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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 22 of 22. This is the beginning of the thread.
Posted by Louisiana Sportsman on May 5, 2014, at 15:30:25
Right now, I am prescribed an attenuated prescription regiment as follows:
Brintellix 20mg.
Desoxyn 30mg.
Latuda 40mg.
Trokendi XR (Topamax) 200mg.
Xanax XR 0.5mg. TID
This is what I'm prescribed after we abated my medications from EIGHT.
I and my PDOC decided that I was on too many meds because three of my medications' mechanisms of actions could be utilized by other drugs within my regiment. Together, we decided to surcease [drug with agnate MOA is provided in brackets]: Gabapentin [Xanax XR], Lamictal [Topamax XR] and Nuvigil [methamphetamine].
Au courant, I believe that my present regiment is the optimum that psychopharmacology can administer. I have obeisance for the previous medications, sure. Do I miss them? So-so. The gabapentin, I have developed such a tolerance to it that I didn't even notice its effect-- same thing with the lamotrigine, I have no idea what it was doing for me. The Nuvigil is the only one I would like back and even then, there was a tolerance issue to where she wrote #60 150mg. (insurance QDD didn't notice?) equivalent to 600mg. modafinil, and I still didn't get much puissance. I still think its cessation has reduced my motivation. I have a strong feeling she will add it again.
Current symptoms:
* lack of motivation to progress my life
* chronic laziness
* emotional outbursts over minor things
* lay in bed on the computer during complaisant days outside
* "weird, nervous" anxious feeling arises, solicitous and disquieted-- tachycardia present, randomly on certain days that stops me from doing anything (not caused by methamphetamine, tested it)
* thoughts about death since my best friend overdosed on prescribed Xanax (guess he took the whole bottle) by my own PDOC that I sent him to which kills me inside. He told me earlier the evening the died that he was going to take some hydrocodone his mom gave him, and I told him that wasn't kosher. He mixed the two and died. I tried to help him with setting up the PDOC appointment-- not kill him. He was very stressed, anxious, insipid around people, and I would have wrote him a benzo as well; I guess he just made a mistake. Kills me inside everyday. Now, when I drive, for instance, I'll think about crashing into the median or something; whereas, before, it didn't bother me as much.
Ideas:
1. Switch Latuda to Geodon 80mg. or less-- this would give me energy at this lower dose-- reuptake of norepinephrine and 5-HT2C receptor activity providing a boost. It would give less dopamine occupancy (60% or <) at this dosage which may allow the Desoxyn to work better to improve motivation. Also, I would get the similar AAP serotonergic activity that Latuda provides. *** see alternative idea below** Also concomitantly add Aptiom (eslicarbamazepine) by the makers of Latuda, ironically, (April 2014) that is the cleanest --carbamazepine yet -- it is a metabolite of oxcarbamazepine that lacks epoxide metabolites that contribute to side effects and also allows rapid tiration (one week) to the 800mg. suggested maintenance dosage which comes in convenient pill. I think this would help with the emotional issues and the weird, anxious feelings and maybe the negative thoughts. It would be a good mood stabilizer since the discontinuation of Lamictal. For emotional outbursts, switch Xanax XR to Ativan SL 1mg. BID (I don't feel like my PDOC would want to give 3mg. of benzos yet) I'd try to save one for bedtime, but they'll probably be used during the day lol. I don't have a sleeping issue.
Sum it up:
* Switch Latuda 40mg --> Geodon 80mg. *** see alternative idea below***
* Augment Aptiom (eslicarbamazepine) 800mg.
Alternative idea to switching Latuda to Geodon is to add Protriptyline at about 30mg. I base it on one of the more well-written posts: http://www.crazymeds.us/CrazyTalk/index.php/topic/15793-protriptyline-vivactil-manufacturers/?p=108531
I think it would aggrandize the strength of my Desoxyn, and it may provide motivation and depression relief.
Appurtenant Ideas:
Nortriptyline
Oleptro ER, see my topic about it here: http://www.crazymeds.us/CrazyTalk/index.php/topic/25291-oleptro-xr-the-new-abilify/SSRI, see my my topic about it here: http://www.crazymeds.us/CrazyTalk/index.php/topic/25298-augmention-of-a-ssri-to-brintellix-not-overkill-a-theory-based-on-a-study/
Clomipramine (Anafranil): really well regarded extremely serotonergic TCA that may help symptoms-- and PDOC would likely augment modafinil if she wrote this
Ideas? Thoughts? Opinions? Inputs?
