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Dr. Bob is Robert Hsiung, MD,
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Posted by zeugma on February 21, 2005, at 7:08:55
In reply to Re: Provigil » zeugma, posted by ed_uk on February 20, 2005, at 10:44:44
Hey there Ed.
>
> >Ritalin LA
>
> Out of curiosity, did you ever try any of the other controlled release methylphenidate brands. Have you ever taken Concerta?No. Just standard IR Ritalin and Ritalin LA. Oh, and Cylert, which has a half-life similar to Provigil's. Concerta is interesting, it provides increasing plasma levels throughout the day, and my experience was that for focus, increasing plasma levels were necessary. The LA would work best from 1 to 2:30 pm, when the noon dose and the 6:30 am dose would 'collide.' Concerta might be a great idea for someone. I had therapeutic effects from MPH, but anxiety and irritability are really common s/e with this med, and I am predisposed to both.
>
> >I still feel unable to do much of anything after 4 pm, and that is a substantial limitation.
>
> Have you ever tried taking a high dose in the morning and a small dose at noon? eg. 100mg in the morning + 50mg at noon.
>
I'm thinking about it. i meet with my pdoc this week. The insomnia I had from 100 mg am has dissipated. I suppose what i'm thinking is that the long half-life of Provigil can be used to advantage to maintain efficacy through to the evening by taking enough in the am.I wonder if somehow my experience with Ritalin made me tolerant of the effects of dopaminergic meds. The feelings I had on high doses of Ritalin (30 mg BID) were similar at times to what I got from Provigil (a certain numb feeling, combined with an increased ability to focus).
-z
> >Buspirone has no withdrawal syndrome whatsoever.
>
> I vaguely remember (once) hearing someone complain that they'd had some withdrawal symptoms. I don't remember what they were though.
>
> Thanks for keeping me up-to-date :-)
>
> Ed.
Posted by lorilu on February 21, 2005, at 23:35:44
In reply to Re: Provigil » ed_uk, posted by zeugma on February 21, 2005, at 7:08:55
hi,
I take a full 200 in the am. If I take 100 mg I am sleepy all day and in bed by 8. I have even taken 100 mg at lunch time and have gone to bed at a normal time. I can also take 100 mg and take a nap. 200 mg will will sometimes wane for me in the early afternoon but then I will perk up again and can stay up late, like tonight it is 9:30 and I am wide awake. I have stayed awake until the wee hours of the night. If I go too many days or weeks at 200 mg I will get too obsessive and then I will go back to 100 for a day or 2 to get some extra sleep. People will notice a difference, though, I will look exhausted.FYI I take a lot of Topamax and Effexor so that makes me tired, plus I used to have sleep apnea and I haven't got retested since my deviated septum surgery to see if I still have it, plus I'm pretty busy so I have a lot of reasons to be tired.
lorilu
Posted by zeugma on February 22, 2005, at 4:48:55
In reply to Re: Provigil, posted by lorilu on February 21, 2005, at 23:35:44
hi lorilu,
That's very encouraging. I was in bed by 8 last night. 100 mg leaves me exhausted, but I feel that it helps my ADD, and i'm a little less exhausted than I would be normally.
Btw, I get the same comments, "You look exhausted," "You look like you don't sleep," even though I generally get a full eight hours of sleep a night.
-z
Posted by SLS on February 22, 2005, at 7:48:47
In reply to Re: ed- your opinion please » ed_uk, posted by zeugma on February 20, 2005, at 5:48:09
You might want to save your caffeine intake for your 4:00 lull. Don't use caffeine at all except for this time, and you will probably retain or enhance an energizing effect from it.
- Scott
Posted by SLS on February 22, 2005, at 8:02:47
In reply to Re: Provigil » zeugma, posted by ed_uk on February 20, 2005, at 10:44:44
> > Buspirone has no withdrawal syndrome whatsoever.
> I vaguely remember (once) hearing someone complain that they'd had some withdrawal symptoms. I don't remember what they were though.
I would be curious to know if anyone has tried to discontinue an SSRI or Effexor while taking Buspar. I am wondering if the agonism of 5-HT1a autoreceptors won't help buffer the understimulation of these receptors that might occur when serotonin reuptake inhibition rapidly vanishes.
