# Advice for an antidepressant needed



## Gene53 (Jun 20, 2008)

Hi,

After being "overly nervous and anxious" most of my life, I was finally diagnosed with Chronic Anxiety Disorder, Panic Disorder, PTSD and other CNS disorders 12 years ago and after trying all kinds of meds, my ex-physician and I concluded that Rivotril (clonazepam, 1mg twice/day) was the most successful one at keeping me on an even keel.

Due to some events which have been happening for the past few years, I slowly sunk into depression and for the past year, severe depression.

I've finally coaxed myself to see a psychologist and he suggested I also get a prescription for an antidepressant (plus psychotherapy) but I'm quite aware that clonazepam doesn't jive too well with other meds.

Any advice on compatible meds would be appreciated.

Thanks,
Gene


----------



## braveheart (Jun 21, 2008)

I don't know about compatible meds, but I'm on mirtazapine for similar problems. [I have depression as well.] Others've been on efexor for such diagnoses, but it didn't work out for me, mainly because I needed a sedating anti-depressant.


----------



## Into The Light (Jun 21, 2008)

you did really well going to a psychologist. that's the first step, and not easy when depressed! :goodjob:

with regard to medication, i don't know too much about that. i think your best bet would be to see your doctor about this, or get a referral to a psychiatrist who is specialized in these medications. i am sure there must be some med combination out there that will work.


----------



## Retired (Jun 21, 2008)

The selection of an appropriate medication can only be made by your physician.

Based on your medical history, along with family medical and medication history, along with your physician's clinical experience, your physician may have a medication regimen to propose.

No one on the internet can make a diagnosis and recommend medications reliably and especially ethically.



> but I'm quite aware that clonazepam doesn't jive too well with other meds.



Specifically what are your concerns about clonazepam?


----------



## David Baxter PhD (Jun 21, 2008)

There's not usually a problem being on an SSRI and clonazepam at the same time. Many of my clients take both.


----------



## Gene53 (Jun 21, 2008)

> you did really well going to a psychologist. that's the first step, and not easy when depressed!


How right you are, I started thinking about seeing one more than 6 months ago but procrastinated till I just couldn't take it any more. I've been cooped up for so long (went out only once since January) that I almost flipped-out (anxiety attack) about an hour before the appointment.



> i am sure there must be some med combination out there that will work


Sure hope so, everything I looked at on the net left me confused more than anything else.



> Specifically what are your concerns about clonazepam?


After being on this for over 12 years, I'm afraid I'm starting to feel the side-effects more than it's benefits. The first 7 years were OK then we had to increase the dosage from 1mg to 2mg/daily due to tolerance to the med and it wasn't working as well as it did.

When this med was working well, I used to take half a tablet in the morning and the other half before going to bed. Before the depression set in, the morning dosage would make me feel a little "woozy" 30 to 45 minutes after taking it but this feeling only lasted about 20 minutes or so.

But, for the past 8 months or so, I've been feeling more side effects and those uncomfortable feelings lasted for over an hour and for the past 6 weeks, even worse. It starts off with dizziness and tiredness (kind of like a 'hangover' effect), after an hour or two I feel irritable, restless, tremors, muscle cramps, tense, etc. and frequently builds up to an anxiety attack. I also have difficulty sleeping (frequent insomnia), feeling tired when getting up in the morning and a major decrease in libido.

In conclusion, I wonder if all of this is due to the clonazepam's side-effects, the depression or a combination of both. For the past 5 days I've been experimenting with the dosage (not exceeding the prescribed amount) and medication schedule. I now wait about 2 hours after breakfast and only take .500mg then wait 4-5 hours for the other 
.500mg then have my usual 1mg before bedtime and these strange feelings have subsided quite significantly.



> There's not usually a problem being on an SSRI and clonazepam at the same time. Many of my clients take both.


Thanks David, that was quite reassuring. I'll look up the various SSRI's so I'll have some kind of knowledge (compatibility, side-effects, etc.) before I see a physician or psychiatrist, had a few bad experiences in the past (diagnosis) and now do my "homework" before I commit myself to any kind of treatment...

Thank you all,
Gene


----------



## Retired (Jun 21, 2008)

You may want to ask your doctor if the reason you are experiencing these adverse effects now that you are taking an anti-depressant along with clonazepam, that you may be experiencing some drug / drug interaction, which may require:


switching to a different benzodiazepine (minor tranquilizer) or 
switching to a different anti depressant, or
you may require a dosage change.

Most SSRI's _do_ cause some side effects during the first few weeks, while your brain chemistry becomes acclimated to the new medication, but if after eight months you are experiencing drowsiness, light headedness and agitation, you would do well to report these to your doctor.

As for the decrease in libido, it may also be caused by the SSRI, but may also be a by-product of the illness of depression.  But it too should be included in your discussion with the doctor.  Usually an SSRI will cause difficulty in ejaculation, but it is well worth discussing with your doctor.

In your research, to prepare for your discussion with your doctor, consider that, based on the prescribing information for clonazepam, the manufacturer warns against potential drug / drug interactions at a site in the liver involving the cytochrome p-450 enzyme.

In the Psychlinks section discussing drug interactions, you will find extensive material on cytochrome p-450.

Some SSRI's compete for cytochrome p-450 while others do not, as do many other classes of medications.

That is to say, among many classes of medications, there are some which do require this metabolic pathway, while others do not, so the goal is to minimize the number of meds competing for the same liver enzyme.

The effect of two or more medications competing for this liver enzyme is that one or more of the medications may be poorly absorbed into the bloodstream, or too much may be absorbed resulting in adverse effects.

Your doctor along with your pharmacist should be able to provide you with options in the selection of the best combination of medications.

You can always use one of the medication interaction checkers that are listed in the Psychlinks medications interactions section.

Please also read Medicine-Net on clonazepam drug interactions

The Roche product monograph for clonazepam


----------



## Gene53 (Jun 21, 2008)

Hi Steve, thanks for the reply and the useful links.



> You may want to ask your doctor if the reason you are experiencing these adverse effects now that you are taking an anti-depressant along with clonazepam, that you may be experiencing some drug / drug interaction, which may require:
> 
> * switching to a different benzodiazepine (minor tranquilizer) or
> * switching to a different anti depressant, or
> * you may require a dosage change.


As I mentioned in my first post _"I've finally coaxed myself to see a psychologist and he suggested I also get a prescription for an antidepressant (plus psychotherapy) but I'm quite aware that clonazepam doesn't jive too well with other meds. Any advice on compatible meds would be appreciated."_, so I haven't been prescribed an antidepressant yet because I only went to see the psychologist yesterday (Friday) so I'll have to wait till Monday to find an MD or psychiatrist. I've been living in Central America for the past 7 years and had to return to Canada 14 months ago to take care of a family emergency and will be going "back home" in 3 or 4 months. Needless to say, I don't have a physician here.

The weird thing is that those ill effects are probably a result of either the side-effects of the clonazepam (which is the only med I take and can provoke and/or aggravate depression after long-term use), a combination of the clonazepam and the depression or maybe the clonazepam just doesn't cut it any more and needs to be replaced with another med (or a combination of).

Once again, thanks for the links and info, much appreciated.

Cheers,
Gene


----------



## David Baxter PhD (Jun 22, 2008)

As I said in the PM, you might do best by starting one of the dual action SSRI/SNRIs - Cymbalta or Effexor - and then trying to taper down or off the clonazepam slowly. Your psychologist might provide a bit of background with such a recommendation to a family physician.


----------



## Gene53 (Jun 22, 2008)

Hi David,



David Baxter said:


> As I said in the PM, you might do best by starting one of the dual action SSRI/SNRIs - Cymbalta or Effexor - and then trying to taper down or off the clonazepam slowly.



