:46:51
Try Seroquel. I know you take lorazepam and I used to take 2mg with Restoril when i was prescibed alot of benzos and sometimes I dindt get to sleep. I had pretty bad insomnia. Seroquel will absolutly knock you out at about 300-400mg. BUT It will have resuidel effects after you wake up. If you have tried all meds for sleep you may have a chance with higher potency benzos. I was going to mention Seconal but usally its not used much anymore due to dangerous sedation it gives.
Posted by jono_in_adelaide on October 19, 2011, at 19:11:58
In reply to Re: chronic unremitting insomnia - I can't take it!!!, posted by rjlockhart04-08 on October 19, 2011, at 19:00:06
My suggestion was going to be a benzo (temazepam of flurazepam 30mg) and a drug that works on the histamine or 5HT2 receptors (doxepin 25mg or Seroquel 50mg) taken together at bedtime.
Posted by Christ_empowered on October 19, 2011, at 19:35:12
In reply to Re: chronic unremitting insomnia - I can't take it!!!, posted by jono_in_adelaide on October 19, 2011, at 19:11:58
I don't know what to suggest; maybe 30mgs temazepam and a low dose of Thorazine?
Your situation sounds terrible. I hope things improve.
Posted by jono_in_adelaide on October 19, 2011, at 19:40:07
In reply to Re: chronic unremitting insomnia - I can't take it!!!, posted by Christ_empowered on October 19, 2011, at 19:35:12
Flurazepam (Dalmane) is approved in doses upto 60mg, and would be well worth a try in the range 30-60mg.
The effect would be enhanced if you took 25mg of doxepin (dirt cheap) or 50mg of Seroquel (quite expensive) along with it.
Are you currently taking any meds known to cause insomnia? (amphetamines, Parnate, Welbutrin etc)
Is there anything physical that keeps you awake (pain, noise, bedroom to warm/cold etc) that could be remidied?
Posted by sigismund on October 19, 2011, at 20:27:08
In reply to chronic unremitting insomnia - I can't take it!!!, posted by linkadge on October 19, 2011, at 17:46:36
How long has it been like this?
Five hours is fine, three is not, for me anyway.
Posted by violette on October 19, 2011, at 21:57:16
In reply to chronic unremitting insomnia - I can't take it!!!, posted by linkadge on October 19, 2011, at 17:46:36
Maybe taking a few extra Xanax or Ativan and sleeping for 14 hours will reset your system for awhile?
Posted by jono_in_adelaide on October 19, 2011, at 22:19:55
In reply to Re: chronic unremitting insomnia - I can't take it!!!, posted by violette on October 19, 2011, at 21:57:16
"Maybe taking a few extra Xanax or Ativan and sleeping for 14 hours will reset your system for awhile?"
Thats probably what Marilyn Monroe thought that last night in 1962
Posted by jono_in_adelaide on October 19, 2011, at 23:17:40
In reply to Re: chronic unremitting insomnia - I can't take it!!!, posted by jono_in_adelaide on October 19, 2011, at 22:19:55
You might want to ask your doctor about a sleep lab study instead of just more, stronger drugs.
Posted by creepy on October 20, 2011, at 2:55:14
In reply to chronic unremitting insomnia - I can't take it!!!, posted by linkadge on October 19, 2011, at 17:46:36
What have you tried for sleep? Have you tried the melatonin agonist hypnotics? Antihistamines? Antipsychotics?
As one person said a sleep study is a good idea.
Posted by SLS on October 20, 2011, at 4:32:53
In reply to chronic unremitting insomnia - I can't take it!!!, posted by linkadge on October 19, 2011, at 17:46:36
> I don't know what to do. I am completely helpless and hopeless.
>
> I can't get more than about 3 hours of sleep a night. This is with some of the best sleeping medications.
>
> I feel like am going to accidently end up like Michael Jackson.
How much trouble do you have falling asleep (initiation)?
How much trouble do you have staying asleep (maintenance)?When do you fall asleep?
When do you awaken?How are your levels of depression and anxiety upon awakening?