- Scott
Posted by lorilu on February 22, 2005, at 8:45:20
In reply to Re: ed- your opinion please » zeugma, posted by SLS on February 22, 2005, at 7:48:47
> You might want to save your caffeine intake for your 4:00 lull. Don't use caffeine at all except for this time, and you will probably retain or enhance an energizing effect from it.
>
>
> - ScottI will have an icetea at that time if I have only had 100 mg and it does wonders! Thanks for reminding me. I can't have any caffeine on 200 mg or I will never go to sleep.
lorilu
Posted by ed_uk on February 22, 2005, at 8:58:56
In reply to Re: Provigil » ed_uk, posted by SLS on February 22, 2005, at 8:02:47
Hi Scott!
>I would be curious to know if anyone has tried to discontinue an SSRI or Effexor while taking Buspar. I am wondering if the agonism of 5-HT1a autoreceptors won't help buffer the understimulation of these receptors that might occur when serotonin reuptake inhibition rapidly vanishes.
Yes, I'm curious too. Perhaps you should start a new thread to ask people whether they've found this strategy useful.
Btw, I'd like to be able to contribute to your thread about avoiding Effexor withdrawal symptoms. Sadly, I don't have any useful experiences to post because I discontinued Effexor 'cold turkey' when my mother threw the capsules in the bin. I also discontinued Seroxat (Paxil) without tapering but I started Prozac the next day and so it's not really surprising that I didn't have any withdrawal symptoms.
Ed.
Posted by ed_uk on February 22, 2005, at 9:01:09
In reply to Re: Provigil » ed_uk, posted by zeugma on February 21, 2005, at 7:08:55
Hi Z!
How are you doing? Any side effects from the Provigil? Have you increased the dose?
Ed.
Posted by zeugma on February 22, 2005, at 15:28:20
In reply to Re: ed- your opinion please » zeugma, posted by SLS on February 22, 2005, at 7:48:47
> You might want to save your caffeine intake for your 4:00 lull. Don't use caffeine at all except for this time, and you will probably retain or enhance an energizing effect from it.
>
>
> - Scott
Hi Scott. I just got home from work, and am experiencing the 4:00 lull in a *big* way. I went shopping for dinner, and wondered if I would be able to stay alert and awake enough to eat it! (It's low preparation stuff, but when I went off stims altogether a few weeks ago, I had to eat dinner at 3:30 p.m. in order to ensure that I would actually have the energy to consume food.)I am making my pot of coffee now.-z
Posted by zeugma on February 22, 2005, at 15:33:13
In reply to Re: ed- your opinion please, posted by lorilu on February 22, 2005, at 8:45:20
lorilu, I have a question: did you experience increased anxiety when you went to 200 mg? Or irritability? It seems that provigil is totally non-anxiogenic for me at 100 mg, in fact I start feeling anxious around 1 pm when I start becoming hazy and exhausted again. I had an iced tea at that time (great minds think alike :)) and it helped but I am still exhausted and am making the pot of coffee scott suggested.
Thanks,
z
Posted by SLS on February 22, 2005, at 15:48:08
In reply to Re: ed- your opinion please » SLS, posted by zeugma on February 22, 2005, at 15:28:20
> > You might want to save your caffeine intake for your 4:00 lull. Don't use caffeine at all except for this time, and you will probably retain or enhance an energizing effect from it.
> >
> >
> > - Scott
>
>
> Hi Scott. I just got home from work, and am experiencing the 4:00 lull in a *big* way. I went shopping for dinner, and wondered if I would be able to stay alert and awake enough to eat it! (It's low preparation stuff, but when I went off stims altogether a few weeks ago, I had to eat dinner at 3:30 p.m. in order to ensure that I would actually have the energy to consume food.)I am making my pot of coffee now.
>
> -z
>Hi Z.
You need to treat caffeine as if it were a drug. You would like to find the optimum dosage for you to glean the desired effect. Too much caffeine for some people can produce a "paradoxical" loss of energy, brain fog, and sleepiness. You actually should experiment with low dosages first and work your way on up. Try 1/2 to one cup to start with. If after a 1/2 hour you feel nothing, then take more. Don't be reluctant to experiment with caffeine as you have with Provigil.
