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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 67. This is the beginning of the thread.
Posted by g_g_g_unit on November 29, 2013, at 9:02:52
I was taking a low dose of Mirtazapine (between 3 and 7mg)as a sleep aid for a couple of weeks. I also used propranolol (20-40mg prn) for about 10 days during that period, and ended up discontinuing both drugs at the same time.
For the past week I've had a mild-moderate feeling of restlessness (e.g. watching TV isn't really possible) and it's driving me crazy. My legs are also cramped/restless and my jaw aches from clenching. I know there's a lot of confusion here about akathisia, and I'm not totally bed-bound (which happens when it's bad), but there's that same feeling of needing to be on the move constantly accompanied by fear/dread.
I reinstated propranolol at 10mg b.i.d., and it takes the edge off but doesn't alleviate the feeling; I also don't like being on it because I'm hypoglycemic and it drops my blood sugar. Melatonin at night helps a lot.
Which is the likely culprit? I would've thought Mirtazapine, but wasn't sure if it hits anything other than H1 at those doses. I would ride it out if I knew it might pass, but the not knowing sucks.
Posted by gadchik on November 29, 2013, at 11:16:14
In reply to how did I induce akathisia?, posted by g_g_g_unit on November 29, 2013, at 9:02:52
doesnt klonopin work for this? im sorry to hear that u have this. It would be miserable.
Posted by ed_uk2010 on November 29, 2013, at 14:14:21
In reply to how did I induce akathisia?, posted by g_g_g_unit on November 29, 2013, at 9:02:52
Mirtazapine makes me restless, except at very low doses indeed. Whichever drug is responsible, it seems pretty much certain that this feeling will pass as soon as it began. Keep that in mind.
You could try a touch of OTC diphenhydramine for a few days. Just a little. High doses can make you feel weird. If you can get one of the allergy diphenhydramines they are cheaper than the sleep aid diphenhydramines. Try 12.5-25mg up to three times a day and 25-50mg at night, then reduce as you improve. Obviously, don't drive on this med.
And remember, it will be over soon.
Posted by Phillipa on November 29, 2013, at 18:24:19
In reply to Re: how did I induce akathisia?, posted by ed_uk2010 on November 29, 2013, at 14:14:21
Took 15mg or remeron for a month just stopped it as was expensive at time and didn't know I had stopped it as did nothing for sleep for me? Seems like theres a lot with akathesia lately?
Posted by g_g_g_unit on November 29, 2013, at 21:23:55
In reply to Re: how did I induce akathisia? » g_g_g_unit, posted by gadchik on November 29, 2013, at 11:16:14
> doesnt klonopin work for this? im sorry to hear that u have this. It would be miserable.
thanks gadchik; it is pretty miserable. unfortunately I react paradoxically to benzodiazepines, so they're a no-no.
Posted by g_g_g_unit on November 29, 2013, at 21:28:51
In reply to Re: how did I induce akathisia?, posted by ed_uk2010 on November 29, 2013, at 14:14:21
> Mirtazapine makes me restless, except at very >low doses indeed. Whichever drug is responsible, >it seems pretty much certain that this feeling >will pass as soon as it began. Keep that in >mind.
Thanks, I try to ed, though OCD has a tendency to make things worse (i.e. "what if this lasts forever?" etc.).
Mirtazapine made me restless at higher doses too, though I was fine on the lower ones. Since Mirtazapine can help treat akathisia, it was my first guess as being the culprit, though I'm not sure about receptor affinities at the lower doses. Do you know if it still hits 5HT2 receptors in any meaningful way below 7mg?
>
> You could try a touch of OTC diphenhydramine for a few days. Just a little. High doses can make you feel weird. If you can get one of the allergy diphenhydramines they are cheaper than the sleep aid diphenhydramines. Try 12.5-25mg up to three times a day and 25-50mg at night, then reduce as you improve. Obviously, don't drive on this med.
>Ah, okay thanks for the tip -- I'll check if diphenhydramine's available here.