Share!
Thanks!
Posted by Louisiana Sportsman on May 5, 2014, at 15:33:35
In reply to Reduction of Meds; Symptoms Persist, posted by Louisiana Sportsman on May 5, 2014, at 15:30:25
I meant Ativan 1mg. SL TID based on current dosing of benzodiazepine. I definitely need an increase of benzodiazepine, I feel like.
Posted by Louisiana Sportsman on May 5, 2014, at 15:40:07
In reply to Re: Reduction of Meds; Symptoms Persist, posted by Louisiana Sportsman on May 5, 2014, at 15:33:35
I'm currently taking Oleptro ER 300mg. but I discontinued it thus I didn't include it in the above list. I copied and pasted this from another forum to hype my post.
Posted by Louisiana Sportsman on May 5, 2014, at 15:57:10
In reply to Oleptro ER I Discontinued, posted by Louisiana Sportsman on May 5, 2014, at 15:40:07
I forgot to mention Luvox CR.
There are many reasons why I like it (I can make a whimsical detailed post, but I don't have time) -- conveniently, it is the least potent SERT which would be best to go with my Brintellix.
That's an idea too.
Posted by Louisiana Sportsman on May 5, 2014, at 15:58:21
In reply to Luvox CR, posted by Louisiana Sportsman on May 5, 2014, at 15:57:10
> I forgot to mention Luvox CR.
>
> There are many reasons why I like it (I can make a whimsical detailed post, but I don't have time) -- conveniently, it is the least potent SERT which would be best to go with my Brintellix.
>
> That's an idea too.It effects sigma-1 receptors, for instance would be one element of my detailed post about why I would choose this SSRI with Brintellix if I had to choose an SSRI with Brintellix.
Posted by linkadge on May 5, 2014, at 16:20:59
In reply to Luvox CR, posted by Louisiana Sportsman on May 5, 2014, at 15:57:10
Luvox also has the highest ratio of sigma agonism to SERT antagonism.
Linkadge
Posted by Louisiana Sportsman on May 5, 2014, at 16:30:20
In reply to Re: Luvox CR, posted by linkadge on May 5, 2014, at 16:20:59
> Luvox also has the highest ratio of sigma agonism to SERT antagonism.
>
> LinkadgeVery interesting! I like this effect.
I have an appointment the 14th and the 28th-- by the 28th, I expect my regiment to look something like this:
(Aptiom 800mg.) --> depends on suggestions
Brintellix 20mg.
Desoxyn 60mg.
(Geodon 80mg.) --> depends on suggestions
(Luvox CR 150mg.) --> depends on suggestions
Nuvigil 250mg. (needed if placed on Luvox imo)
Trokendi XR (Topamax) 200mg.
(Ativan SL 2mg. TID) --> somewhat depends on suggestions: I must have have a benzodiazepine strategy around 2mg. -- apparently lorazepam doesn't interfere with the 1A2 enzyme that Luvox effects like other benzos.
Back to eight medications, yep, but I think my and PDOC and I are understanding that this is the type of polypharmacology that I require. She's had me on eight medications for a long, long time. I don't see her having a problem with this.
Posted by linkadge on May 5, 2014, at 17:33:06
In reply to Re: Luvox CR, posted by Louisiana Sportsman on May 5, 2014, at 16:30:20
yeah, unfortunately, luvox does interact with other medications. However, as far as doing what it is supposed to do, I like it.
I just take the IR version.
Linkadge
Posted by joe f on May 5, 2014, at 17:34:19
In reply to Re: Luvox CR, posted by Louisiana Sportsman on May 5, 2014, at 16:30:20
be careful with luvox interactions as some dr's do not like using it
Posted by Phillipa on May 5, 2014, at 18:59:22
In reply to Re: Luvox CR, posted by linkadge on May 5, 2014, at 17:33:06
I take IR also.