Thanks for reply and I do feel I should taper down on the clonazepam till completely off it, I read on quite a few Mental Health forums/sites that prolonged use of this drug may cause most of what I've been feeling since the depression started and the side effects have increased along with the severity of my depression, which is now at it's worst (I really feel like I'm "losing it" and spend most of my days on an"anxiety roller coaster ride").

Another good reason to ween myself off it is that I have to take a SSRI/SNRI and the combo of any two meds do have interactions (from Drugs.com):

_Clonazepam and Prozac, Effexor, Cymbalta, Celexa or escitalopram *(Moderate Drug-Drug)*
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.

MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring complete mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities._

So, if I'm going to be on a certain med (or a combo of), I'd sure as heck would like to have the least interactions/side-effects possible plus not making other ailments worse (PTSD, panic and other CNS disorders). If ever "big pharma" needs a "Side-Effects Poster Boy", I'd sure as heck be eligible, this is one of the reasons why I take meds only when absolutely necessary.



> Your psychologist might provide a bit of background with such a recommendation to a family physician.


I'm seeing the psychologist again on Friday and we'll take a little time to discuss the above meds, darn thing is, with so few available doctors, I'm afraid it might take a little time before I do find one who will do follow ups in case I might need to modify the dosage and/or drug(s).

Cheers and thanks again,
Gene


----------



## Halo (Jun 22, 2008)

Gene,

I know that I am sort of late coming into this thread and you have already received a lot of great information and suggestions but I just wanted to say that I am on an SSRI and Clonazepam together and have been now for almost 2 years and have had no interactions between the two.  While I am now on a milder dose of Clonazepam, at one point I was on a stronger dose and even then I didn't have any difficulties.  I know that it is scary to be adding medication with the potential of side-effects and all but I just basically wanted to let you know that it is possible to take both an SSRI or SNRI and Clonazepam together.

Anyway, I do think the best thing to do is to talk to your psychologist and then to your family doctor/psychiatrist and work out the best plan of action for you.

Good luck :goodluck:


----------



## Gene53 (Jun 22, 2008)

Hi Halo,



> I am on an SSRI and Clonazepam together and have been now for almost 2 years and have had no interactions between the two


Thanks, that's quite comforting to know. Mind you, the clonazepam isn't doing what it's supposed to anymore, as I mentioned in one of my posts, I'm on an "anxiety roller coaster ride", as if the clonazepam has turned into a placebo.



> then to your family doctor/psychiatrist and work out the best plan of action for you


That'll be the hardest part, finding a doctor and/or a psychiatrist.. 

Thanks,
Gene


----------



## Halo (Jun 23, 2008)

Gene53 said:


> That'll be the hardest part, finding a doctor and/or a psychiatrist..



I know that it will probably be difficult giving what the waiting lists can be for a family doctor and psychiatrist however hopefully your psychologist will have some ideas or solutions which may help.

Good luck :goodluck: and let us know how it goes.


----------



## Retired (Jun 23, 2008)

There should be no concern about being prescribed an antidepressant medication along with a minor tranquilizer (benzodiazepine) since this a common treatment strategy.

The only consideration should be the correct choice of the combination, and most physicians should be aware of the potential for metabolic interaction between compounds.  If there is an oversight, the pharmacist will usually pick these up, as long as all prescriptions are purchased at the same pharmacy (chain).



> as if the clonazepam has turned into a placebo



Perhaps not.  Your dosage may need to be adjusted, to regain the effectiveness you previously experienced.  Another explanation might be that you are taking another prescription or even a non prescription medication that may be interfering with the clonazepam.

A number of non prescription meds such as cold and cough remedies or digestive disorder remedies (eg. Tagamet) or even pain relievers could be interfering with the clonazepam.

Gene,  you may want to make a list of everything you are taking and have a conversation with your pharmacist.  Be sure to speak to a pharmacist and _not_ a pharmacy technician.  You may get some insight into what's going on.


----------



## Gene53 (Jun 23, 2008)

Halo said:


> I know that it will probably be difficult giving what the waiting lists can be for a family doctor and psychiatrist however hopefully your psychologist will have some ideas or solutions which may help.


Gee, this doctor situation is awful, the list of available doctors posted on the College of Physicians websites (both Ontario and Quebec) are outdated. So far, I must have called 15 places and got a "nay"... 



> Good luck :goodluck: and let us know how it goes.


Thanks and will do.

Such a lousy health care system, I'll be ecstatic to return to Central America in a few months, where everything is so much easier... :wave4:

Cheers,
Gene


Hi Steve, how are you?



TSOW said:


> There should be no concern about being prescribed an antidepressant medication along with a minor tranquilizer (benzodiazepine) since this a common treatment strategy.


I'm now convinced that it's the way to go, along with psychotherapy (and a heck of a good diagnosis).



> The only consideration should be the correct choice of the combination, and most physicians should be aware of the potential for metabolic interaction between compounds.  If there is an oversight, the pharmacist will usually pick these up, as long as all prescriptions are purchased at the same pharmacy (chain).


Makes sense but finding an MD is quite challenging whereas pharmacists are readily available, sure wish they could prescribe... On second thought, maybe I'd have better luck seeing my cat's veterenarian. LOL!



> _"as if the clonazepam has turned into a placebo"_
> Perhaps not.  Your dosage may need to be adjusted, to regain the effectiveness you previously experienced.  Another explanation might be that you are taking another prescription or even a non prescription medication that may be interfering with the clonazepam.


You may be right about the clonazepam, maybe a simple adjustment in dosage (along with an SSRI/SNRI) just might do the trick.



> A number of non prescription meds such as cold and cough remedies or digestive disorder remedies (eg. Tagamet) or even pain relievers could be interfering with the clonazepam.


As I mentioned in one of my above posts, I'm not the type who likes to take meds. The only other "natural" med I'm now using is DGL ([SIZE=-1]Deglycyrrhizinated Licorice, wanted to post a link but I don't have the right to yet) [/SIZE]which I'm taking for my peptic ulcer and GERD (which the depression and anxiety has "revived" after many years of "inactivity"). I used to use Nexium but dropped it after 3 weeks usage, took care of the heartburn and GERD but left me feeling nauseous, bloated and constipated.



> Gene,  you may want to make a list of everything you are taking and have a conversation with your pharmacist.  Be sure to speak to a pharmacist and _not_ a pharmacy technician.  You may get some insight into what's going on.


Done and I do talk to one pharmacist in particular, he's quite "savvy" and has always pointed me in the right direction. Also, I keep a very detailed journal on my computer and it's only a matter of printing it when needed.

Cheers,
Gene


----------



## Retired (Jun 23, 2008)

Gene,

Please review the following article:

Licorice (Glycyrrhiza glabra L.) and DGL (deglycyrrhizinated licorice)-MedicinePlus-NIH

The article describes DGL and licorice from a scientific perspective provided by a reliable source (The National Institutes of Health (NIH) where licorice / drug interactions are described.

You may want to print that article and discuss it with your doctor and or pharmacist, because my reading of the interactions suggests that perhaps there may be a liver metablism issue causing the onset of the adverse reactions you are experiencing.

Quoted from the article:



> In general, prescription drugs should be taken one hour before licorice or two hours after licorice because licorice may increase the absorption of many drugs. Increased absorption may increase the activities and side effects of some drugs (for example, nitrofurantoin). Phosphate salts have been shown to increase licorice absorption. Liver metabolism of certain drugs may be affected by licorice but further study is needed before a conclusion can be drawn


----------



## Gene53 (Jun 24, 2008)

Hi Steve and thanks for the concern.