> And remember, it will be over soon.
Fingers crossed.
Posted by ed_uk2010 on November 30, 2013, at 6:30:30
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on November 29, 2013, at 21:28:51
>Thanks, I try to ed, though OCD has a tendency to make things worse (i.e. "what if this lasts forever?" etc.)
I'm the same. It won't last forever though, I'm sure of it.
>Do you know if it still hits 5HT2 receptors in any meaningful way below 7mg?
I don't know. Pharmacokinetics also vary from person to person, so the amount reaching your receptors at 7mg won't be the same as the person next door.
>Ah, okay thanks for the tip -- I'll check if diphenhydramine's available here.
There's also doxylamine, which is similar but maybe a bit more sedating. Both meds are pharmacy meds.
In Australia, there appears to be a brand of doxylamine cause Dozile, marketed as a sleep aid. It's a capsule though so not ideal for dose adjustments.
Oh, I found a doxylamine tablet called Restavit. That might be more suitable.
And UniSom Sleep Gels - diphenhydramine 50mg. The dose is too high and the caps can't be split easily. No good.
Snuzaid 50mg diphenhydramine tablets. Could be OK assuming they're easy to cut.
Sorry if you actually live in Switzerland or something!
Posted by g_g_g_unit on November 30, 2013, at 9:32:21
In reply to Re: how did I induce akathisia? » g_g_g_unit, posted by ed_uk2010 on November 30, 2013, at 6:30:30
> Oh, I found a doxylamine tablet called Restavit. That might be more suitable.Yeah, I used that as a sleep aid prior to Mirtazapine ..
>
> Snuzaid 50mg diphenhydramine tablets. Could be OK assuming they're easy to cut.
>
> Sorry if you actually live in Switzerland or something!
>No, I'm in Australia! I discovered Snuzaid while googling ..
I've seen people say that Benadryl actually exacerbates their RLS/akathisia .. would that be due to its SSRI properties and also dose dependent?
Posted by gadchik on November 30, 2013, at 15:56:27
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on November 30, 2013, at 9:32:21
If I take benadryl too much, I have this feeling of agitation, and restlessness, is that a paradoxical reaction? I also do that with vistaril. When I tried to go up to 15mg Remeron, my anxiety worsened, restless legs, but I did fine at 7.5mg. Also, do well on .5mg klonopin, no restlessness.
Posted by sigismund on November 30, 2013, at 17:21:57
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on November 30, 2013, at 9:32:21
Benadryl was dreadful the next day for me.
Posted by Phillipa on November 30, 2013, at 18:14:56
In reply to Re: how did I induce akathisia?, posted by sigismund on November 30, 2013, at 17:21:57
Took it once before on any meds for bee stings and felt horrible neither tired or sleepy just strange. Phillipa
Posted by ed_uk2010 on December 1, 2013, at 6:43:24
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on November 30, 2013, at 9:32:21
>I've seen people say that Benadryl actually exacerbates their RLS/akathisia .. would that be due to its SSRI properties and also dose dependent?
I think it is very dose dependent, and possibly due to anticholinergic toxicity. It is a very bad idea to exceed the recommended dose (as a lot of people do). If you'd like to try it, I'd initially take only 12.5mg doses during the day and 25mg at night. You can easily increase if needed, but avoid single doses higher than 25mg during the day, and 50mg at night. They will make you feel weird, and probably worse.
Posted by ed_uk2010 on December 1, 2013, at 6:46:01
In reply to Re: how did I induce akathisia?, posted by gadchik on November 30, 2013, at 15:56:27
Hello,
> If I take benadryl too much, I have this feeling of agitation, and restlessness, is that a paradoxical reaction?
I do as well, but only at high doses. More is less IMO.
>When I tried to go up to 15mg Remeron, my anxiety worsened, restless legs.
Same here, but with Remeron I think it's due to its effect at alpha-2 receptors. I do not like Remeron at all!