Sweet dreams...
:-)
- Scott
Posted by zeugma on February 22, 2005, at 15:50:57
In reply to Re: Provigil » zeugma, posted by ed_uk on February 22, 2005, at 9:01:09
> Hi Z!
>
> How are you doing? Any side effects from the Provigil? Have you increased the dose?
>
> Ed.Hi Ed!
The only side effect i have had from Provigil so far is gastrointestinal distress.
[z pauses to gulp down some dark caffeinated liquid]
I am at a loss to explain why Provigil would cause such severe side effects on my first trial, and be apparently so tolerable now.
I see my pdoc tomorrow. I do want to try a higher dose, especially since its effects seem to be the opposite of Ritalin's (i.e. increased appetite, slowed rather than speeded thinking, calming rather than agitating). The effects wear off around noon- 1 pm, with less of a steep fall than I had with the Ritalin but unpleasant nonetheless. I'm trying the experiment of some 4 o'clock coffee to see if I can get anything constructive done on Provigil 100 mg after 4 p.m. The iced tea at 1 pm did help :)
-z
Posted by SLS on February 22, 2005, at 16:20:42
In reply to Re: ed- your opinion please » zeugma, posted by SLS on February 22, 2005, at 15:48:08
Ideally, you would like to find the optimum amount of caffeine such that you only need to take a single dose at 4:00. If you are lucky, this might be all you need to get you through the rest of the day. I like the way I feel using coffee rather than caffeine pills. However, I always carry around with me a few pills just in case.
- Scott
> > > You might want to save your caffeine intake for your 4:00 lull. Don't use caffeine at all except for this time, and you will probably retain or enhance an energizing effect from it.
> > >
> > >
> > > - Scott
> >
> >
> > Hi Scott. I just got home from work, and am experiencing the 4:00 lull in a *big* way. I went shopping for dinner, and wondered if I would be able to stay alert and awake enough to eat it! (It's low preparation stuff, but when I went off stims altogether a few weeks ago, I had to eat dinner at 3:30 p.m. in order to ensure that I would actually have the energy to consume food.)I am making my pot of coffee now.
> >
> > -z
> >
>
> Hi Z.
>
> You need to treat caffeine as if it were a drug. You would like to find the optimum dosage for you to glean the desired effect. Too much caffeine for some people can produce a "paradoxical" loss of energy, brain fog, and sleepiness. You actually should experiment with low dosages first and work your way on up. Try 1/2 to one cup to start with. If after a 1/2 hour you feel nothing, then take more. Don't be reluctant to experiment with caffeine as you have with Provigil.
>
> Sweet dreams...
>
> :-)
>
>
> - Scott
>
>
>
>
Posted by zeugma on February 22, 2005, at 16:51:48
In reply to Re: ed- your opinion please, posted by SLS on February 22, 2005, at 16:20:42
Ideally, you would like to find the optimum amount of caffeine such that you only need to take a single dose at 4:00. If you are lucky, this might be all you need to get you through the rest of the day. I like the way I feel using coffee rather than caffeine pills. However, I always carry around with me a few pills just in case.>>
I don't like using the pills all that much either. When i was off stims completely, though, I was taking a lot of them, and in spite of warnings from my former ADD coach I did not find them addicting in the least.
I've got a cup of mostly caffeinated coffee in me now, and I definitely feel the effect. It's much closer to ritalin than Provigil in its peripheral effects. I think the pills had less in the way of this, for some reason.
-z
Posted by zeugma on February 22, 2005, at 18:36:05
In reply to Re: ed- your opinion please » SLS, posted by zeugma on February 22, 2005, at 16:51:48
I remember this negative caffeine-Provigil interaction from last summer. The small amount of caffeine in the iced tea was tolerable, but I had one cup of two-thirds caffeinated coffee and now I feel overstimulated. I felt awful last week too when I absolutely HAD to drink some coffee to stay focused at work when the Provigil lessened in effect, about 1 pm.
It's interesting that for me, Provigil and caffeine don't go well together at all, whereas with ritalin, I was able to tolerate a cup late in the afternoon pretty well.