Out of curiosity, how does one night's total sleep deprivation affect you the next day? Do receive an antidepressant effect? Do you sleep well the following night?
My sleep is pretty screwed up because I allow myself to fall asleep at 7:30 and awake three hours later, only to sleep sporadically for the remainder of the night. I can't seem to get past the overwhelming sleepiness that hits me at that time. When I do manage to remain awake until 10:00pm and promptly go to sleep, I do sleep better.
Did amitriptyline and nortriptyline help?
What does your sleep-wake pattern look like?
Maybe you can use Seroquel 25-50mg every few nights in an attempt to entrain the brain to sleep more regularly.
Which drugs make your insomnia worse? Does this occur with SSRIs?
Trimipramine might be useful as a sedative and help to improve sleep architecture. I don't know if this change in architecture would translate to an improvement in your sleep pattern. Being devoid of monoamine reuptake inhibition, this probably reduces the likelihood that Trimipramine will disturb sleep.
- Xyrem?
- Agomelatine?
- Ritanserin? (Used only experimentally)
Ritanserin specifically increases slow-wave sleep and decreases REM sleep.
HOMEWORK: Evaluate the pharmacology of Ritanserin. Design a drug cocktail containing the mechanisms displayed by this drug. 5-HT2a/b/c receptor antagonism. Actually, 5-HT2b antagonism serves to promote wakefullness and motor activity while its agonism helps to initiate sleep. It would probably be ideal to have a drug that acts as 5-HT2a/c antagonist + 5-HT2b agonist. Low dose Remeron combined with zaleplon would be an interesting combination. The zaleplon would help compensate for the lack of 5-HT2b agonism and enhance sleep initiation. Or perhaps allowing 5-HT to occupy this receptor is agonist enough to serve this purpose. Varying the ratios in the activity and manipulation of receptor subtypes might be important.
http://www.ncbi.nlm.nih.gov/pubmed/15265808
http://www.ncbi.nlm.nih.gov/pubmed/21459634
Ritanserin and insomnia:
http://www.ncbi.nlm.nih.gov/pubmed?term=ritanserin%20insomnia
Can you think of any clues that might help identify the problem? Do tricyclics help or hurt? Which SRI gives you the most trouble?
Does melatonin make you more depressed?
If I were in your situation, I would try low-dose Seroquel first. The dose must remain low enough such that the accumulation of norquetiapine (an active metabolite of Seroquel) remains negligible. Otherwise, we see it inhibit enough NET and possibly worsen insomnia. I wonder if Seroquel offers 5-HT2c antagonism. I bet it does. This would provide an explanation for why Seroquel works so fast to facilitate sleep. Of course, it could be the antihistamine effect.
If you do indeed suffer from MDD, perhaps your depression is of the endogenous/melancholic subtype, for which insomnia is a prominent symptom. The most common sleep pattern to occur in endogenous depression is early-morning awakenings, Generally, the morning brings the most severe depressive state of the day; with an improvement to be seen in the evening.
This has been quite a rambling post. I hope it makes some sense.
- Scott----------------------------------------------
Post Script:I decided to look into the possibility that Seroquel possessed 5-HT2c antagonism properties. As I noted above, this could explain why Seroquel often acts as a potent sedative/hypnotic. Well, the Seroquel (quetiapine) molecule does not act this way. However, its metabolite (norquetiapine) does. With so little D2 blockade occurring at low dosages, one could make an argument to use Seroquel as a sleep aid.
http://www.ncbi.nlm.nih.gov/pubmed/20931407
Posted by polarbear206 on October 20, 2011, at 9:55:46
In reply to Re: chronic unremitting insomnia - I can't take it!!! » linkadge, posted by SLS on October 20, 2011, at 4:32:53
Tiny dose of Seroquel should do the trick.
