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Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 1 to 6 of 6. This is the beginning of the thread.
Posted by CareBear04 on October 31, 2004, at 1:02:57
if anyone has any input on any of these subjects, PLEASE write back! i know this is a long post, but PLEASE at least try to skim.
as background, i've been feeling really sick for about six weeks now. it started with appetite loss and irritability and led to extreme mood instability, muscle twitching and tremors, hypoglycemia (never had this problem before), memory loss, perception and judgment problems, and just generally feeling horrible. during the summer, i was on 1800mg of lithium and had a level of 1.1. i couldn't tolerate the side effects at this dose, so i lowered to 1350, and i was on this dose for months and was really stable. when i started feeling out of control of my mood and responses, i asked my dr for a higher lithium dose, and she ordered a Li+ level to see how much room we had to increase. the level came back at 1.5 with no good reason to explain why a lower dose would lead to a much higher level. my dr told me to stop lithium for a few days, and three days later, i started again at 900mg. right away, i started feeling toxic again, and when i saw my dr three days after restarting, she saw that i had all the symptoms-- couldn't stand without falling over, couldn't walk straight, couldn't focus my eyes, etc-- and she told me to stop lithium and wait for the levels to drop. she didn't order a level or other blood work until two days later. i felt worse and worse over the next few days, and the morning i got the blood drawn, i actually felt better. the labwork came back stat and showed that my lithium level was over 2.5. my other bloodwork didn't show any explanation for how the level could be that high three days after my last dose. i was in the hospital until the levels came down, but the drs had no explanation and didn't really look. i've had outpatient visits with my PCP, my GI dr, and my pdoc, but there's still no good theory as to what's going on.
last week, i had an upper endoscopy (unrelated to lithium toxicity) and they had trouble getting the scope through. when i still had what felt like strep throat x 10 a week later, my GI dr got me in to see an ENT specialist. by passing some instrument through the nose, he was able to see lacerations and abrasions in the throat. he put me on antibiotics and recommended continuing narcotics for a few weeks or until the throat healed. since i can't swallow, the drs are pushing the pain pills so that i can hopefully hydrate and eat some while the pills are working. i've been taking vicodin, darvocet, and percocet as well as throat lozenges that numb the mouth. it's still really hard to eat and drink, especially anything hot or cold or pretty much with flavor.
in general, i just feel really sick. i'm a student and have been trying to keep up with classes while all this has been going on. the specialists last week noticed that my heart was going really fast and skipping beats, but they referred me back to my PCP who won't be seeing me for another week and a half. i've lost about 15 lbs over 5-6 weeks, almost 15% of my starting weight. worse, my mood suddenly plummeted a few days ago. i had been pretty good about keeping up a good attitude, but all of a sudden, depression blindsided me and i can't see anything better ahead. in the past two years, i've had two serious suicide attempts, and i've been down this road before. the further into the hole i slip, the harder it is to pull myself out. i'm freaked out because i don't know what's going on with my body, and i don't know what these drugs are going to do to me. altogether, i'm on over 15 meds, about half psych and half medical, prescribed by 5-6 different drs and filled at as many different pharmacies, and there's no predicting the interactions. i'm on a lot of ativan, xanax, and klonopin, on vistaril and propranolol. throw in the narcotics and how i'm feeling physically, and i go to bed at night not sure whether i'll wake up. i don't have any active plans yet, but i'm so spacey and forgetful and hopeless right now that i could accidentally take too many pills. if i ever get really suicidal, i have tons of benzos, sleeping pills, narcotics, and alcohol, more than enough to finish the job. i know enough to know that i need to make myself safe.