-z
Posted by zeugma on February 22, 2005, at 20:16:57
In reply to results are lousy, posted by zeugma on February 22, 2005, at 18:36:05
I guess tomorrow I can try 1/2 cup of half-caffeinated coffee, and see if the peripheral stimulation and anxiogenicity is less pronounced.
By the way, Scott, what was the result of your abilify experiment?
-z
Posted by SLS on February 23, 2005, at 6:23:51
In reply to addendum-and an SOS for SLS, posted by zeugma on February 22, 2005, at 20:16:57
> I guess tomorrow I can try 1/2 cup of half-caffeinated coffee, and see if the peripheral stimulation and anxiogenicity is less pronounced.
You are pretty sensitive to caffeine. I hope you can find a dose that enhances your functional state rather than detract from it.
> By the way, Scott, what was the result of your abilify experiment?I discontinued Abilify using a rapid taper. I went from 10mg to 5mg for a few days and then stopped completely. Abilify has a long half-life. The only withdrawal symptom I had was some mild anxiety. I did experience a return of some libido. However, without the Abilify, I began to lose some energy and motivation, and was getting less done. Since I really, REALLY can use all the help I can get to attenuate the depression, I restarted the Abilify. I also found that Abilify reduces ruminations during difficult times (for which any sane person *would* ruminate) and helps prevent the evolution of suicidal states.
I hate having to rely on so many drugs for so little benefit.
<growl>
Parnate 70mg
nortriptyline 100mg
Lamictal 300mg
Abilify 10mg
memantine 20mg
- Scott
Posted by lorilu on February 23, 2005, at 18:34:33
In reply to Re: ed- your opinion please » lorilu, posted by zeugma on February 22, 2005, at 15:33:13
> lorilu, I have a question: did you experience increased anxiety when you went to 200 mg? Or irritability? It seems that provigil is totally non-anxiogenic for me at 100 mg, in fact I start feeling anxious around 1 pm when I start becoming hazy and exhausted again. I had an iced tea at that time (great minds think alike :)) and it helped but I am still exhausted and am making the pot of coffee scott suggested.
>
> Thanks,
> z
Yes! You are going to have anxiety for the first week or two. I have posted that before on earlier posts a few months back. It needs to get in your system. Now if you want to take it with Adderall, like my PDoc wants me too, that will reverse that. I don't like to focus that much. :) It slows me down and makes me feel like everything is in slow motion. I guess that's how the real world is. I was driving to my other doctor, my therapist, after taking Adderal, and I was going 80 on the freeway, and I told him it felt like I was going 55 on the freeway. I thought the medicine wasn't working. I thought it was a "stimulant". He said that was what it was supposed to do. Since that day I haven't taken it. Crazy isn't it. I like the energy Porvigil gives me. My therapist would rather I get off Porvigil and only take Adderall, go figure.When I first started Provigil my skin would crawl, I was overstimulated by little sounds and any noise. Elevator noise would drive me crazy! Work through it!!!!!!!!!!!!!!!!!!! It is really worth it! Gotta go or I will be late to pick up the kids. See I am always in a rush, my brain works better that way.
Any suggestions... :)
Posted by zeugma on February 24, 2005, at 15:46:55
In reply to Re: addendum-and an SOS for SLS » zeugma, posted by SLS on February 23, 2005, at 6:23:51
> > I guess tomorrow I can try 1/2 cup of half-caffeinated coffee, and see if the peripheral stimulation and anxiogenicity is less pronounced.
>
> You are pretty sensitive to caffeine. I hope you can find a dose that enhances your functional state rather than detract from it.I self-medicated with caffeine for years. So the sensitivity to caffeine is a recent phenomenon, and is most pronounced with concomitant Provigil usage. I first encountered the phenomenon with Strattera, and that's why I'm convinced the latter drug has stimulant properties, regardless of how fatiguing I later found it. I took about 50 mg Provigil with lunch, and found the onset of pm drowsiness very much attentuated. That's especially noteworthy considering this is Thursday, and I experience a steady increase in drowsiness as the week progresses. Going without caffeine today was not a planned move, although I had planned not to take any after the second modafinil dose. I was simply too run down this morning to make coffee this morning. But Provigil's onset of action seems rapid enough to wake me up by the time my morning commute is over.
