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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by silmarilone on October 24, 2005, at 22:01:09
I'm on trilafon 4mg twice a day. I'm feeling slightly restless, and unable to relax, and yet a bit lethargic, and vaguely anxious. Does this go away over time? Is it a side effect or the main effect?
Thanks
Posted by ed_uk on October 25, 2005, at 13:50:40
In reply to Antipsychotic [side] effects?, posted by silmarilone on October 24, 2005, at 22:01:09
Hi S,
>I'm feeling slightly restless, and unable to relax...
For what condition have you been prescribed Trilafon? Do you have a diagnosis? Were you restless before you started taking Trilafon?
Trilafon can cause a side effect called akathisia - a particularly unpleasant form of restlessness. If akathisia occurs, a dose *reduction* is often helpful. If an alternative drug is available, you might be able to discontinue the Trilafon and take something else instead.
If a reduction in dose is not feasible and no alternative drugs are available, several meds can be prescribed to relieve akathisia. Procyclidine (or another anticholinergic) and propranolol are examples.
Perphenazine (Trilafon), haloperidol (Haldol), trifluoperazine (Stelazine) and similar high-potency neuroleptics have the advantage of causing less weight gain than some of the newer antipsychotics such as Zyprexa. Tardive dyskinesia is much more likely though. It's best to use the absolute minimum dose necessary. The presence of akathisia suggests that the dose is too high.
Some of the newer antipsychotics, Abilify in particular, have a reduced risk of weight gain. Have you tried Abilify?
Kind regards
~Ed
Posted by silmarilone on October 25, 2005, at 15:52:11
In reply to Re: Antipsychotic [side] effects? » silmarilone, posted by ed_uk on October 25, 2005, at 13:50:40
>
> For what condition have you been prescribed Trilafon? Do you have a diagnosis? Were you restless before you started taking Trilafon?Bipolar disorder--I was on zyprexa but stopped because of high blood sugar, and weight gain.
>
> Perphenazine (Trilafon), haloperidol (Haldol), trifluoperazine (Stelazine) and similar high-potency neurolepticsTrilafon, according to my doc falls in the "medium" potency category...
have the advantage of causing less weight gain than some of the newer antipsychotics such as Zyprexa.
I certainly hope so!
Tardive dyskinesia is much more likely though. It's best to use the absolute minimum dose necessary. The presence of akathisia suggests that the dose is too high.
I'm taking 8mg per day, bid
>
> Some of the newer antipsychotics, Abilify in particular, have a reduced risk of weight gain. Have you tried Abilify?Abilify caused EXTREME akithisia and anxiety, and insomnia...
I decided to try the trilafon after hearing about the study where they said it was just as effective as atypicals and with fewer side effects in low doses...
Posted by ed_uk on October 25, 2005, at 16:29:44
In reply to Re: Antipsychotic [side] effects?, posted by silmarilone on October 25, 2005, at 15:52:11
Hi S,
>Bipolar disorder
Perphenazine can treat mania. In general, it doesn't relieve depression - and has a tendency to make it worse.
>Trilafon, according to my doc falls in the "medium" potency category...
Semantics........
IMHO, perphenazine is really very similar to haloperidol (Haldol) ...but it (perphenazine) does tend to be a bit more sedating. Haloperidol has the advantage of being a more thorougly studied drug. Partly due to the tendency of pdocs to prescribe vastly excessive doses, haloperidol has achieved a particularly infamous reputation. Such high doses can cause horrendous side effects. At equivalent doses, perphenazine and haloperidol would be expected to have a similar incidence of side effects. 8 mg perphenazine is comparable to about 2.5 mg haloperidol.
>I'm taking 8mg per day, bid
I think you should reduce the dose. I'd recommend trying 2mg twice a day. 2mg bid might sound too low - but it probably isn't. Traditional doses of perphenazine were generally excessive.
>Abilify caused EXTREME akithisia and anxiety, and insomnia...
What dose did you try? Have you tried Geodon?
>I decided to try the trilafon after hearing about the study where they said it was just as effective as atypicals and with fewer side effects in low doses...
The problem with perphenazine (and haloperidol) is the high incidence of tardive dyskinesia following long-term use.
Kind regards
~Ed
Posted by silmarilone on October 25, 2005, at 16:43:31
In reply to Potent neuroleptics » silmarilone, posted by ed_uk on October 25, 2005, at 16:29:44
> Perphenazine can treat mania. In general, it doesn't relieve depression - and has a tendency to make it worse.I'm taking wellbutrin xl as well.
