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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by zeugma on August 10, 2004, at 22:58:20
I am currently trying Provigil in the hope of findng a way to keep my energy from getting depleted too easily without causing insomnia. I find that 100 mg causes me to crash in the mid-afternoon. My pdoc is reluctant to prescribe any more, because I reported a lot of insomnia when i started the med. The situation is perverse: I am ALWAYS fatigued, no matter how much sleep I get (the week I went off Strattera and was taking 100 mg nortriptyline I had the best sleep of my life, but still felt severely anergic) but also have great difficulty falling asleep. I seem to have narcolepsy in which the auxiliary symptoms (sleep paralysis, hypnagogic hallucinations) interrupt my sleep UNLESS I have something (nortriptyline, buspirone) that potently blocks REM in my system. By 4 pm it seems the REM suppressant effect of nortriptyline has worn off and when I try to take a nap I immediately go into REM and wake up in discomfort. Actually it's probably cataplexy because I still feel awake at the time I start dreaming, and have the REM atonia.
Anyway, just babbling, i'm frustrated with how tired I always am but hate the insomnia too. Insomnia does not make me more tired, but does induce a nasty dysphoria. Tomorrow i'll try a little Ritalin and see if that helps my sleepiness without keeping me up all night.
Posted by Sad Panda on August 11, 2004, at 0:33:33
In reply to perversely caught between insomnia and fatigue, posted by zeugma on August 10, 2004, at 22:58:20
> I am currently trying Provigil in the hope of findng a way to keep my energy from getting depleted too easily without causing insomnia. I find that 100 mg causes me to crash in the mid-afternoon. My pdoc is reluctant to prescribe any more, because I reported a lot of insomnia when i started the med. The situation is perverse: I am ALWAYS fatigued, no matter how much sleep I get (the week I went off Strattera and was taking 100 mg nortriptyline I had the best sleep of my life, but still felt severely anergic) but also have great difficulty falling asleep. I seem to have narcolepsy in which the auxiliary symptoms (sleep paralysis, hypnagogic hallucinations) interrupt my sleep UNLESS I have something (nortriptyline, buspirone) that potently blocks REM in my system. By 4 pm it seems the REM suppressant effect of nortriptyline has worn off and when I try to take a nap I immediately go into REM and wake up in discomfort. Actually it's probably cataplexy because I still feel awake at the time I start dreaming, and have the REM atonia.
>
> Anyway, just babbling, i'm frustrated with how tired I always am but hate the insomnia too. Insomnia does not make me more tired, but does induce a nasty dysphoria. Tomorrow i'll try a little Ritalin and see if that helps my sleepiness without keeping me up all night.
>
>Hi Z,
In the list of AD's that I can get on the Australian PBS, Clomipramine is reserved for Cataplexy associated with narcolepsy, Obsessive-compulsive disorder & Phobic disorders in adults.
Might be the excuse you need to try Clomipramine. It would be fairly easy to switch between Clomip. & Nort.
Cheers,
Panda.
Posted by King Vultan on August 11, 2004, at 7:40:12
In reply to perversely caught between insomnia and fatigue, posted by zeugma on August 10, 2004, at 22:58:20
FWIW, Nardil potently inhibits REM sleep, and I do not recall having a single dream in the months I was on it at therapeutic dosages. Unfortunately, it often induces insomnia and certainly did for me, anyway. As I tapered down recently, I began encountering this REM rebound syndrome thing when I got down to around 45 mg/day. I found it relatively unpleasant, but it is starting to go away.
It seems like any drug that works strongly on norepinephrine has a tendency to inhibit REM sleep. Other possibilities for you that might help with your fatigue are Parnate or selegiline, but both of these are likely to induce insomnia (however, they do both have a significant effect on norepinephrine). It would seem easy enough to take a sedating benzo or antihistamine as a sleep aid for this, but I don't know how well these kinds of things work for you with your narcolepsy/cataplexy issues.