I also experienced a burst of ravenous appetite around 1:30. That's a good sign when you consider that stimulant-induced anorexia has been a lifelong obstacle to treatment for me.
>
>
> > By the way, Scott, what was the result of your abilify experiment?
>
> I discontinued Abilify using a rapid taper. I went from 10mg to 5mg for a few days and then stopped completely. Abilify has a long half-life. The only withdrawal symptom I had was some mild anxiety. I did experience a return of some libido. However, without the Abilify, I began to lose some energy and motivation, and was getting less done. Since I really, REALLY can use all the help I can get to attenuate the depression, I restarted the Abilify. I also found that Abilify reduces ruminations during difficult times (for which any sane person *would* ruminate) and helps prevent the evolution of suicidal states.
It sounds like the Abilify is worth the s/e then. Have you experienced similar benefit from any other atypical AP? It seems that Seroquel is considered least likely to cause sexual s/e:http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15672600 But it might well be too sedating for you to tolerate an effective dose.
>
> I hate having to rely on so many drugs for so little benefit.
>
> <growl>
>
> Parnate 70mg
> nortriptyline 100mg
> Lamictal 300mg
> Abilify 10mg
> memantine 20mg
>
>Any discernible effect from memantine yet?
-z
> - Scott
>
Posted by zeugma on February 24, 2005, at 16:01:46
In reply to Re: ed- your opinion please, posted by lorilu on February 23, 2005, at 18:34:33
thanks so much lorilu for your reply. Yes, I noticed that the higher dosage of Provigil creates heightened sensitivity to sound. Ritalin did this too, and I assumed that I heard the noises because I was more 'awake.' So I didn't mind the effect; in fact I was always worried (when not on stims) that I would get run over by an ambulance or something at a crosswalk because I am oblivious to sounds and sights.
So Adderall will reverse provigil-induced anxiety? That's interesting. Luckily, provigil seems pretty anxiety-free so far. It also seems (if I understand you) that we have opposite reactions to provigil: it REALLY slows down my cognition, which is both good (I tend to think too fast and the result is a mental blur) and bad (my reaction time is awful and makes driving a car, for example, impossible). Ritalin speeded me up enough to think about driving again someday, but also made me irritable and had a very jagged effect that caused me to have 'issues' with my co-workers (note the euphemism). My pdoc thinks that if I can get into a less stressful line of work, then maybe a little Ritalin would be a good idea, because it did make me focus a lot better. I did find that Provigil with a little Ritalin LA (10 mg) was synergistic. But I definitely prefer the Provigil overall, not least because it causes less tachycardia (I also take 100 mg nortriptyline and the Ritalin-TCA combo can be quite dicey).
-z
Posted by SLS on February 24, 2005, at 20:51:53
In reply to no caffeine day » SLS, posted by zeugma on February 24, 2005, at 15:46:55
Hi Zeugma.
I'm very happy that you have been able to optimize your dosing of Provigil to make it unnecessary use caffeine.
> It sounds like the Abilify is worth the s/e then.
Gosh. We are asked to make so many compromises with these illnesses and the medications we take to treat them. It seems like it never ends.
Have you experienced similar benefit from any other atypical AP?
Zyprexa treats me pretty well when things get bad. I am prone to weight gain, though, so I am happy to be on Abilify, although I am having trouble taking off the weight that Zyprexa and imipramine put on.
It seems that Seroquel is considered least likely to cause sexual s/e:
Hmmm. I didn't know that. I tried Seroquel once about 5 years ago. I didn't have a problem with sedation. However, I felt irritable and a bit dysphoric on it, so I didn't go beyond 2 weeks with it. Thanks for the link.
> Any discernible effect from memantine yet?
Nothing positive. I have been feeling fatigued and a bit spacey. I didn't experience that the first time I was on it. I attribute that to titrating up too rapidly. I started right at the therapeutic dosage of 20mg. Over the summer, I used the starter pack, which offered a gradual titration. I might back off on the dosage for a few days until the side effects resolve before moving back up to 20mg. The first time I tried it, I gleaned an antidepressant response in the third week that lasted episodically for about a week. I don't feel anything that remotely resembles that right now.