> >I'm taking 8mg per day, bid
>
> I think you should reduce the dose.I meant to say, 4mg bid, for a total of 8.
> >Abilify caused EXTREME akithisia and anxiety, and insomnia...
>
> What dose did you try? Have you tried Geodon?I got the akathisia and anxiety with 5mg abilify. Geodon was similar, altho sedating as well. Plus it was very difficult to get the same effect every time, since it varied widely with the type and amount of food eaten with it.
>
> >I decided to try the trilafon after hearing about the study where they said it was just as effective as atypicals and with fewer side effects in low doses...
>
> The problem with perphenazine (and haloperidol) is the high incidence of tardive dyskinesia following long-term use.Is the incidence high with long term use in LOW doses? I'm not sure that's even been studied. Plus, no one has any idea whether the atypicals will also have TD after long term use, as they've not been around long enough... ?
>
> Kind regards
>
> ~EdThanks very much!
ps--I may start a clinical trial of namenda, the alzheimer's drug by Forest which is being tried on bipolar....
Posted by ed_uk on October 26, 2005, at 14:08:48
In reply to Re: Potent neuroleptics, posted by silmarilone on October 25, 2005, at 16:43:31
Hi Thomas,
>I meant to say, 4mg bid, for a total of 8.
I know :-)
>Is the incidence high with long term use in LOW doses?
It's probably quite high. In the treatment of bipolar disorder, classical neuroleptics are most suitable for short-term use.
>Plus, no one has any idea whether the atypicals will also have TD after long term use, as they've not been around long enough...?
Evidence suggests that the atypicals are significantly less likely to cause TD than the classical neuroleptics. The newest atypicals eg. Abilify have not yet been well studied RE the risk of TD.
Kind regards
~ed
Posted by med_empowered on October 27, 2005, at 14:57:32
In reply to Re: Potent neuroleptics » silmarilone, posted by ed_uk on October 26, 2005, at 14:08:48
hi! OK, so the situation with old-school antipsychotics is kinda complicated right now. Since the atypicals have their problems--they do cause TD, and they often cause weight gain and/or diabetes--there's been renewed interest in trying lower doses of the standard drugs, since consensus seems to be that they were given in excessive amounts in the past (interestingly, there also seems to be a tendency to prescribe atypicals ABOVE studied doses). TD tends to occur more often where there are "mood issues"--schizoaffective, schizophrenia with significant mood components, bipolar, and psychotic mood disorders--so its definitely something to be concerned about. TD **might** be related to "oxidative stress"; apparently, antipsychotics tend to promote free radical formation and damage to the brain (maybe atypicals do this a bit less?)...its this theory that's formed the basis of using vitamin E to treat tardive dyskinesia, with mixed (and not too exciting) results. My concern is that you're taking this for bipolar disorder--although bipolar often has a psychotic component, it is first and foremost a mood disorder, so your risk of TD is higher than that of people with schizophrenia. The rate for TD with the old drugs is given as 20% after 5 years; long term, the estimates range from 30% to over 50%..my own guess is that the higher estimates are probably closer, since they take into account ALL forms of TD (some of the lower numbers were calculated by artificially removing the most mild and most severe cases, and also removing the number of cases of TD that were expected to go into remission...a good number of TD cases will stop or get better, but the process can take years). TD is also linked by some people to an overall decline on cognitive function, and there's some indication that, at least with the old drugs, long-term neuroleptic use can cause a reduction in cognitive skills. Keep in mind that when Thorazine was first being used on the mentally ill, it was openly referred to as a "chemical lobotomy"; the il-effects on cognition and personality can be pretty profound. For the akathisia..you should first try dose reduction. While reducing the dose, your doc can also add something--propranolol, Cogentin, a benzo-- to help as well. The best numbers I've heard for TD with the new drugs relate to zyprexa...the incidence is I believe estimated to be .5-1%/year. Abilify doesn't have good data on it for TD yet, but it looks pretty promising...there doesn't appear to be very much up-regulation of the D2 receptors (probably b/c of the agonist/antagonist action) and it also appears to be great at treating existing cases of TD w/o worsening the syndrome (this is similar to clozapine, which has a very low rate of TD). I dont want to push you to change something thats working for you but...with Abilify, the akathisia seems to go away after the start-up; co-prescribing with a benzo or propranolol can help significantly (20mgs propranolol, 3-4X daily helped a lot for me). The added benefits are clearer cognition (b/c of the lack of sedation, probably), weight-neutrality, and some antidepressant action. Abilify can also be used with old drugs--I read a case study where a woman with marked TD was given Abilify, 30mgs, plus Thorazine, 300mgs..the TD went away pretty much completely, and the added Thorazine didn't cause a worsening of the TD or much of a change at all from "normal" on the involuntary movements scale. I imagine you could do a cross-taper, so you could eventually end up just on abilify after a bit of time on perphenazine+abilify. But..if you opt to stay on perphenazine, I guess I'd recommend that you keep the dose at an **absolute** minimum, especially since you have bipolar..the goal should be no EPS, no akathisia w/o having to use add-on medication. In addition, supplementing antioxidants might be useful--when I was on neuroleptics, I always took a multi-vitamin, plus extra vitamin e/c (combo pill), selenium, and alpha lipoic acid. Adding a benzo may also help minimize the antipsychotic dose (some studies show xanax, ativan, and klonopin as being the benzos of choice for this sort of thing). Good luck!