Posted by ed_uk2010 on December 1, 2013, at 6:46:58
In reply to Re: how did I induce akathisia?, posted by sigismund on November 30, 2013, at 17:21:57
> Benadryl was dreadful the next day for me.
It's not too long-acting, but definitely not one to take in the middle of the night. The likes of promethazine are much worse for hangovers!
Posted by ed_uk2010 on December 1, 2013, at 6:47:48
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on November 30, 2013, at 9:32:21
> > Oh, I found a doxylamine tablet called Restavit. That might be more suitable.
>
> Yeah, I used that as a sleep aid prior to Mirtazapine.Any side effects? Did it help?
Posted by ed_uk2010 on December 1, 2013, at 6:49:23
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on November 30, 2013, at 9:32:21
Normally I would suggest diazepam for acute akathisia, due to its sedative muscle relaxant properties. Do you respond paradoxically to all benzos?
Posted by g_g_g_unit on December 1, 2013, at 16:12:58
In reply to Re: how did I induce akathisia?, posted by ed_uk2010 on December 1, 2013, at 6:49:23
> Normally I would suggest diazepam for acute akathisia, due to its sedative muscle relaxant properties. Do you respond paradoxically to all benzos?
Thank you so much for all your help ed!
Yes, once the initial sedation wears off all benzodiazepines seem to make me worse unfortunately.
Doxylamine was helpful for sleep until I grew tolerant. I also think it was causing irritability the next day and worsening my anxiety in the long run.. I've read that antihistamines can up regulate adrenergic receptors with chronic use.
I'll pick up some benadryl later and see how I fair.
Posted by g_g_g_unit on December 2, 2013, at 7:54:46
In reply to Re: how did I induce akathisia? » gadchik, posted by ed_uk2010 on December 1, 2013, at 6:46:01
I actually took a tiny dose of Mirtazapine (around 1.5mg) last night and the akathisia was considerably reduced, though replaced by a mild stimulation that wasn't unpleasant but made me anxious/restless in a different fashion.
I guess it suggests that even at that low dose the drug was psychoactive (anything about 1.5mg makes me extremely irritable to the point of rage).
I didn't have a chance to try the Benadryl yet .. I had bought a couple of supplements (Vitamin E and P5P) hoping they would help, but stupidly overlooked the fact that the Vitamin E caps are 40iu (compared to the ~400IU recommended for akathisia) and the P5p made me more anxious.
ed, wouldn't taking Benadryl several times a day eventually produce some kind of rebound akathisia anyway once it's stopped?
Posted by ed_uk2010 on December 2, 2013, at 12:09:23
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on December 1, 2013, at 16:12:58
Hello,
I've never heard of rebound akathisia on stopping antihistamines. If you use it for a few weeks, you may notice some vivid dreams on stopping, and possibly some nausea (the 'anticholinergic rebound'). I think this is normally easy to overcome by gradual dose reductions. I suggest limiting treatment to a couple of weeks, by which time you'll hopefully feel better anyway.
The only people who seem to have major problems with diphenhydramine/doxylamine are those who:
a) Take more than the recommended dose because they think it will make it work better, and end up feeling very peculiar.
b) Deliberately take small overdoses to cause an anticholinergic hallucinogenic type effect, using including considerable confusion.
c) Just take it for weeks on end, after which point it's about as much use as a sleep aid as peppermint tea. Probably less. Oh, and then have vivid dreams on withdrawal, encouraging it to be pointlessly restarted.
d) Take it and then go for a drive on the motorway or something. Enough said. It's hardly a concentration booster.
Good luck!
Posted by g_g_g_unit on December 2, 2013, at 21:35:13
In reply to Re: how did I induce akathisia?, posted by ed_uk2010 on December 2, 2013, at 12:09:23
Thanks again for all your help, ed!
No chemists seem to stock the Benadryl sleep preparation (SnuzAid), so I picked up Doxylamine instead.