> In general, prescription drugs should be taken one hour before licorice or two hours after licorice because licorice may increase the absorption of many drugs. Increased absorption may increase the activities and side effects of some drugs (for example, nitrofurantoin). Phosphate salts have been shown to increase licorice absorption. Liver metabolism of certain drugs may be affected by licorice but further study is needed before a conclusion can be drawn


I was already aware of that warning and do follow the 1 and 2 hour recommendation but you may be right, I'll ask my pharmacist and I'll also email Dr. Michael Murray and also Dr. Andrew Weil  (well known Natural Medicine MD's and ND's) and see what they have to say about the clonazepam/DGL combo.

I'll keep you updated on this matter. Darn thing is, if it does interfere, I'll have to hunt for another med for the gut problems that won't interact with the clonazepam and there's no way I'm going back to PPI's. DGL is doing a fantastic job, even better than the Nexium which I used to take.

Cheers,
Gene


Gee, wonderful, Got this automated reply from Dr. Murray's site:


> Thank you for contacting me. Unfortunately, due to the enormous number of e-mails like yours that I was receiving I am unable to personally answer your question. Blah blah blah...



I'm sure he gets flooded with hundreds of questions per day but wouldn't it be courteous to simply remove "Ask Dr. Murray" from the main menu? Sure would prevent people from wasting time writing and getting nowhere.

:hissyfit:

Gene


----------



## Retired (Jun 24, 2008)

I was unable, in the time I researched DGL to gain an understanding of the mechanism of the interaction described in the article.

That being said, when interactions take place in the liver, one of the most common mechanisms involves the cytochrome p-450 liver enzyme, where the compounds compete.

If there is a sound reason, where the benefits outweight the disadvantages or risks, to continue using DGL,  and if the site of interaction is the one I suspect...and if your medical consultants link the interaction to the emergence of adverse reactions you have experienced, then perhaps a change from clonazepam to another minor tranquilizer (benzodiazepine) might be an option.

Your doctor would select a benzodiazepine appropriate to the diagnosis *and* select one with properties more compatible with the DGL.

There are benzodiazepines which are metabolized differently, some which do not require cytochrome p-450 stage of metabolism, which makes them options to consider when another compound is being taken that does require this stage of metabolism.

Hence no interaction.

There are a number of issues to be investigated by a _competent medical specialist_, who has a good understanding of pharmacokinetics and who can prescribe the right combination of medications to treat your diagnoses.

I have speculated based on the information you have provided.  I would strongly suggest printing the resources I have referred to, and bringing them to your medical doctor to see if any of these options might apply to your situation.


----------



## Gene53 (Jun 24, 2008)

Hi Steve,



TSOW said:


> I was unable, in the time I researched DGL to gain an understanding of the mechanism of the interaction described in the article.


So have I, for the past 3 weeks or so, I must have read just about everything I could find on DGL but the info is so vague that you're left with more questions than answers. 



> That being said, when interactions take place in the liver, one of the most common mechanisms involves the cytochrome p-450 liver enzyme, where the compounds compete.


Thanks for the heads up on p-450, ever since you mentioned it in a previous post, I've been reading up a lot on it.



> If there is a sound reason, where the benefits outweight the disadvantages or risks, to continue using DGL,  and if the site of interaction is the one I suspect...and if your medical consultants link the interaction to the emergence of adverse reactions you have experienced, then perhaps a change from clonazepam to another minor tranquilizer (benzodiazepine) might be an option.


This is a "damned if you do and damned if you don't" type of situation and I think a little experimentation is mandatory, I think I'll skip the DGL for 36 to 48 hours and see if I metabolize the clonazepam better, darn thing is, my gut might flare up again (heartburn and GERD). As far as changing benzodapines go, I'm all for it but according to what I've read and heard, you just can't go "cold turkey" on the clonazepam, it has to be done over an extended period of time, especially that I've been on this med for over 12 years.

Here's an excerpt of what you'll find all over the net:
_"*Avoid Abrupt Cessation*, taper dose gradually to D/C if at risk for physical dependence (abrupt cessation of benzodiazepines or barbiturates may cause a withdrawal syndrome including irritability, anxiety, agitation, dysphoria, confusion, memory deficits, hallucinations, sensory disturbances, paresthesias, psychosis, seizures, insomnia, tremors, muscle twitching, muscle cramps, abdominal cramps, GI disturbances, tachycardia, diaphoresis)"_



> There are benzodiazepines which are metabolized differently, some which do not require cytochrome p-450 stage of metabolism, which makes them options to consider when another compound is being taken that does require this stage of metabolism.
> 
> Hence no interaction.


I've already sent the DGL manufacturer (Natural Factors) an email asking if any DGL/clonazepam interactions have ever been reported and here's an excerpt from their reply:
"_Our Research and Information Services department have advised that there are no known drug interactions between this product and the drugs you have listed_"

So, I assume that the next question I should ask them would be "does DGL or any of it's components require a cytochrome p-450 stage of metabolism?". I kind of wonder what kind of answer I'll get and hopefully there are microbiologists in their R&D dept. who can answer that question.



> There are a number of issues to be investigated by a _competent medical specialist_, who has a good understanding of pharmacokinetics and who can prescribe the right combination of medications to treat your diagnoses.


That's what my problem is, can't even find a run-of the-mill physician, we must have called over 30 clinics since yesterday and the answer is carbon copy, "sorry, we don't accept new patients at this time but if you wish, you may leave us your name and phone number and we'll add you to our waiting list"... 

What really "tees me off" is that if my business here in Canada was done and over with, I could hop a plane back to Costa Rica tonight and see any doctor or specialist by tomorrow afternoon or the next day at the latest... Not bad for a  "Third World Country" or a "Banana Republic", they have better healthcare than we do.



> I have speculated based on the information you have provided.  I would strongly suggest printing the resources I have referred to, and bringing them to your medical doctor to see if any of these options might apply to your situation.


Thanks for the care and research Steve, but as I said, "no doctor, no care". As David mentioned in a PM "_SSRIs are not difficult to manage medically so family physicians are usually comfortable prescribing them. If not, your only choice would be a walk-in clinic but they would be less likely to prescribe such medication to someone they don't know._" and the darn this is, the only option I have left is a walk-in clinic...

Cheers,
Gene


----------



## Retired (Jun 24, 2008)

Gene,

Sorry to hear about the difficulty you're having to find a doctor.  It's a frustration we experience in many parts of Canada.



> Avoid Abrupt Cessation, taper dose gradually .......



As a general rule, abrupt discontinuation of any medication should be avoided.  However everything in medicine, has to have a rationale, and this rule depends largely on either the mechanism of action or the biologic half life of the medication in question.

In the case of benzodiazepines, the rationale dealing with cessation rate depends on half life, however if a person has been taking the medication for a long time (years) _or_ at a relatively high dose, tapering would similarly be advisable to help avoid symptoms of withdrawl.

Clonazepam ranks in the short to moderate half life grouping of minor tranquilizers, and one would be wise to follow a tapering schedule if cessation were planned.

However if your doctor is switching to another benzodiazepine, there would be no need to cease the first, as a "wash out" is not required when switching from one benzodiazepine to another.

Here is an article which describes the implications of the half life of benzodiazepines and provides a good list of the half lifes of many benzodiazepines.

*No medication should be stopped without consulting a physician, and a schedule for tapering the dose should be discussed with the physician to help avoid symptoms of withdrawl.*


----------



## Gene53 (Jun 24, 2008)

TSOW said:


> Gene,
> Sorry to hear about the difficulty you're having to find a doctor.  It's a frustration we experience in many parts of Canada.


Wonderful, isn't it? The way I hear it in my region is that a lot of MD's have moved their practices from Quebec to Ontario (OHIP pays more than RAMQ does) and Ontario doctors move to the States, where there's no socialized healthcare and make even more money. It is unfortunate that medicine is now a business instead of a vocation.