Posted by theo on October 27, 2005, at 22:59:49
In reply to Re: Potent neuroleptics, posted by med_empowered on October 27, 2005, at 14:57:32
I'm glad to catch your post on Abilify. I have a full scrip of 5mg tabs and I'm suppose to start at 2.5mg. My pdoc wants me to try it because all SSRI's have failed and not much luck with anticonvulsants. My symptoms are depression, (possibly BP2) and/or ADD.
I have been scared to death because of all the TD info I read with the older and some newer antipsychotics. Are Abilify's stats pretty low so far for TD?
My pdoc and regular doc seem pretty unconcerned with this med especially for short term. They both seem to express TD usually comes after many years of exposure. It just freaks me a little bit because I can function without meds but it is a horrible struggle and I feel I need to try to find something to help me function daily versus having so many "off" days.
Do you take Abilify at night or morning? My doc prescribed it at night, but it seems I keep hearing about it being activating?
Posted by med_empowered on October 28, 2005, at 12:21:42
In reply to Re: Potent neuroleptics » med_empowered, posted by theo on October 27, 2005, at 22:59:49
Honestly, no one knows the extent to which Abilify can cause TD, and we probably won't know for a good 5-10 years. I havent heard of any TD cases with Abilify, but that just may be poor reporting. I think its kind of scary how much health professionals have bought into this whole "the atypicals are great! patients and doctors love them so!" myth. I mean, they certainly beat out having to take Haldol, but they're serious drugs..its not like popping an aspirin. Abilify did help me when other stuff couldn't...I had what I guess would be "low-grade" psychosis at the time, the kind of thing that pops up in some forms of Bipolar. Low-dose, short-term Abilify could be helpful but...as a general rule, I think its a good idea to try other things before turning to antipsychotics unless you're floridly psychotic. So..you the SSRIs haven't helped (thats pretty common). Have you tried Tricyclics? benzos? If you're dealing with depression, has your doc tried stimulant+ad combos and what not? If you want to take Abiify, please do its just...I hate to see people kind of cornered into making decisions by docs who tell them "we've tried everything else" when, in fact, they **haven't**. Surmontil is a good Tricyclic that has low-level antipsychotic action (no EPS at usual doses, from what I understand). Its kind of clozapine-ish, only weaker on the D2 receptors, so there's more of a calming, mood-stabilizing and lifting action than with say..Prozac. If bipolar is a possibility, adding in some Klonopin might help. You might also want to try Provigil. Good luck!
Posted by theo on October 28, 2005, at 23:03:14
In reply to Abilify and TD, posted by med_empowered on October 28, 2005, at 12:21:42
My pdoc seems to think stimulants are the absolute last resort, as if they are more dangerous than Abilify.
The problem is sometimes I don't, nor my doc, know what I am (diagnosis wise)! It's such a guessing game trying to find a med that fits. I'm sure at this point I'll give it a trial and see how I react to it. I'll be taking just 2.5mg. Would a couple of weeks with this type of med be a fair trial or does it take more time like with SSRI's?
Do you take it AM or PM?
Posted by SLS on October 29, 2005, at 1:36:56
In reply to Re: Abilify and TD » med_empowered, posted by theo on October 28, 2005, at 23:03:14
> I'll be taking just 2.5mg. Would a couple of weeks with this type of med be a fair trial or does it take more time like with SSRI's?
>
> Do you take it AM or PM?
Personally, I don't think 2.5mg is enough to adequately evaluate Abilify for depression. 5.0mg would be better. If the 5.0mg works, you can always attempt to reduce it. You should know in a couple of weeks what this drug is going to do for you. Be prepared for some anxiety, insomnia, or mild to moderate akathisia to appear in the first week as a startup side effect. It usually disappears.
- Scott
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