Posted by rjlockhart37 on May 5, 2014, at 19:33:18
In reply to Re: Luvox CR, posted by linkadge on May 5, 2014, at 16:20:59
desoxyn is a vary good medication for focus.....yet it's rare.....the best thing that helped me where dexedrine spansules.....
right now the only thing that helps me is caffeine, nuvigil, and prozac....
my doctor does not treat me for ADHD, and will refuse any request for treatement....
see and the thing is in this situation....i can't take any amphetamines in the household where i live because past history of abuse, and then the doctor will not even use methyphenidate and bullies me around saying that annoying term, you don't need medication, you need coping skills....see and then another patient comes in and totally get blasted with meds....that's why i have a rebutal against this...selectivty of patients....my doctor tells me my file is too complicated to treat, and just leaves me on this crap.....that's the treatment....
but the medication your taking may...the laduda may decrease some of desoyn's effects, it is a neurotransmitter antagonist, it may give it a smoother effect....when i was on dexedrine i took 60mg in morning, 4 15mg spansules...and xanax 2mg's and it was similar to a drug in the 60's called Dexamyl....it was dextroamphetamine with amobarbital and the dosages varied.....it was like a relaxed stimulation, there was the waking part from the amphtaminne, but the alprazolam reduced some vigilance and made it more smooth, but it did take away somee of the motivation and made it more releaxed easy going mood.....
what i think would help is Namenda it's a smart drug, it improves cognitive preformance yet it doesnt really work well if people just take it and rely on it all the time, what i learned from taking stimulants, i used to lean on them to get me going, and then i realized that if i didnt take it was lazy....you have to force yourself to like work, and then if you take the stimulant or nemanda it improves what your currently doing....
you could ask about increasing xanax xr....i took xanax with dexedrine every morning, it did help ith mood, but it blunted the psychomotor stimulation....
suggestions:
nemanda
strattera or any other NE reuptake inhibitor, some of the TCA's
nasty wellbutrin.....
adding focalin to desoxyn
buy supplements at GNC paticulary L-tyrosine for increased dopamine production
your on brintellix, my personal thing...prozac does increase amphatmine's effect.....i've read that on the net on some websites, yet it's older and doctors are starting leave it behind for the new generation meds.....it will increase the mood and the stimulationhope that helps.....
r
Posted by Louisiana Sportsman on May 5, 2014, at 19:36:29
In reply to Re: Luvox CR, posted by joe f on May 5, 2014, at 17:34:19
> be careful with luvox interactions as some dr's do not like using it
I'm almost 100% positive that my particular PDOC will be fine with it if I'm fine with it.
Stahl even suggests augmenting it with clomipramine for treatment-resistant OCD as well as many other medicament.
Can the discussion not just be about Luvox? There's a lot more in my posts.
Posted by Louisiana Sportsman on May 5, 2014, at 19:43:40
In reply to Re: Luvox CR, posted by rjlockhart37 on May 5, 2014, at 19:33:18
> suggestions:
> nemanda
> strattera or any other NE reuptake inhibitor, some of the TCA's
> nasty wellbutrin.....
> adding focalin to desoxyn
> buy supplements at GNC paticulary L-tyrosine for increased dopamine production
> your on brintellix, my personal thing...prozac does increase amphatmine's effect.....i've read that on the net on some websites, yet it's older and doctors are starting leave it behind for the new generation meds.....it will increase the mood and the stimulation
>
> hope that helps.....
>
> r
>I was looking into Nameda myself! Great suggestion.
The excerpt from the vortioxetine study:
"These findings indicate that either the co-administration of an SSRI in addition to a 5-HT3 receptor antagonist or a multimodal agent that acts as a SSRI and 5-HT3 receptor, such as vortioxetine, could enhance 5-HT neurotransmission to produce AD and antiemesis effects, similar to that of litoxetine, after long-term administration."
Memantine is one of the few 5-HT3 receptor medications and may be a perfect fit with Brintellix. I will look into it more. It may be a great general augmentation agent instead of modafinil. Good suggestion.
Bad experience with atomoxetine which makes me wary of the NE TCAs, honestly. I'm not sure why I'm thinking Protriptyline will be different from Strattera in terms of sedation?
Recently discontinued bupropion.
My PDOC is amazing, but I just don't see her doing the Focalin to Desoxyn thing.
Vortioxetine should theoretically increase amphetamine's effect, I believe, according to drugs.com-- but I'm not sure, but yes Prozac does and I believe Brintellix does as well.
Thanks for your suggestions, buddy!
