Posted by LouisianaSportsman on October 1, 2013, at 12:50:27
In reply to Re: Augmenting Bipolar 'Cocktail' with Trodenki XR » LouisianaSportsman, posted by phidippus on October 1, 2013, at 8:57:15
Eric, your response was amazing! I really appreciate it. This is *EXACTLY* what I've been looking for. I sincerely thank you giving up your time to make this response.
> All good, but Lyrica may be overkill. Not sure you should be on Pristiq. That dose of Lamictal is on the low side.
>I do want to go up on the Lamictal, absolutely. I think I will go ahead and aim for 400mg., as you suggested. Pristiq was added to help out my "lows", but maybe more Lamictal will make the Pristiq useless. I was already on Wellbutrin in the form of Aplenzin (a different bupropion salt) at 522mg. But, I switched pdocs and she took me off of it saying that it increases anxiety.
> What are you going to be taking the Topomax for? Anxiety?
>WEIGHT-LOSS!! Abilify is causing severe weight loss.
> >topiramate extended-release capsules would be a great adjunct to my Lamictal.
How so? As a mood stabilizer? Topiramate is fairly useless as a mood stabilizer. I would just go up on the Lamictal, or add something useful, like Trileptal.
>I understand Trileptal is a better mood stabilizer, but I was wanting to add Topamax for its weight loss properties.
> It ain't called dopamax for nothing. 100mg will be useless. Most meaningful studies start dosing at 300 mg. [time-release] looks good on paper, but in reality, you're going to get side effects at any relevant dose.
>Thanks for the advice about the time-release. I still think I will go for the time-release knowing full well I will get the side effects.
> Weight loss is something you need to address therapeutically. ACT comes to mind...
>I disagree. I really want a medication to help with the weight-loss, but I might decide to forgo topiramate if I decide to get Vyvanse.
>
> Because you're dose is too low. [Lamictal]
>I agree. It is too low.
> No, not really. Try something with a little better evidence supporting its efficacy, like Carbamazapine.
>Good suggestion as an adjunct mood stabilizer.
> Powerful? Topiramate is like, 4th line treatment for bipolar disorder. Here's a list of mood stabilizers with proven track records:
Depakote, Trileptal, Carbamazapine, Lithium, Lamictal...Topiramate (Topamax) is not FDA approved for bipolar disorder, either; and a 2006 Cochrane review concluded that there is insufficient evidence on which to base any recommendations regarding the use of topiramate in any phase of bipolar illness.
>I agree that Topamax is not the best mood stabilizer.
> Yet, you just overlook...look there...There...Just up your dose of lamictal instead of adding a side-effect conducive medication which has no meaningful data supporting it as a mood stabilizer.
>Yes, but didn't you see me wanting to lose weight?
> Of course you are. That dose is as useful as the dopamax. Its not so easy treating bipolar depression. Its better to rely on AAPs and other novel treatments. Have you tried Riluzole? More data exists supporting its efficacy as a mood stabilizer than Dopemax.
>I am definitely going on Pristiq 100mg. I actually have been taking that since I have an extra pill bottle from a source. It is actually kind of helping, I think. I feel more energy, but it might be the Nuvigil, of course. Most likely is.
> Pristiq's effects on dopamine are negligible. The jusry is still out when it comes to norepenephrine and its role on depression.
>I understand that; however, I do want the NE action as possibly treating my symptoms better.
> NUVIGIL IS NOT A TREATMENT FOR ADHD. Really, only stimulants are the only way to treat ADHD effectively. Maybe you have a little depression masquerading as ADHD.
>I might have depression masquerading as ADHD, but I assure you, as a college student, I have genuine ADHD and the Nuvigil is doing wonders at keeping awake during clas. It is not a substitute for a stimulant which is why I'm thinking about augmenting with Vyvanse-- not Topamax due to your great suggestions!
> It doesn't quite work that way. Research on receptor subtypes has shown that the therapeutic effects of stimulants are strongest at D1 receptors. Stimulants are widely considered the first-line treatment recommendation for ADHD because of their high reported success rate. However, atypical antipsychotics have been shown to treat ADHD symptoms. Specifically, risperidone was shown to improve attention and hyperactivity,26 and aripiprazole has been shown to improve cognitive functioning. Basic Dopamine Theory suggests that stimulants and antipsychotics have activity at most DA receptor-subtypes and in most DA pathways. Basic science confirms this. Complex Dopamine Theory suggests possible new insights into mechanisms of action, but further research is needed. Studies on clinical risks and benefits of concurrent use appear promising but often show conflicting data, and significant kinetic side effects have been described. Most physicians are not concerned, but it can be dangerous to ignore potential receptor interactions. Physicians considering the concurrent use of stimulants and antipsychotics should appreciate the following guiding points:
>Concurrent use of stimulants and antipsychotics should be accompanied with hesitation and caution because of both theoretical and empirical concerns. When using a stimulant and a comorbid disorder indicates an antipsychotic, or vice versa, a trial with a non-DA-medication should be initiated first. (... explanation on dopamine theory)I have tried non-DA medication with no success. I think I will be fine with a stimulant medication in conjunction with my Abilify. Very, very informative on dopamine theory. One of the best pieces of information I've read in a long time. Thank you!
> How so? The exact mechanism of action is unknown.