> In the case of benzodiazepines, the rationale dealing with cessation rate depends on half life, however if a person has been taking the medication for a long time (years) _or_ at a relatively high dose, tapering would similarly be advisable to help avoid symptoms of withdrawl.
> 
> Clonazepam ranks in the short to moderate half life grouping of minor tranquilizers, and one would be wise to follow a tapering schedule if cessation were planned.


I did follow the below link and found it to be quite interesting but mind you, I've been taking this med for more than 12 years at 2MG's/day.



> However if your doctor is switching to another benzodiazepine, there would be no need to cease the first, as a "wash out" is not required when switching from one benzodiazepine to another.


Interesting but the big challenge now is to find a doctor who's quite savvy in that area but as I said, so far I've only encountered "nays".



> Here is an article which describes the implications of the half life of benzodiazepines and provides a good list of the half lifes of many benzodiazepines.


As I mentioned above, quite informative and I saved it so I may print it, if ever I do find a doctor.

What really caught my attention was:
"Nevertheless, people on potent benzodiazepines such as alprazolam, lorazepam (Ativan) or clonazepam (Klonopin) tend to be using relatively large doses. This difference in potency is important when switching from one benzodiazepine to another"
"Clearly, with repeated daily dosing accumulation occurs and high concentrations can build up in the body (mainly in fatty tissues). There is a considerable variation between individuals in the rate at which they metabolise benzodiazepines."

*



			No medication should be stopped without consulting a physician, and a schedule for tapering the dose should be discussed with the physician to help avoid symptoms of withdrawl.
		
Click to expand...

*What is a Physician? Where do you find one? Are they on the Endangered Species list? Think I should try finding one in a museum? Would it be easier to get an appointment with the German Chancellor? (sorry, rambling...)

BTW, Steve, I sent another message to Natural Factors asking if any of the DGL ingredients require the cytochrome p-450 stage (liver enzyme) of metabolism. I'll probably have an answer tomorrow. I also skipped the DGL at dinner and as I said in an above post, won't be taking it for a day or two only to see if there's any change.

Today was awful, I woke up restless and could feel that I had had an anxiety attack during the night. About an hour after getting out of bed, I went on another anxiety roller coaster ride and my head was spinning as if I were experiencing vertigo so I ended-up pacing the living/dining area for about 4 1/2 hours (which is what I always do when anxious, have to move) and now feel like I participated in a marathon (and came in last).

Also, I'd like to mention that the other DGL ingredients besides the licorice are dextrose, cellulose, maltodextrine, guar gum and magnesium stearate. Wonder if any of those (or the licorice) need the p-450 to metabolize...

Thanks again,
Gene


----------



## Retired (Jun 24, 2008)

These assertions from the article caught my attention as well, and IMO weaken an otherwise solid discussion



> "Nevertheless, people on *potent benzodiazepines *such as *alprazolam, lorazepam (Ativan) or clonazepam (Klonopin) tend to be using relatively large doses.*



I'm puzzled by this statement, by someone who identifieshimself as a pharmacologist.  Once a compound is found to be safe and effective, the next step is to determine the lowest effective dose.  Depemding on the structure and properties of any given molecule, it may take more or less quantity to achieve a similar clinical result.

Therefore 1 mg. lorazepam would give the approximate clinical effect as 10 mg of diazepam, and 30 mg oxazepam.

A common analogy used to differentiate effective dose and potency is a like comparing an ounce of whiskey to a jug of beer.  The smaller quantity is more potent, so you use less a similar effect.

The statement made "tend to be using relatively large doses" completely eludes me fails to make a point.





> This difference in potency is important when switching from one benzodiazepine to another"



Again, I don't see the clinical point to this statement, as the prescribing physisican will take dosage into consideration.   More important is the metabolic half life, active metabolites and metabolic pathways in making changes from one benzo to another.



> "Clearly, with repeated daily dosing accumulation occurs and high concentrations can build up in the body (mainly in fatty tissues).



Whether clinicall significant is not clear and I would want to see literature supportig that claim.  More insidious is the accumulation in the bloodstream of long acting compounds such as diazepam and chlordiazepoxide, which have cause serious deterioration in quality of life due to technical overdosing, especially in older patients with compromised liver and kidney function.



> There is a considerable variation between individuals in the rate at which they metabolise benzodiazepines."



Now that's true!  Depends on many factors such as body weight, overall health, liver and kidney function, and especially age.  Anyone over 65 and especially over 70 must be prescribed a fraction of the usual adult daily dose; and must be monitored more closely.

The opinions I have expressed are based on my understanding of the literature as it pertains to these medications.  _I am not a health care professional._  Please use this information as a resource to discuss your options with a qualified and competent health professional.


----------



## Gene53 (Jun 25, 2008)

Steve, I reread the article once again and even though I'm a "newbie" at this, I did find a few contradictions (and gray areas) myself. Talk about confusion...



> The opinions I have expressed are based on my understanding of the literature as it pertains to these medications.  _*I am not a health care professional*._  Please use this information as a resource to discuss your options with a qualified and competent health professional.


I sure wish you were, perhaps you'd be taking in new patients...  :doctor:

Thanks and I'll keep you updated on the DGL (or lack of) thing.

Cheers and thanks again,
Gene




> Thanks and I'll keep you updated on the DGL (or lack of) thing.


So far, so good. I stopped taking the DGL yesterday morning and today my anxiety level was way down compared to yesterday and my ulcer hasn't acted up yet. It might be a little too soon to come to a conclusion, let's wait another day or two...

Cheers,
Gene

p.s. called another 20 or so doctors today and still no luck...


----------



## Halo (Jun 26, 2008)

Gene,

Are you looking in Quebec or Ottawa or both?  I ask because although I have no magical solution, I may be able to help in your search and just wanted to know which province you were looking at.


----------



## Gene53 (Jun 26, 2008)

Halo said:


> Gene,
> 
> Are you looking in Quebec or Ottawa or both?  I ask because although I have no magical solution, I may be able to help in your search and just wanted to know which province you were looking at.



Hi Halo,

I'm looking in both the Ottawa-Carleton and Outaouais regions, being that I haven't renewed my health insurance card (my permanent residence is in Central America) so I pay as I go along just like a tourist would (which I now consider myself to be, LOL!).

The only reason I had to come back here over a year ago was for a family emergency and I expect that everything I need to do here will be done and over with in 4 to 5 months then will be heading "back home". 

Thank you,
Gene


----------



## Gene53 (Jul 7, 2008)

Sorry for reviving this thread but I was wondering about the following:

Being that I have an appointment with the psychiatrist on the 22nd. I wonder if it would be appropriate for me to ask for a "mild" antidepressant, only to take the edge off. Personally, I don't want to be over-sedated to the point that it puts too much of a damper on my emotions for I strongly believe that "letting it all out" and "dealing with my demons" is the key to my recovery, as it has in the past.

I'm quite aware that he's the expert but I would like to put my 2 cents worth in this matter.

Cheers,
Gene


----------



## Into The Light (Jul 7, 2008)

i don't think you need to worry about anti-depressants "suppressing" your real emotions. really what they do is help with the worst of the feelings depression brings on but in no way do they erase your issues (it sounds like you may think they do).

depression causes strong negative emotions that are out of proportion. the anti-depressants reduce that intensity. but they aren't happy pills, they're a tool to help you be able to deal with your issues.


----------



## Retired (Jul 7, 2008)

Gene,

Any discussion can be revived at any time.  You are always welcome to do so.

My view of what a relationship between a patient and their physician should be, is that of a partnership.

There should be open dialigue regarding the patient's concerns and the treatment options.

Most of today's physicians have adopted that style, although there may be some hold outs to the paternalistic and authoritatrian style of the fifties, where the physician was never questioned, challenged or provided with input.

Therefore you could most certainly ask your doctor if s/he would think it appropriate to prescribe an antidepressant medication to help relieve the mood changes and anxiety you might be feeling.