Posted by joe f on May 5, 2014, at 21:38:45
In reply to Re: Luvox CR, posted by Louisiana Sportsman on May 5, 2014, at 19:43:40
seems like us babblers are fascinated by the weirdness of luvox
Posted by Phillipa on May 5, 2014, at 22:47:02
In reply to Re: Luvox CR, posted by joe f on May 5, 2014, at 21:38:45
It is wierd as after 11 years can't get off a mere subtheraputic dose of 25mg. Now that is weird. Phillipa
Posted by LouisianaSportsman on May 5, 2014, at 22:54:19
In reply to Re: Luvox CR, posted by rjlockhart37 on May 5, 2014, at 19:33:18
<your on brintellix, my personal thing...prozac does <increase amphatmine's effect
<Micromedex does confirm that Prozax does increase amphetamine's effect.
Micromedex, which is a drug interactions checker which is professional and you have to pay for, does also give a warning with Brintellix; however, it does not give a warning with Zoloft, Luvox, Lexapro, Paxil or even mirtazapine. Weird.
Micromedex:
Dextroamphetamine Sulfate (Dexedrine) : Vortioxetine Hydrobromide (Brintellix)
Severity: Major
Onset: Not Specified
Documentation: FairInteraction Effect:
Concurrent use of VORTIOXETINE and SEROTONERGIC AGENTS may result in an increased risk of serotonin syndrome (hypertension, hyperthermia, myoclonus, mental status changes).Clinical Management:
Concomitant use of vortioxetine with serotonergic agents may increase the risk for serotonin syndrome and should be undertaken with caution. If concomitant use of vortioxetine with a serotonergic agent is clinically warranted, close monitoring of the patient is recommended, particularly during treatment initiation and dosage increases. If serotonin syndrome develops, discontinue vortioxetine and concomitant serotonergic agents and initiate supportive care (Prod Info BRINTELLIX oral tablets, 2013).Probable Mechanism:
additive serotonergic effects
Posted by LouisianaSportsman on May 5, 2014, at 23:46:19
In reply to Yep, Micromedex: Warning on Brintellix + Dexedrine » rjlockhart37, posted by LouisianaSportsman on May 5, 2014, at 22:54:19
Eslicarbazepine is a CYP34A inducer so it would reduce my Latuda requiring me to up the dosage--
Based on this study:
RESULTS: ESL significantly decreased the systemic exposure to both ethinylestradiol and levonorgestrel. GMR (90%CI) for AUC0-24 of ethinylestradiol were 68% (64%; 71%) following 1200mg ESL and 75% (71%; 79%) following 800mg ESL. GMR (90%CI) for AUC0-24 of levonorgestrel were 76% (68%; 86%) following 1200mg ESL and 89% (82%; 97%) following 800mg ESL.
I would need about ~25% increase of Latuda which would be 75mg., so there are 80mg. tablets which I have handled perfectly fine in the past. No biggie.
But, Aptiom is a CYP2C19 inhibitor which means it would increase my Brintellix, which is perfectly fine with me, as I was thinking about moving up my dose anyway, this sounds like a perfect way to do it. -- this is the Benefit as discussed in the Subject.
Posted by phidippus on May 6, 2014, at 19:58:42
In reply to Reduction of Meds; Symptoms Persist, posted by Louisiana Sportsman on May 5, 2014, at 15:30:25
> * lack of motivation to progress my life
> * chronic lazinessThese two sound more like psychological issues that would best be addressed with therapy. Unless you want to take on a cocaine habit.
> * emotional outbursts over minor things
Some DBT could help here.
> * lay in bed on the computer during complaisant days outside
Is this the problem or your guilt about it?
> * "weird, nervous" anxious feeling arises, solicitous and disquieted-- tachycardia present, randomly on certain days that stops me from doing anything (not caused by methamphetamine, tested it)
May be a limited symptom attack. Topomax can cause anxiety.
> * thoughts about death...Now, when I drive, for instance, I'll think about crashing into the median or something; whereas, before, it didn't bother me as much.
Intrusive and recurrent thoughts form the basis of OCD. Brintellix should be treating these symptoms or at least reducing their frequency. Often times, OCD requires treatment with antidepressants at higher doses that would normally be used for depression. You can always try and increase the Brintellix and see how you respond.
Another possibility is the replacement of Desoxyn with dextroamphetamine, which has been used as augmentation in the treatment of OCD.
> 1. Switch Latuda to Geodon 80mg. or lessGeodon is worthless at an 80 mg dose. At 160 mg it does all its supposed to do.
>It would give less dopamine occupancy (60% or <) at this dosage which may allow the Desoxyn to work better to improve motivation.