>I believe it increases histamine, oxerin, and dopamine to some extent, but you're right-- it's still a mystery.
> Not likely. You know what else helps witht cognitive dulling of Topamax? Not taking it.
>You're right. I might not need the Topamax is my doctor puts me back on Vyvanse 60mg.
Abilify 10mg.
>
> Good for mood and keeping your head straight. This can also be increased to improve mood.
>So it is good to increase it since it does improve my mood? I notice you suggest 20. What about 15?
> > Lamictal 200mg.
>
> A higher dose will improve your mood.
>I will definitely move to a higher dosage.
> > * Nuvigil #60 150mg. [300mg.] substituted for Concerta 54mg.
>
> Nuvigil is not a subsitute for Concerta.It is not, but it does help with my fatigue. And, it has helped my stay awake in class. I actually prefer to Concerta for ADHD. I swear. But, not Vyvanse, per se. I switched to Concerta because I wanted to try something different, and it worked OK.
> > * Pristiq 100mg. increase from Pristiq 50mg.
>
> I'd replace this with Rilutek, which shows to be very effective at treating bipolar depression.
>I will definitely look into it seriously since I trust your advice.
> [topiramate] Useless for bipolar disorder - great indications for anxiety, however.
>I need the anxiety relief and weight loss which is why I still think the topiramate is beneficial, and I may stay with Nuvigil for my ADHD since it sincerely helps with that. I might be a special case when it comes to this.
> > Mirapex (pramipexole)
>
> Mood? Has been studied as a treatment for bipolar depression.
>I will consider it also for some slight sexual dysfunction from Pristiq as well as for mood.
> > Namenda (memantine)
>
> May confer some mood benefits.
>I was also hoping for cognitive benefits as well?
> >Gabatril (baclofen)
>
> Useless.
>Good to know.
> Here are my suggestions:
>
> Abilify 20 mg
> Lamotrogine 400 mg
> Switch from Concerta to Vyvanse - dex confers mood benefits and helps with anxiety.
> How about Wellbutrin instead of Pristiq-much better indications for bipolar depression.
> Add Rilutek for depression.Thanks so much for your suggestions. I'm not sure if you read my recap. Here's what I'm on now:
Abilify (aripiprazole)10mg.
Nuvigil (armodafinil) 250mg.
Lamictal (lamotrigine) 200mg.
Neurontin (gabapentin) 1,800mg. [400mg. QID]
Pristiq (desvenlafaxine) 50mg.I'm thinking, based on your advice:
I will stick with this, notice the increase in Abilify, Lamictal and Pristiq:
Abilify (aripiprazole)20mg.
Nuvigil (armodafinil) 300mg.(150mg.x 2)
Lamictal (lamotrigine) 400mg.
Neurontin (gabapentin) 1,800mg. [400mg. QID]
Pristiq (desvenlafaxine) 100mg.I don't think the gabapentin is overkill. It is my primary anti-anxiety med. I found it more effective than my previous clonazepam 0.5mg. TID
I want to add, based on your suggestions:
Aplenzin 522mg. again. I think the Pristiq is minorly effective now, and I'd like to augment with the Wellbutrin in the form of Aplenzin.
Vyvanse 60mg. in conjuction with the Nuvigil.
Augment with Riluzole. This is the exact sort of medication advice I was thinking of! What dosage?
I still want to augment with topiramate for weight-loss and anxiety relief, however. I did not experience cognitive swelling with gabapentin/pregabalin so I'm hoping I can avoid that. I still want to shoot for 200mg. since I'm already taking Lamictal, and I want it to be an add-on.
Therefore, in conclusion, I'm aiming for:
Abilify (aripiprazole)20mg.
Nuvigil (armodafinil) 300mg.(150mg.x 2)
Vyvanse (lisdextroamphetamine) 60mg.
Lamictal (lamotrigine) 400mg.
Neurontin (gabapentin) 1,800mg. [400mg. QID]
Pristiq (desvenlafaxine) 100mg.
Bupropion XL 450mg. (522mg. Aplenzin)
Trodenki XL 200mg.
Mirapex ER 2mg.
Memantine 20mg.
Riluzole 150mg.My pdoc told me she allows a maximum of ten medications and has no problem prescribing that many, if needed. ^^^ the regimen above will be a slow process to reach and may not be needed if symptoms improve. Which should I add first?
I don't expect this to happen all at once, perhaps in a month or two. I've been seeing the pdoc once weekly so I can make faster changes to see results faster. I really want the topiramate for weight loss and anxiety.
What do you think, Eric, about mirtazapine with the Pristiq? It's nicknamed "California Rocket Fuel". Another question I have for you-- in the past when I took Wellbutrin (Aplenzin) alone, I needed a secondary antidepressant to help with my constant lows. What would be a good antidepressant to switch Pristiq out for? I was thinking Savella milnacipran)Read a great review of it here: http://www.dr-bob.org/babble/20110630/msgs/990711.html
Please share further thoughts, Eric. Your post was beyond informative and useful to me. I really, really look forward to your response. I know the above regimen is overkill as well.
Thanks!!
------------
To SLS, 50mg. Pristiq = 300mg. venlafaxine. And, I appreciate your comment, it was a good one!
poster:LouisianaSportsman
thread:1051278
URL: http://www.dr-bob.org/babble/20130930/msgs/1051500.html