Continue with your research as you have been doing to learn about treatment options, and if you have any questions about what you find, let us know.


----------



## Gene53 (Jul 7, 2008)

Thank you friends, makes things a bit more reassuring.


----------



## Gene53 (Jul 22, 2008)

Hi folks,

I finally went to see the PDoc this morning as I had heard, he was an older gentleman and really looked old school but I figured "what the hey, nothing to lose". He asked me a truckload of questions about my family history, the effects that clonazepam had on me, my depression, sleeping patterns, PTSD, OCD and phobias. Anyways, the interview (or third degree, LOL!) lasted for 45 minutes then he prescribed Celexa (once a day, at bedtime) and Trazodone (at bedtime, but I think I might hold off on that one till I'm sure the Celexa is not interfering with the Clonazepam). According to drug interactions sites, there's a minor drug-drug interaction between Celexa and Clonazepam whereas Celexa and Trazodone have a MAJOR drug-drug interaction.

He also adjusted my Clonazepam by dividing the 2mg/day into 4 dosages of .5mg every 4 hours or so, the way I was taking it wasn't working well anymore (1mg/twice daily) for it would peak and then die off (half-life is 4 hours) so this way, it'll have a continued effect and I shouldn't feel it's ups and downs as badly.

Cheers,
Gene


----------



## David Baxter PhD (Jul 22, 2008)

Gene53 said:


> he prescribed Celexa (once a day, at bedtime) and Trazodone (at bedtime, but I think I might hold off on that one till I'm sure the Celexa is not interfering with the Clonazepam). According to drug interactions sites, there's a minor drug-drug interaction between Celexa and Clonazepam whereas Celexa and Trazodone have a MAJOR drug-drug interaction.



I would strongly advise you to follow the doctor's advice.

1. There is unlikely to be a problematic interaction between Celexa and clonazepam.

2. There is unlikely to be a problematic interaction between Celexa and trazodone at normal doses.

3. The trazodone is generally prescribed to help with sleep.


----------



## Halo (Jul 22, 2008)

I agree with David.  Gene, I really would follow your doctor's advice. Although he may be old school, he still has knowledge and expertise in this area that the average person such as you and I don't and therefore knows what he is talking about.  I really think that the medications are going to be helpful for you but only if they are taken correctly.


----------



## Gene53 (Jul 22, 2008)

All right, David and Halo, you've convinced me, please disregard my previous statement.

LOL! I've had so many bad drug interactions for so long that I'm almost paranoid in trying something new.

BTW David, the Celexa is only once daily and at bedtime also (if I read the prescription right, Celexa, 20mg, 1H and trazodone, 50mg, 1H) so I assume this is low dosage.

Thanks,
Gene


----------



## David Baxter PhD (Jul 22, 2008)

Yes, the Celexa dose is an average starter dose and the trazodone at 50 mg is a low dose.

The reason for the warning, incidentally, is because they are both antidepressants - however, trazodone is not commonly prescribed for depression because it makes people sleepy - hence, its use for insomnia. If one were taking these medications together at high doses, there might be a problem to worry about but your doctor will already know this.


----------



## Gene53 (Jul 22, 2008)

David Baxter said:


> Yes, the Celexa dose is an average starter dose and the trazodone at 50 mg is a low dose.
> 
> The reason for the warning, incidentally, is because they are both antidepressants - however, trazodone is not commonly prescribed for depression because it makes people sleepy - hence, its use for insomnia. If one were taking these medications together at high doses, there might be a problem to worry about but your doctor will already know this.



Thanks David, great explanation and I now feel reassured.

What freaked me out is the following:  MONITOR CLOSELY: Concomitant use of agents with serotonergic activity such as serotonin reuptake inhibitors, monoamine oxidase inhibitors, tricyclic antidepressants, 5-HT1 receptor agonists, ergot alkaloids, lithium, St. John's wort, phenylpiperidine opioids, dextromethorphan, and 5-hydroxytryptophan may potentiate the risk of serotonin syndrome, which is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5-HT1A receptors.

Cheers,
Gene


----------



## Halo (Jul 22, 2008)

Gene,

I am glad that you are going to follow your doctors advice and take the medication as prescribed.  As I said, I really do think that it is going to help.

Let us know how it goes.

Take care


----------



## Retired (Jul 22, 2008)

Gene,

This is one of those situations where, along with the good research you are doing to understand the actions and kinetics of the medications you have been prescribed,  you need to rely on the clinical judgment of your physician.

That is not to say you should not discuss your findings with the doctor, because by doing what you are doing, you are working as a partner in your healthcare with your physician.

That being said, physicians gain clinical experience using certain combinations of medications that generally work well for their patients,  and they gain a familiarity with these therapeutic strategies.

Older physicians generally stay in touch with newer treatment strategies through regular information exchanges in hospital (rounds) as well as specialized conferences, journal articles and other resources.

For your interest I will point you to the official Canadian product monograph on file with Health Canada.  While monographs may vary slightly from one Country to the next, as you are in Canada, being treated by a Canadian physician, it would help to be on the same page.

Trazodon (Desyrel tabs) CDN monograph 

Celexa (cetalopram) CDN monograph

On both these pages, click on _Product Monograph _to view the PDF file



> What freaked me out is the following...................




As David and the others have reassured you, following your doctor's prescribing regimen is unlikely to cause difficulties.  The concern here is primarily Serotonin syndrome which should not be a concern given the combination of compounds you listed.

However, more likely to be of concern is the potential for drug / drug interaction with trazodone, since this compound utilizes the cytochrome P-450 liver enzyme system.

Going back to the very beginning of this discusssion, I pointed out that clonazepam utilizes cytochrome P-450 for its metabolism as well.  This competition for the enzyme may result in higher than expected blood levels of trazodone, causing unexpected adverse effects.

Your doctor is probably aware of this intereaction potential and has likely modified the dosage accordingly, but this is a subject worthy of discussion with the doctor as well as the pharmacist.

In addition there are a number of OTC medications that use this same metabolic pathway, so you need to review everything you use with your pharmacist.

Typical examples are cimetidine ( for digestive disorders) cough and cold preparations containing dextromethorphan and anti histamines, some anti biotics,  and for women, oral contraceptives.

In summary, 


I would say follow your doctor's recommendations.
Discuss your findings about drug interactions for your doctor's comments
Review all meds, Rx'ed, OTC, herbs etc with your pharmacis for any interaction potential.
Give the medications a chance to reset your neurochemistry, and look forward to improved days ahead.


----------



## Into The Light (Jul 22, 2008)

it sounds like he really looked at your personal history before he gave you those prescriptions and that he put a lot of thought into it. i am glad to hear it, it sounds like he's on the ball, which is reassuring. keep us posted on how you are feeling. i hope there will be improvements very soon for you


----------



## Gene53 (Jul 22, 2008)

TSOW said:


> Older physicians generally stay in touch with newer treatment strategies through regular information exchanges in hospital (rounds) as well as specialized conferences, journal articles and other resources.


The PDoc has quite a few years under his belt working mostly in institutions and hospitals so I guess I do have to have faith in someone.



> Trazodon (Desyrel tabs) CDN monograph
> 
> Celexa (cetalopram) CDN monograph
> 
> On both these pages, click on _Product Monograph _to view the PDF file


Thanks for the links.



> However, more likely to be of concern is the potential for drug / drug interaction with trazodone, since this compound utilizes the cytochrome P-450 liver enzyme system.
> 
> Going back to the very beginning of this discusssion, I pointed out that clonazepam utilizes cytochrome P-450 for its metabolism as well.  This competition for the enzyme may result in higher than expected blood levels of trazodone, causing unexpected adverse effects.
> 
> Your doctor is probably aware of this intereaction potential and has likely modified the dosage accordingly, but this is a subject worthy of discussion with the doctor as well as the pharmacist.