Todd
Posted by Racer on August 11, 2004, at 12:30:36
In reply to perversely caught between insomnia and fatigue, posted by zeugma on August 10, 2004, at 22:58:20
I've had a problem similar to what you're describing, and I take Provigil -- and I found a solution that works for me and might be worth a try for you, too.
When I first started Provigil, I went into the Land Of Speediness And Discomfort -- which lasted about a week, maybe less. Sounds as if you have visited, too? And then, at 100mgs each morning, I'd crash about 3:30, 4:00 in the afternoon. (Morning dose between 7 and 8 AM) Going up to 150mg in the morning made me speedy again -- until the afternoon crash came at the same time. Great...
What seems to work pretty dang well, though, is taking the 100mg at breakfast, and 50mg at lunch. The first few days, of course, were {ahem} not so pleasant, but after that it's been quite nice. There's not so much a crash, anymore, as a smooth slide into sleep around 10:30 or 11:00; the speediness eased after a few days; and I'm pretty consistently feeling the benefits all day.
Ironically, on the single, 100mg dose, with the afternoon crash -- I'd have more trouble with insomnia than I do now with the second, smaller dose at noon. (I know, I'm weird in my reaction to this drug. Still, it might be helpful to you, too, so it might be worth a try.) (Oh, yeah, and I do like provigil, so I probably overshare the enthusiasm for it. This is an anecdotal report of something that helped me through something that sounds similar to what you're experiencing. Nothing more.)
Best luck.
Posted by zeugma on August 11, 2004, at 16:51:38
In reply to Re: perversely caught between insomnia and fatigue » zeugma, posted by Racer on August 11, 2004, at 12:30:36
Hi, thanks to all for your helpful suggestions.
I have a torturous concatenation of problems, but 10 mg Ritalin LA had me much more calm than 100 mg Provigil. of course I don't know yet how it's going to affect my sleep.
Racer, YES, the Provigil crash! it is absolutely horrendous. I did wonder what would happen if I split the Provigil dosage, or took an extra 25 or 50 mg mid afternoon. I will keep that in mind if the Ritalin doesn't work out. But it seems, from today's trial, that Ritalin does a much better job of making me feel cognitively normal, as well as lowering the fatigue level. It could be that my ADD is so severe that maintaining any kind of sustained attention results in exhaustion, and the Ritalin kept my nerves at a much lower pitch as I did my tasks. And so far no sign of that afternoon crash, although I do feel tired.
Panda, I'll consider CMI if and when my depression returns. Playing around with Provigil and Ritalin is enough tweaking for the moment. Clomipramine is my preference over adding Lexapro to nortriptyline, but I don't feel absolute about that: the advantage of lexapro would be the ability to add, say, 2.5 mg to my existing regimen and seeing what happens. But that's looking ahead a little.
KV, I know the MAOI's are powerful REM suppressors. I metabolize TCA's quickly, so nortriptyline's REM-suppressant effect wears off by the afternoon, and I understand that would not be a problem with an MAOI. I think a nortriptyline-Ritalin combination would be similar to Parnate, theoretically at least. I think Ritalin, because of its stronger NE properties, has been shown to be more effective than provigil in suppressing cataplexy, although many narcoleptics need TCA's too. Also, as you point out, MAOI's tend to induce insomnia. Benzos are out as sleep aids for me, as Klonopin can actually induce cataplexy. I don't know if the other benzos are as problematic in this regard, but my current dose of nortriptyline (100 mg) has resulted in an complete suppression of dreaming at night and I'm quite happy with that.
Thanks to all, and I will keep you updated,
z
Posted by zeugma on August 11, 2004, at 17:33:57
In reply to Re: perversely caught between insomnia and fatigue, posted by zeugma on August 11, 2004, at 16:51:38
just for a quick update (as well as a guage of how unpleasant the 'crash' about this time is for me), I fell asleep twice in the last 25 minutes and went into REM immediately (full-blown dreaming- both episodes were unpleasant but one of them I was REALLY glad was only a dream!- I'll say no more!). There is no question that the stimulants worsen my sleep hygiene and that makes me much more prone to these episodes, which then aggravate the problem as the struggle to awaken leads me to develop tension headaches- and no, I can't simply stay asleep, as I'm actually awake and asleep at the same time- it's like getting two sets of mutually contradictory sense evidence simultaneously- extremely strange and disruptive.