On another note... What happens to your REM sleep when you take an antimuscarinic? I don't recall your history, but Parnate and Nardil totally suppressed dreaming for me. They are more powerful in this regard than the TCAs. If these MAOIs cause insomnia, you just treat the insomnia aggressively. Many people describe a period of tiredness, fatigue, or somnolence in the afternoon with Parnate. You could continue to take Provigil to help counteract this. Just a few rambling thoughts.
- Scott
Posted by zeugma on February 24, 2005, at 21:35:49
In reply to Re: no caffeine day » zeugma, posted by SLS on February 24, 2005, at 20:51:53
Hi Scott.
>
> I'm very happy that you have been able to optimize your dosing of Provigil to make it unnecessary use caffeine.:)
>
>
>
> Gosh. We are asked to make so many compromises with these illnesses and the medications we take to treat them. It seems like it never ends.
>No. It's a full-time occupation. And then when the meds stop working, it's a full-fledged emergency. I hope I'm learning how to deal with that.
>
>
> It seems that Seroquel is considered least likely to cause sexual s/e:
>
> Hmmm. I didn't know that. I tried Seroquel once about 5 years ago. I didn't have a problem with sedation. However, I felt irritable and a bit dysphoric on it, so I didn't go beyond 2 weeks with it. Thanks for the link.
>Dysphoria above baseline is intolerable. but irritability can sometimes be a sign of lifting depression. But what you say makes sense in light of some info I've come across, to the effect that Zyprexa has the strongest efficacy as an antidepressant among the AP's. Although I wonder if you have ever looked into clozapine as an alternative.
>
> On another note... What happens to your REM sleep when you take an antimuscarinic? I don't recall your history, but Parnate and Nardil totally suppressed dreaming for me. They are more powerful in this regard than the TCAs. If these MAOIs cause insomnia, you just treat the insomnia aggressively. Many people describe a period of tiredness, fatigue, or somnolence in the afternoon with Parnate. You could continue to take Provigil to help counteract this. Just a few rambling thoughts.
I came across a case report of a man with severe narcolepsy who was treated with Parnate and high-dose provigil and it worked quite well. So it's good to know there are some options. To answer your questions: I haven't taken a pure antimuscarinic since I was on benztropine for EPS due to perphenazine. that was many years ago, and before I began manifesting the abnormalities of REM sleep that came later. I do recall that nortriptyline (which was substituted later) had a much more suppressant effect on dreaming than the benztropine, though I'm sure the AP had something to do with that. Antimuscarinics haven't found a place in the treatment of cataplexy, though a leading clinician notes that some of the best anticataleptic drugs are antimuscarinic.I've never been on an MAOI. Has your tolerance to the REM suppressant effects of AD's become complete by now? :(
-z
>
Posted by SLS on February 25, 2005, at 7:00:18
In reply to Re: no caffeine day » SLS, posted by zeugma on February 24, 2005, at 21:35:49
> I've never been on an MAOI. Has your tolerance to the REM suppressant effects of AD's become complete by now? :(
Yes!
<series of expletives>
That's pretty scary to me. If treatment resistence can be measured by the non-suppression of REM by previously suppressive antidepressants, then I'm totally screwed.
That's great that nortriptyline helped. It should open up some doors of hope. Perhaps muscarine receptor antagonism is required, but sufficient, to suppress REM.
- Scott
Posted by ed_uk on February 26, 2005, at 10:22:54
In reply to Re: no caffeine day » SLS, posted by zeugma on February 24, 2005, at 21:35:49
Hey Zeugma, how are you doing?
Ed.
Posted by zeugma on February 26, 2005, at 17:04:45
In reply to Re: Provigil » zeugma, posted by ed_uk on February 26, 2005, at 10:22:54
Hey Ed!
I'm doing OK. I had some insomnia when I added 50 mg at lunch, and that gave me some heavy rebound sleep (10 hours) last night. But it seems that doing the 150-50 mg dosing regimen, give or take some dusty milligrams, is viable, because last night I didn't have insomnia.
provigil slows my reaction time. but it increases my ability to get things done. Bizarre, isn't it?
-z
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