I did mention the P-450 enzyme (he never expected that, caught him off-guard, LOL!) but as I said, he adjusted the clonazepam dosage by splitting it in 4 smaller dosages instead of 2 larger ones. I guess the only way to find out is to try and see what happens. The last thing that bugs me about Celexa/trazodone/clonazepam cocktail is "MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects" and the darn thing is, I do have the occasional bout with asthma (seasonal allergies) and am prone to bronchitis which I did mention but he did assure me that the dosages weren't high enough to cause repiratory-depressant effects.



> I would say follow your doctor's recommendations.


Makes sense, I really want to beat this beast before heading back south.



> Discuss your findings about drug interactions for your doctor's comments


I do keep a journal and I made sure I could call him in case of adverse side effects.



> Review all meds, Rx'ed, OTC, herbs etc with your pharmacis for any interaction potential.


I will double check with the pharmacist but at least, I don't take any OTC medicines (not even tylenol unless I really have to).



> Give the medications a chance to reset your neurochemistry, and look forward to improved days ahead.


Don't you wish we had reset (or reboot) buttons? LOL! Seems that it may take a few weeks for the medications to do it's trick. I do have another appointment with him on Sept. 2 for monitoring purposes.

Thanks Steve,
Gene

Thanks Halo and Into the Light, I'll keep you posted.

BTW, are any of you on that clonazepam/trazodone/celexa cocktail? If so, I'd appreciate some feedback.

Cheers,
Gene


----------



## Retired (Jul 22, 2008)

> not even tylenol unless I really have to



You can safely take Tylenol (acetomenophen) as it does not compete for cytochrome P-450.



> I did mention the P-450 enzyme



Good..remember when referring to this particular mode of liver metabolism, refer to it by it's complete name: _cytochrome P-450_

There are a number of very thorough articles on Psychlinks describing this mechanism in our Interactions section.



> The last thing that bugs me about Celexa/trazodone/clonazepam cocktail is "MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects" and the darn thing is, I do have the occasional bout with asthma (seasonal allergies) and am prone to bronchitis which I did mention but he did assure me that the dosages weren't high enough to cause repiratory-depressant effects.



On this point, you can rely on your doctor's clinical judgement.  All medications that suprress the Central Nervous system, and these cross many lines of classifications such as psychotropic meds, pain relievers (analgesics) and many others contain this very warning in their monographs (Regulatory Agency requirement) and is dose related.

Your doctor is well aware of the additive effect of these medications and is protecting your health interests.

You could always ask your pharmacist for a second opinion,for your personal satisfaction, but in an earlier post, Dr. Baxter shared his reasurance based on his clinical experience as well.

In time you should be feeling better.  However monitor your body responses, and be prepared to report any changes, good or bad with your doctor on your next visit.


----------



## David Baxter PhD (Jul 22, 2008)

> Going back to the very beginning of this discusssion, I pointed out that clonazepam utilizes cytochrome P-450 for its metabolism as well. This competition for the enzyme may result in higher than expected blood levels of trazodone, causing unexpected adverse effects.



50 mg of trazodone is a _very_ low dose, so even if the result _is_ higher blood levels it's still unlikely to be a concern.



> Your doctor is probably aware of this intereaction potential and has likely modified the dosage accordingly, but this is a subject worthy of discussion with the doctor as well as the pharmacist.



Almost certainly, since trazodone and clonazepam are not new medications and the potential for interaction is well known.


----------



## Gene53 (Jul 22, 2008)

David Baxter said:


> 50 mg of trazodone is a _very_ low dose, so even if the result _is_ higher blood levels it's still unlikely to be a concern.


You're quite right David, I had a good talk with my pharmacist and he said that side effects are to be expected and carefully monitored until my system gets used to them and when I talked about the CYP-450, he assured me that there are over 30 human P-450 isoenzyme and that there was nothing to worry about and stop fretting over everything I read on the Net.



> Almost certainly, since trazodone and clonazepam are not new medications and the potential for interaction is well known.


He also confirmed the same.

Cheers,
Gene



TSOW said:


> You can safely take Tylenol (acetomenophen) as it does not compete for cytochrome P-450.


That's good to know, even though I rarely use them.



> You could always ask your pharmacist for a second opinion,for your personal satisfaction, but in an earlier post, Dr. Baxter shared his reasurance based on his clinical experience as well.


As you'll see in one of my replies to David, I had a long talk with the pharmacist and he assured me that there was nothing to worry about.



> In time you should be feeling better.  However monitor your body responses, and be prepared to report any changes, good or bad with your doctor on your next visit.


You can be sure I'll be monitoring the effects and if I feel that something is really out of whack, I'll call him.

Thanks,
Gene


----------



## Gene53 (Jul 25, 2008)

*Update*

Hi,

As I mentioned in one of my above posts, my PDoc has changed my clonazepam dosage from 1mg twice/daily to .5mg every 4 hours, prescribed Celexa 20mg and Trazodone 50mg both at bedtime.

I'm aware that my brain chemistry will take a bit of time to adjust to the new meds but I've been having unpleasant side effects and was wondering if they were normal and not to be really concerned with or should I call up my pharmacist being that my PDoc is away till Monday.

Wednesday (day 1):
Tremors (which I already had due to CNS problems but twice as intense)
Dizziness and drowsiness (hangover type of feeling)
Slight nausea
Slightly blurred vision

The above feelings lasted till 4PM then gradually decreased.

Thursday (day 2)
Same as above but very light, no nausea and was quite functional.

Today (day 3)
Same as Wednesday (day 1) but a bit more intense plus muscle aches (cramps in my left leg). It's now 5:40 and the side effects haven't significantly decreased yet.

When I saw my therapist on Wednesday, I told him how I was feeling (really out of it) and he mentioned that the probable cause for these side effects would be the Trazodone.

Feedback would be appreciated.

Thanks,
Gene


----------



## David Baxter PhD (Jul 25, 2008)

Side-effects for a new SSRI within the first 5-7 days aren't uncommon - they're really more like adaptation effects in that time frame and usually start to decline within 5 days or so. My general advice is to get back to your doctor if they don't show signs of diminishing within 5-7 days.

I'm not sure the leg cramps are related to any of your medications, and the tremors you said were preexisting. If you're worried and things don't improve within the next day or so, you could discontinue the trazodone until you can see the doctor again, but I'd try to stay on the Celexa.

Alternatively, you could try reducing the clonazepam slightly but don't try to do anything big there or you'll find yourself spiking with anxiety and insomnia.


----------



## Gene53 (Jul 25, 2008)

Hi David and thanks for answering.



David Baxter said:


> Side-effects for a new SSRI within the first 5-7 days aren't uncommon - they're really more like adaptation effects in that time frame and usually start to decline within 5 days or so. My general advice is to get back to your doctor if they don't show signs of diminishing within 5-7 days.


Thanks, I wasn't aware that such symptoms would start tapering off after 5 to 7 days. I assume I should keep on going till Monday (it'll be 5 days by then) and call my PDoc if there's no significant decrease in side effects.



> I'm not sure the leg cramps are related to any of your medications, and the tremors you said were preexisting. If you're worried and things don't improve within the next day or so, you could discontinue the trazodone until you can see the doctor again, but I'd try to stay on the Celexa.


I read on E-Drugs that either or both Trazodone and Clonazepam may cause muscle cramps, aches or pains. As far as the tremors go, they were preexisting but are twice as bad. As I said, I'll stick with the program and if tomorrow's worse, I'll take your advice and discontinue the trazodone but will stick with the Celexa.



> Alternatively, you could try reducing the clonazepam slightly but don't try to do anything big there or you'll find yourself spiking with anxiety and insomnia.