What dosing schedule would you recommend? 25mg typically makes me feel sedated and bored, yet also completely uninterested in anything, so I'd like to avoid that if possible.
Posted by ed_uk2010 on December 3, 2013, at 3:41:48
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on December 2, 2013, at 21:35:13
>What dosing schedule would you recommend? 25mg typically makes me feel sedated and bored, yet also completely uninterested in anything, so I'd like to avoid that if possible.
I think you should cut the tablet into quarters and take 1, then 1 more after 30-60 mins if necessary. You'll have to play it by ear. I do hope it helps. May need to re-dose after about 8 hours perhaps.
Some tablets are awkward shapes, but the tablet cutting does not need to be accurate.
Posted by g_g_g_unit on December 3, 2013, at 4:05:42
In reply to Re: how did I induce akathisia? » g_g_g_unit, posted by ed_uk2010 on December 3, 2013, at 3:41:48
> I think you should cut the tablet into quarters and take 1, then 1 more after 30-60 mins if necessary. You'll have to play it by ear. I do hope it helps. May need to re-dose after about 8 hours perhaps.
>Thanks, ed. I did end up taking 1/4 this afternoon and didn't feel anything after an hour, so took a further 1/4.
I think it helped the akathisia a bit, but hasn't done anything for the jaw stiffness. I also feel overstimulated on it -- irritable, dysphoric, sensitive to noise etc. I tend to get that stuff the following day after I use Doxylamine for sleep, so maybe the sedation on the higher doses masks it.
Since lowering the dose wouldn't help, what would be the next sensible step? Should I just ask my doctor for a Cogentin script or something?
Feeling angry, worried, frustrated .. it's been 12 days now; wish I'd never taken the Mirtazapine to begin with, *sigh*
Posted by ed_uk2010 on December 3, 2013, at 6:56:03
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on December 3, 2013, at 4:05:42
Sorry to hear it didn't work out for you.
I know you said propranolol drops your blood sugar, have you tried any other beta blockers? You'd (presumably) need one of the lipid soluble beta blockers that enter the brain, but perhaps one of the more selective drugs such as metoprolol could alleviate your restlessness with fewer adverse effects? (Although you are not a rat (!), only lipid soluble beta blockers reduce drug-induced movement disorders in rats. Fortunately, beta-1 selective drugs such as metoprolol still appear to be effective. Atenolol is not lipid soluble, I suspect it wouldn't help. None of this is very evidence-based, I'm just thinking out loud really. Personally, I would dump the propranolol and give metoprolol a shot. It's often used for other 'brain related' disorders such as migraine, so I expect your doctor won't be too averse to trying it.
As far the jaw clenching, perhaps your doctor could prescribe a low dose of a muscle relaxant? I'm unsure what's sold in Australia. I'll look on the Pharmaceutical Benefits Scheme website. Hmm, seems to be even fewer choices than over here. The Americans have millions of muscle relaxants, most of dubious value but at least the choice is there. Diazepam tends to be useful for jaw clenching, do you react paradoxically to all benzos? I believe the differences between the various drugs are greater than is often appreciated. Diazepam is particularly muscle relaxant.
>Should I just ask my doctor for a Cogentin script or something?
You could, but I'm unsure how you'd respond. It may be a little like doxylamine with more dry mouth. It would be ideal if your doctor could give you a prescription for small quantities of a few different meds to try (not all at once!). Eg. Metoprolol, diazepam, Cogentin. What do you think?
Posted by g_g_g_unit on December 3, 2013, at 7:25:42
In reply to Re: how did I induce akathisia? » g_g_g_unit, posted by ed_uk2010 on December 3, 2013, at 6:56:03
> Sorry to hear it didn't work out for you.