Geodon will be hitting D2 receptors while the desoxyn works primarily on D1 receptors. There should be little competition between the agents.
>I would get the similar AAP serotonergic activity that Latuda provides.
You would get 5ht1a partial agonism, 5ht1b partial agonism, plus serotonin reuptake inhibition.
>Also concomitantly add Aptiom
Are you bipolar with adhd and ocd? I don't think you've ever told me your diagnosis.
>I think this would help with...the negative thoughts.
No.
>For emotional outbursts, switch Xanax XR to Ativan SL 1mg.
I thought benzos only helped with anxiety...How does GABA-A agonism influence behavior?
> Alternative idea to switching Latuda to Geodon is to add Protriptyline at about 30mg.
Adding Vivactil to your regimen sounds like a fine idea what with you taking methamphetamines.
> NortriptylineMay be useful for depression.
> Oleptro ER
Ha ha.
> Clomipramine
Sure, instead of Brillantix.
> Ideas? Thoughts? Opinions? Inputs?
I think you're obsessed with trying out drugs. Remember, the more drugs you take, the more mucked up things get.
Eric
Posted by klein on May 6, 2014, at 20:11:17
In reply to Micromedex Warning on Aptiom But With Benefit, posted by LouisianaSportsman on May 5, 2014, at 23:46:19
> Eslicarbazepine is a CYP34A inducer so it would reduce my Latuda requiring me to up the dosage--
>
> Based on this study:
>
> RESULTS: ESL significantly decreased the systemic exposure to both ethinylestradiol and levonorgestrel. GMR (90%CI) for AUC0-24 of ethinylestradiol were 68% (64%; 71%) following 1200mg ESL and 75% (71%; 79%) following 800mg ESL. GMR (90%CI) for AUC0-24 of levonorgestrel were 76% (68%; 86%) following 1200mg ESL and 89% (82%; 97%) following 800mg ESL.
>
> I would need about ~25% increase of Latuda which would be 75mg., so there are 80mg. tablets which I have handled perfectly fine in the past. No biggie.
>
> But, Aptiom is a CYP2C19 inhibitor which means it would increase my Brintellix, which is perfectly fine with me, as I was thinking about moving up my dose anyway, this sounds like a perfect way to do it. -- this is the Benefit as discussed in the Subject.Hi L.
Eslicarbazepine (never heard of it before) sounds like a good choice for mood issues. Any chance that some of these issues are due to minor withdrawal?
Also: gabapentin and lamictal are usually anxiolytic, are you sure you're tolerating the Desoxyn well? Maybe lowering the dosage could make you feel less edgy. (no personal experience there)
You know that I'm going to recommend Saphris. Here's my experience: it's highly sedating for a few hours, promoting really good sleep (6 hours). Then when I wake up, I feel really motivated and clear-headed (no hangover). I love the stuff because the effect is pretty much immediate, whereas with most AAPs you need to wait for a few days til you notice an effect.
Geodon is a good second choice, it works within a few days, but the results, IME, are nowhere near as dramatic as with Saphris. If you stick to a low dose it should be mildly activating (be weary of akathisia though!). The only major issue with Geodon is having to take it with food (at least 500 calories) twice daily.
Switching to Ativan is an excellent choice, as you won't have to worry about eslicarbazepine lowering its level or Luvox (never tried it) raising the blood levels.
OK, hope this helps :)
Posted by Phillipa on May 6, 2014, at 20:23:44
In reply to Re: Micromedex Warning on Aptiom But With Benefit » LouisianaSportsman, posted by klein on May 6, 2014, at 20:11:17
Ativan is the only benzo recommended with luvox. For some reason it doesn't change with luvox. Phillipa
Posted by joe f on May 7, 2014, at 5:47:09
In reply to Re: Micromedex Warning on Aptiom But With Benefit, posted by Phillipa on May 6, 2014, at 20:23:44
more luvox weirdness
Posted by klein on May 7, 2014, at 7:38:57
In reply to Re: Micromedex Warning on Aptiom But With Benefit, posted by Phillipa on May 6, 2014, at 20:23:44
> Ativan is the only benzo recommended with luvox. For some reason it doesn't change with luvox. Phillipa
Luvox inhibits a bunch of liver enzymes, some of which metabolize benzos. Ativan is metabolized by another mechanism (glucuronidation) so it's not affected by Luvox.
This is the end of the thread.
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