That could be a good idea but I find that the symptoms diminish slightly about an hour after I've taken the clonazepam.

Forgot to mention, I've been having occasional elocutionary problems since yesterday, I start a sentence and it turns into gibberish (somewhat like mispronunciation that leads to nonsense) about half-way through. LOL! Makes me laugh cause I can't even understand myself.

Thanks again,
Gene
:woohoo:

The bad feelings are starting to diminish, about time, it's 7:10...


----------



## David Baxter PhD (Jul 25, 2008)

> I read on E-Drugs that either or both Trazodone and Clonazepam may cause muscle cramps, aches or pains.



Hmmm... I've never heard of that.


----------



## Gene53 (Jul 25, 2008)

Opps, sorry, that was on Drug Digest but the database seems to be down at the moment.


----------



## David Baxter PhD (Jul 26, 2008)

No I meant I've never heard ofthat side effect - I'd guess it's pretty rare.


----------



## Gene53 (Jul 26, 2008)

David Baxter said:


> No I meant I've never heard of that side effect - I'd guess it's pretty rare.



OK, they're site's back up:
Trazodone side effects:
http://www.drugdigest.org/DD/DVH/Uses/1,3915,678|Trazodone%2BTablets|872,00.html#sideEffects
Clonazepam:
http://www.drugdigest.org/DD/DVH/Uses/1,3915,163|Clonazepam%2BTablets|486,00.html#sideEffects

I'm feeling much better today, similar as I did on Thursday but I find it funny that the Trazodone doesn't knock me out at night.

Cheers,
Gene


----------



## David Baxter PhD (Jul 26, 2008)

> I find it funny that the Trazodone doesn't knock me out at night



It shouldn't knock you out, especially not at that low a dose. It's not a hypnotic like Imovane. It should just make you a little drowsy and help you get to sleep.


----------



## Gene53 (Jul 26, 2008)

David Baxter said:


> It shouldn't knock you out, especially not at that low a dose. It's not a hypnotic like Imovane. It should just make you a little drowsy and help you get to sleep.



Thanks David, I wasn't aware of that on account that my GF is also on Trazodone and 1/2 hour after taking it, it makes her quite sleepy and as soon as she hits the pillow, she's out like a light. I thought it would do the same to me LOL!

Cheers,
Gene


----------



## David Baxter PhD (Jul 26, 2008)

No doubt some people are more sensitive than others. For many people, 0.5 mg or even 0.25 mg of lorazepam or clonazepam will have that effect. For my wife, most cold tablets will do it.


----------



## Gene53 (Jul 26, 2008)

David Baxter said:


> No doubt some people are more sensitive than others. For many people, 0.5 mg or even 0.25 mg of lorazepam or clonazepam will have that effect. For my wife, most cold tablets will do it.



Thanks, makes sense to me. 

Gene


----------



## Halo (Jul 26, 2008)

Gene,

I remember being on Trazadone a few years back and it didn't knock me out at all.  What it did though was help me to relax enough that I was able to fall asleep and stay asleep and feel rested in the morning.


----------



## Gene53 (Jul 26, 2008)

Halo said:


> Gene,
> 
> I remember being on Trazadone a few years back and it didn't knock me out at all.  What it did though was help me to relax enough that I was able to fall asleep and stay asleep and feel rested in the morning.



Thanks, that's exactly what it does to me. Did you also experience weird side effects for the first few days?

Cheers,
Gene


----------



## Halo (Jul 26, 2008)

I normally always experienced side effects from medications for about a week.  I have come to realize that it happens with most if not all of them, for me at least.  If after a week some side-effect doesn't subside then that is when I go back to my doctor and talk about it.


----------



## Gene53 (Jul 27, 2008)

Halo said:


> I normally always experienced side effects from medications for about a week.  I have come to realize that it happens with most if not all of them, for me at least.  If after a week some side-effect doesn't subside then that is when I go back to my doctor and talk about it.



Thanks for the swift answer, I'm fine today (Saturday), only a bit groggy. Let's see what tomorrow will bring... 

Cheers,
Gene

Thanks for the reassurance everyone, it seems that the new meds side effects are fading, today (Sunday), I'm only feeling a bit tired and my tremors have diminished a lot.

Cheers,
Gene


----------



## Halo (Jul 27, 2008)

Glad that the side-effects are fading and that you are feeling better


----------



## Gene53 (Jul 27, 2008)

Halo said:


> Glad that the side-effects are fading and that you are feeling better



Thanks and I forgot to mention that I haven't had any bouts with anxiety since taking the new meds. 

Cheers,
Gene


----------



## ladylore (Jul 27, 2008)

That's so cool Gene! Glad your feeling better.  :jiggy:


----------



## Gene53 (Jul 27, 2008)

ladylore said:


> That's so cool Gene! Glad your feeling better.  :jiggy:


LOL! Thanks, I almost forgot what it was like not having to deal with anxiety.

Cheers,
Gene


----------



## Gene53 (Aug 1, 2008)

I guess I celebrated too fast.

As i mentioned in some of my previous posts, except for the tremors and slight dizziness, I thought that the worse of side effects were gone but, wow, was I wrong.

When I got up yesterday, I felt dizzier than usual, had trouble breathing (shallow), the tremors were so bad that I had to use my two hands to hold my coffee mug and felt slightly nauseous. Nevertheless, I did my usual morning thing, had my coffee, took my clonazepam (which usually puts a damper on the side effects) and 15 minutes later, had breakfast.

About 45 minutes after taking the clonazepam, all hell broke loose.

I got progressively hyper agitated that I couldn't sit still or stay in one place so I started pacing the living/dining area (the same as I usually do when having either an anxiety or panic attack), with major trembling inside and out.

Less than an hour later, I really felt dizzy and experienced 6 hot flashes, the first 2 were terrible, I felt like I was going to lose consciousness and had to grab on to something in case I might have fallen and the other 4 decreased in intensity.

After those episodes, intense nausea and abdominal cramping crept in and I felt like vomiting (which I didn't) along with tachycardia, shivering, blurred vision, muscle cramps, increased sweating, slurred speech, dry mouth, trouble swallowing and quite a few other discomforts.

Being that my PDoc is semi-retired and only works morning, from Monday to Thursday and couldn't get a hold of him, I called up my pharmacist, told him what was going on and he suggested I drop the Trazodone and see if the side-effects could be caused by the Celexa/Clonazepam combo and if I still felt as bad after a couple of days, stop the Celexa also until I can talk with my PDoc. He added that he had seen this a few times before with other clients who were on the same meds as I am and needed to be switched to other meds.

LOL! I paced the floor for close to 12 hours, meaning I must have walked more than 15 Kms (good thing I have hardwood flooring). At around midnight, I finally settled down enough to eat a bowl of soup, regardless of the nausea which had subdued a little by then. I finally hit the sack at around 4 A.M. totally exhausted and not wishing to take any chances, only took half of a Celexa tablet and no Trazodone, I sure as heck didn't want to have another day like yesterday.

In conclusion, I got up late today feeling slightly dizzy, the tremors were still present but not as bad as yesterday, had my clonazepam then breakfast and now feeling very tired, a bit lightheaded, with the occasional shivers, cold sweats and slightly nauseous.

So, tonight I'll have the full dosage of Celexa (no Trazodone) and see what tomorrow brings.

Cheers,
Gene


----------



## Retired (Aug 1, 2008)

> the tremors were so bad that I had to use my two hands to hold my coffee mug



Maybe consider switching to de-caf..

Seriously though, if the same thing happens again, you may want to get yourself to Emergency.  Good thinking on calling your pharmacist.


----------



## Gene53 (Aug 1, 2008)

TSOW said:


> Maybe consider switching to de-caf..


I'm on decaf... 



> Seriously though, if the same thing happens again, you may want to get yourself to Emergecy.  Good thinking on calling your pharmacist.