>
> I know you said propranolol drops your blood sugar, have you tried any other beta blockers? You'd (presumably) need one of the lipid soluble beta blockers that enter the brain, but perhaps one of the more selective drugs such as metoprolol could alleviate your restlessness with fewer adverse effects? (Although you are not a rat (!), only lipid soluble beta blockers reduce drug-induced movement disorders in rats. Fortunately, beta-1 selective drugs such as metoprolol still appear to be effective. Atenolol is not lipid soluble, I suspect it wouldn't help. None of this is very evidence-based, I'm just thinking out loud really. Personally, I would dump the propranolol and give metoprolol a shot. It's often used for other 'brain related' disorders such as migraine, so I expect your doctor won't be too averse to trying it.Thanks ed! I did indeed drop the propranolol yesterday -- since reinstating Mirtazapine for a night fixed things, I presumed the propranolol wasn't the culprit.
I'll ask my doctor if I could try another beta-blocker .. 20mg of propranolol took the edge off of things, but never hit the core restlessness. Hopefully something else might do the job, though I don't want to end up stuck on another drug. Do other beta blockers tend to mess up sleep like propranolol? I think I read it reduces melatonin production; either way, it made falling asleep difficult.
>
> As far the jaw clenching, perhaps your doctor could prescribe a low dose of a muscle relaxant? I'm unsure what's sold in Australia. I'll look on the Pharmaceutical Benefits Scheme website. Hmm, seems to be even fewer choices than over here. The Americans have millions of muscle relaxants, most of dubious value but at least the choice is there. Diazepam tends to be useful for jaw clenching, do you react paradoxically to all benzos? I believe the differences between the various drugs are greater than is often appreciated. Diazepam is particularly muscle relaxant.
>Good old 'stralia. I have reacted paradoxically to Xanax, Lorazepam and Clonazepam. I tried Valium while I was on Parnate (in an attempt to treat the anxiety) and just recall feeling a little sedated, though still uncomfortable.. it was hard to tell if it was making things better or worse.
Out of desperation, I almost bought a codeine-based painkiller today, since I figured that might help the restlessness and tension, though am I just asking for more trouble?
> >Should I just ask my doctor for a Cogentin script or something?
>
> You could, but I'm unsure how you'd respond. It may be a little like doxylamine with more dry mouth. It would be ideal if your doctor could give you a prescription for small quantities of a few different meds to try (not all at once!). Eg. Metoprolol, diazepam, Cogentin. What do you think?Yeah, after reading up on Cogentin, it doesn't sound ideal.
I'll see what my doctor has to say! You've given me some good ideas, so thank you for all your help.
Posted by ed_uk2010 on December 3, 2013, at 13:22:02
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on December 3, 2013, at 7:25:42
>Do other beta blockers tend to mess up sleep like propranolol?
Propranolol is probably the worst in this respect, and sometimes causes nightmares. Atenolol doesn't affect sleep but probably wouldn't help. I expect metoprolol would be more tolerable than propranolol but there's still a risk of it affecting your sleep.
If you're near a supermarket, you could get some Chamomile tea (German Chamomile seems to be the variety that helps sleep). For sure, it will do you no harm, and avoids caffeine intake - not what you need when tense.
>Valium, it was hard to tell if it was making things better or worse.
I think it might help, but you'd obviously need to be very cautious. Some people find that paradoxical reactions disappear with dose adjustment, either up or down (confusingly). Diazepam has more of a noticeable muscle relaxant effect than other benzos. It is more sleep inducing than Ativan, but this could be appropriate during your current situation, allowing you to get some rest. Diazepam should ideally be limited to about 2 weeks of treatment. After short term use, tapering is rarely difficult (in stark contrast to after long term use).
>Out of desperation, I almost bought a codeine-based painkiller today, since I figured that might help the restlessness and tension, though am I just asking for more trouble?
It certainly might help, but opioids are very addictive. I advise great caution, with no more than 3 days of use - for the jaw tension/pain. For sure, avoid any products which also contain caffeine.
>I'll see what my doctor has to say! You've given me some good ideas, so thank you for all your help.
You're welcome. Hope you can see your doctor very soon. And I still believe these new symptoms will end fairly soon, even without treatment, it's just a case of getting through the interim period.
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