Posted by jono_in_adelaide on October 20, 2011, at 18:36:28
In reply to Re: chronic unremitting insomnia - I can't take it!!!, posted by polarbear206 on October 20, 2011, at 9:55:46
Link
could you post
- your diagnonis of what is wrong with you
- all the current meds you take
- what you have tried for sleep in the past
- anything you have noticed that helps or makes it worse
cheers
Jono
Posted by linkadge on October 20, 2011, at 20:17:38
In reply to Re: chronic unremitting insomnia - I can't take it!!! » linkadge, posted by SLS on October 20, 2011, at 4:32:53
>How much trouble do you have falling asleep
>(initiation)?
>How much trouble do you have staying asleep >(maintenance)?
>When do you fall asleep?
>When do you awaken?Lately, its been I sleep from about 3 to 5 or 3 to 6 am. I wake with surges of adrenaline and can't get back to sleep. On other nights, its been
longer, but still extremely disturbed (waking every 30 min). Sleep is very shallow.The TCA's have just been making it worse lately. Amitriptyline has turned on me.
Linkadge
Posted by linkadge on October 20, 2011, at 20:21:34
In reply to Re: chronic unremitting insomnia - I can't take it!!!, posted by jono_in_adelaide on October 20, 2011, at 18:36:28
I did sleep better last night after about 4 nights of decreasing sleep (6 then 5 then 4 then about 3).
I first took melatonin (9mg) this did zip, then I took clonazepam 1mg (this slowed my brain to a crawl but just did't turn the consiousness off. Lastly I took zyprexa 2.5mg and this finally shut the light off.
I'm afraid of these nights. I am afraid that either I am going to go crazy from insomnia or overdose accidentally.
I don't like zyprexa, but it does work in emergencies.
I just don't know what is going on anymore.
Linkadge
Posted by jono_in_adelaide on October 20, 2011, at 21:23:32
In reply to Re: slept last night - zyprexa + clonazepam, posted by linkadge on October 20, 2011, at 20:21:34
1mg clonazepam and 2.5mg of zyprexia isnt that strong a doseage, you arnt at risk of overdosing.
Seroquel might be a better bed that Zyprexia, because of its shorter half life, less chance of morning hangover.
Taking 1mg of clonazepam and 25-50mg of Seroquel (or 2.5mg of Zyprexia) is quite a sensible combo, and you could take this without any danger.
Posted by Phidippus on October 20, 2011, at 21:29:31
In reply to Re: slept last night - zyprexa + clonazepam, posted by linkadge on October 20, 2011, at 20:21:34
I have some of the worst insomnia as well. My brain just doesn't shut off. But I've found a few medications that can help turn the light off in the attic.
Seroquel
Ativan
Clonidine
Prazosin
Gabitril
Lyrica
Thorazine
Cyproheptadine
Atarax
MirtazapineEric
Posted by jono_in_adelaide on October 20, 2011, at 21:34:01
In reply to Re: slept last night - zyprexa + clonazepam » linkadge, posted by Phidippus on October 20, 2011, at 21:29:31
If you dont like taking the Zyprexia (and I can understand why you dont) you might try taking 1mg clonazepam along with 25mg doxylamine (1 Unisom Sleeptab) - this should have a pretty potent effect without exposing you to an antipsychotic.... and you'd still have Zyprexia as a fallback for emergencies
Posted by creepy on October 20, 2011, at 21:42:32
In reply to Re: chronic unremitting insomnia - I can't take it!!!, posted by linkadge on October 20, 2011, at 20:17:38
Id ask about prazosin. I get hyperarousal sometimes and its pretty helpful for that. The short halflife means its mostly out of your system by the time you get up in the AM.
Posted by Christ_empowered on October 21, 2011, at 0:44:23
In reply to Re: chronic unremitting insomnia - I can't take it!!!, posted by creepy on October 20, 2011, at 21:42:32
My only concern would be that the klonopin might not be as useful if you take it on a semi-regular basis. I mean, Klonopin can help anxiety for months, but its usefulness as a sleep aid disappears rapidly. I guess with some zyprexa on board that's not too big a deal, though.
Anyway...if this is just an occasional thing, I think you'll be fine. If you need something to lull you to sleep on a regular basis, then I think you might want to see about some Ativan or something, and maybe an antipsychotic that's more weight neutral (I still say a little bit of Thorazine or Compazine).
Good luck.
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