I had thought about it (also wondered what they could have done for me except for telling me the same thing the pharmacist did) but right now, ER waiting time is 18 hours, it would have blown over by then. The only advantage would have been to wear out their floor instead of mine.

Cheers,
Gene


----------



## ladylore (Aug 1, 2008)

So how are you feeling now?


----------



## Gene53 (Aug 1, 2008)

ladylore said:


> So how are you feeling now?



Much better, thank you but my legs hurt like heck from all this pacing around and something tells me I'll be going to bed early tonight. 

Thanks for caring,
Gene


----------



## ladylore (Aug 1, 2008)

No problem. 

At least you got about 2 weeks worth of exercise in last night. 

On a serious note - don't hesitate to call 911 if it happens again.


----------



## Gene53 (Aug 7, 2008)

Well, since ?Terrible Thursday?, I?ve stopped taking the Trazodone and have been doing the Celexa and Clonazepam thing and this too provoked very uncomfortable side effects and much to my surprise, Clonazepam withdrawal symptoms.

Even though Friday wasn?t that bad, Saturday and Sunday were terrible, I had bouts with anxiety, abdominal cramps, nausea, dizziness, tiredness, dry mouth, the occasional heartburn, complete loss of appetite, excessive sweating, trembling, blurred vision, agitation, shivers, hot flashes and light headaches.

 Being that my PDoc is on vacation until the 25th , I decided to call my pharmacist once again (next best thing to a doctor) and she told me that what I was feeling was a combination of the Celexa side effects along with the withdrawal symptoms from the Clonazepam, being that the latter?s dosage had been modified from 1mg twice/daily to .5 four times/day. She explained that even though I was still getting my usual 2mg/day, it was now peaking at half of the usual dosage and also affected the half-life of this med in my system.

 Now, a few days later, some of those symptoms have somewhat diminished while some seem to have disappeared but I still feel slightly light-headed, occasionally anxious, nauseous and agitated, my appetite hasn?t returned, I feel tired most of the time, get hot flashes, don?t feel like doing much of anything and still have above average tremors at certain times of the day.

 In conclusion, my frame of mind isn?t good, I don?t feel like doing much of anything and I?m terribly bored.

BTW, did a bit of research on what the pharmacist told me about the infamous Clonazepam withdrawal symptoms:
Symptoms include seizures, irritability, nervousness, sleep problems, agitation, tremors, diarrhea, abdominal cramps, vomiting, memory impairment, headache, muscle pain, extreme anxiety, tension, restlessness, and confusion.

Cheers,
Gene


----------



## Halo (Aug 7, 2008)

Did your pharmacist make any recommendation as to how you are to deal with the side effects/withdrawal symptoms?


----------



## Gene53 (Aug 7, 2008)

Halo said:


> Did your pharmacist make any recommendation as to how you are to deal with the side effects/withdrawal symptoms?



Hi Halo,

As far as the withdrawal symptoms go, she suggested I should stick "with the program" being that I already had about 10 days "under my belt" and the worst of it should be over soon. She mentioned that if I were to go back to my old dosage (1mg twice/day) and wanted to ween off the clonazepam (which is what I want to do), I'd be right back to square one so I might as well tough it out.

The Celexa side effects are slowly tapering off and this med should be working at it's full potential in another week or two.

Thanks,
Gene


----------



## Halo (Aug 7, 2008)

Although I am not a doctor nor a pharmacist, to me that sounds like good advice that you were given.

Good luck and I hope that the side effects and withdrawals continue to taper off :goodluck:


----------



## David Baxter PhD (Aug 7, 2008)

> BTW, did a bit of research on what the pharmacist told me about the infamous Clonazepam withdrawal symptoms:
> Symptoms include seizures, irritability, nervousness, sleep problems, agitation, tremors, diarrhea, abdominal cramps, vomiting, memory impairment, headache, muscle pain, extreme anxiety, tension, restlessness, and confusion.



Please note that clonazapam is used to treat epilepsy and that at common doses used for anxiety or insomnbia the more extreme side-effects you cite above are very unlikely. The most common symptoms of sudden clonazepam withdrawal would be increased anxiety and imsomnia, which can be avoided by gradually tapering off over a period of time.


----------



## Gene53 (Aug 16, 2008)

I have now been on Celexa for 26 days and wish to stop taking it because it seems that I'm intolerant to this drug and the gravity of the side effects outweigh it's benefits.

Here's a partial list of the side effects that affect me on a daily basis:
- blurred vision
- excessive trembling
- complete loss of appetite, frequent nausea, diarrhea and abdominal cramps
- excessive sweating
- frequent urination
- anxiety, nervousness and agitation
- dizziness
- lack of energy and libido
- tingling and burning sensations on certain parts of my body
- trouble concentrating and sluggishness
- pounding heart
- mood changes

I'm aware that these side effects should be reported to my PDoc but 2 days after I saw him, he went on vacation and won't be back until the 25th so I have to take matters in my own hands till he gets back and get off this med and there's no way that I want to feel like this for another 9 days.

So, my big question is can I just quit them "cold turkey" after only 26 days or do I need to gradually ween myself off it over a few days to avoid withdrawal symptoms, if any after such a short period?

I think I should call my pharmacist tomorrow, maybe she could answer the above.

Thanks,
Gene


----------



## Daniel (Aug 16, 2008)

I have no advice except to talk to your pharmacist as you have suggested and have been doing.   

BTW, Celexa has a longer half-life (35 hours) compared to some other antidepressants like Effexor (3 to 13 hours) and Paxil (21 hours).  Therefore, Celexa seems to be less likely to cause withdrawal symptoms compared to some other SSRIs, though Prozac (between 84 and 144 hours) is by far the safest:



> Effexor (venlafaxine) and Paxil (paroxetine), both of which have relatively short half-lives in the body, are the most likely of the antidepressants to cause withdrawals. Prozac (fluoxetine), on the other hand, is the least likely of SSRI and SNRI antidepressants to cause any withdrawal symptoms, due to its exceptionally long half-life.
> 
> http://en.wikipedia.org/wiki/Withdrawal


http://www.aafp.org/afp/20060801/449.html


----------



## Gene53 (Aug 17, 2008)

Daniel said:


> I have no advice except to talk to your pharmacist as you have suggested and have been doing.
> 
> BTW, Celexa has a longer half-life (35 hours) compared to some other antidepressants like Effexor (3 to 13 hours) and Paxil (21 hours).  Therefore, Celexa seems to be less likely to cause withdrawal symptoms compared to some other SSRIs, though Prozac (between 84 and 144 hours) is by far the safest:
> 
> http://www.aafp.org/afp/20060801/449.html



Thanks Daniel, great info and I will talk to my pharmacist tomorrow.

For the past 2 nights, I've been cutting the dosage by half (10mg instead of 20) and tonight, I'll cut it down to 5mg and see what tomorrow brings.

I found the following quite comforting on aafp.org:


> Antidepressant discontinuation syndrome occurs in approximately 20 percent of patients after abrupt discontinuation of an antidepressant medication that was taken for at least six weeks.


I've been taking this med for 3 1/2 weeks so I assume I'm doing the right thing being that I'm under the aforementioned 6 weeks.

Thanks again,
Gene


----------



## Halo (Aug 17, 2008)

Gene53 said:


> I have now been on Celexa for 26 days and wish to stop taking it because it seems that I'm intolerant to this drug



I understand that there are side effects that are bothering you however my question is if you have only been on the medication for 26 days how can you or did you determine that you are intolerant to it?  In my experience as well as what I have read, it usually takes 4-6 weeks for the medication to reach  maximum effect.

Either way, I would definitely speak to your pharmacist before discontinuing the medication, although from the sounds of it you have already begun to reduce the dose.


----------