I'll have to see. Maybe a higher dose of Ritalin, or a dose later in the day? I had a cup of .5 caffeinated coffee when i got home today, anticipating this sort of problem, but I also obviously didn't want to drink too much java and wind up wired.
I'm going to have to figure out something with my pdoc. These conditions are a pain in the a*** (and I'm not usually prone to outbursts of that kind!). I'll put on some music and try to relax.
-z
Posted by Ktemene on August 12, 2004, at 23:04:09
In reply to Re: perversely caught between insomnia and fatigue, posted by zeugma on August 11, 2004, at 16:51:38
Hi Zeugma,
I was hoping that the Ritalin would not give you the horrible insomnia that you were getting with Provigil. Of course you have only had one or two nights experience with Ritalin's effects by now. But I was wondering how it was going? Any improvements?
Ktemene
> Hi, thanks to all for your helpful suggestions.
>
> I have a torturous concatenation of problems, but 10 mg Ritalin LA had me much more calm than 100 mg Provigil. of course I don't know yet how it's going to affect my sleep.
>
> Racer, YES, the Provigil crash! it is absolutely horrendous. I did wonder what would happen if I split the Provigil dosage, or took an extra 25 or 50 mg mid afternoon. I will keep that in mind if the Ritalin doesn't work out. But it seems, from today's trial, that Ritalin does a much better job of making me feel cognitively normal, as well as lowering the fatigue level. It could be that my ADD is so severe that maintaining any kind of sustained attention results in exhaustion, and the Ritalin kept my nerves at a much lower pitch as I did my tasks. And so far no sign of that afternoon crash, although I do feel tired.
>
> Panda, I'll consider CMI if and when my depression returns. Playing around with Provigil and Ritalin is enough tweaking for the moment. Clomipramine is my preference over adding Lexapro to nortriptyline, but I don't feel absolute about that: the advantage of lexapro would be the ability to add, say, 2.5 mg to my existing regimen and seeing what happens. But that's looking ahead a little.
>
> KV, I know the MAOI's are powerful REM suppressors. I metabolize TCA's quickly, so nortriptyline's REM-suppressant effect wears off by the afternoon, and I understand that would not be a problem with an MAOI. I think a nortriptyline-Ritalin combination would be similar to Parnate, theoretically at least. I think Ritalin, because of its stronger NE properties, has been shown to be more effective than provigil in suppressing cataplexy, although many narcoleptics need TCA's too. Also, as you point out, MAOI's tend to induce insomnia. Benzos are out as sleep aids for me, as Klonopin can actually induce cataplexy. I don't know if the other benzos are as problematic in this regard, but my current dose of nortriptyline (100 mg) has resulted in an complete suppression of dreaming at night and I'm quite happy with that.
>
> Thanks to all, and I will keep you updated,
>
> z
Posted by zeugma on August 13, 2004, at 4:40:53
In reply to Re: perversely caught between insomnia and fatigue » zeugma, posted by Ktemene on August 12, 2004, at 23:04:09
Hi Zeugma,
I was hoping that the Ritalin would not give you the horrible insomnia that you were getting with Provigil. Of course you have only had one or two nights experience with Ritalin's effects by now. But I was wondering how it was going? Any improvements?
Ktemene
Hi ktemene,
Thanks for the concern. On the night when I had a really bad crash, I had taken the Ritalin with a little Provigil. Yesterday I took only the Ritalin, and i had no trouble at all falling asleep, although I woke up early this morning. This is a common reaction I have to starting meds, and isn't so bad anyway. The Ritalin definitely seems to work better for my ADHD. Also (and I suppose this is common) it had an immediate benefit in terms of calmness and attention, while it took the Provigil quite a while to get a benefit from it.
-z
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