few if any drs will support my going back on lithium right now because it's too risky. no one knows why the levels were so wacky or what will happen if i take some now. at minimum, they will require lithium levels every 2-3 days, and even with that, they're still really worried. in the worst case, lithium could kill me, but not taking it also kill me. today, a med resident and good friend suggested ECT. i hadn't thought about it until then. a few months after my first suicide attempt, the pdoc i was seeing suggested ECT, and i think i said, "no way in hell." the fact that i'm seriously considering it now is pretty telling. for one thing, circumstances have changed. whereas before, i had been on 3-4 meds total, now i've been on dozens including all the popular antidepressants, depakote, neurontin, and lamictal, all the atypical antipsychotics except geodon, plus some of the older APs like haldol and trilafon. i haven't tried tegretol and trileptal, but i've been told they're more like depakote, that they don't help depression, and that they're better for rapid-cycling bipolar types, which i'm not. i started lamictal over a month ago, and i'm just getting up to 100mg. i have at least another month to work up to a therapeutic dose, and i can't wait that long for a drug that i don't even know will work. my friend said, "sure there's memory loss with ECT, but it's usually not permanent, and you have that already with your meds." that was a pretty compelling argument. i don't know much about ECT, but i think it's actually a safer option than restarting lithium, especially since they monitor vital signs, heart rhythms and brain activity carefully with each treatment and can compare over time, whereas with the lithium, all we'll have is a level that doesn't give info about the mechanisms going on. i heard there's a complicated process for getting approved for outpatient ECT, so it's better to go IP. i swore i'd never spend time on another psych ward, but at this point, the prospect hardly bothers me. i feel so wiped out that a hospital could be a good place to get away from school and everything else and hopefully start to feel better.
if you've read this far, THANK YOU! if you have any advice or experience, please let me know! i have a bunch of drs but no treatment team and no one coordinating my care, so i'm scrambling to try to hold everything together, and i'm at a loss.
many thanks! cb
Posted by ed_uk on October 31, 2004, at 7:19:12
In reply to HELP!: narcotics, lithium toxicity, and ECT, posted by CareBear04 on October 31, 2004, at 1:02:57
I'm afraid I can't really give you any advice as yet because I don't know enough about you. I'd guess that many of the other people reading your post feel the same way. Please can you post all the meds that you're taking at the moment, the doses and the reason you are taking them. Thanks.
Here is a list of some factors that can increase lithium levels:
1. sodium/salt depletion eg. due to diarrhea, vomiting, profuse sweating or low salt diet.
2. use of diuretics eg. hydrochlorothiazide etc.
3. impairment of kidney function
4. use of certain drugs for high blood pressure eg. ACE inhibitors such as enalapril, lisinopril or most other drugs ending in -prilEd
Posted by ed_uk on October 31, 2004, at 7:26:50
In reply to Re: HELP!: narcotics, lithium toxicity, and ECT, posted by ed_uk on October 31, 2004, at 7:19:12
oops, I forgot to mention that use of NSAIDs (a group of painkillers/anti-inflammatory drugs) can also raise lithium levels eg. ibuprofen, naproxen, ketoprofen, diclofenac... There are many more.
Ed
Posted by CareBear04 on October 31, 2004, at 10:33:57
In reply to Re: HELP!: narcotics, lithium toxicity, and ECT, posted by ed_uk on October 31, 2004, at 7:19:12
ed-- thanks so much for posting back! even if no one can help, it's a comfort to know that someone is listening and that i'm not so alone. here are the meds:
-lamictal-- 100mg/day (titrating up)-- BP disorder
-zoloft-- 50mg/day-- depressive episodes, possible OCD
-ativan-- 1mg three times a day (tid)-- anxiety and to take over for propranolol
-xanax-- 1mg tid-- panicky anxiety
-klonopin-- 2mg at night-- sleep
-vistaril-- can't remember the dose or the reason for this one
-adderall xr-- 30 mg in the morning-- ADHD and lack of energy
-adderall immediate release-- 15 mg late afternoon
-protonix-- 40mg twice a day--ulcers and reflux
-ranitidine-- as much as needed-- more stomach meds
-penicillin-- for now b/c of poss. throat infection from the injury
-percocet-- 7.5/500, 1 pill every 4-6hrs-- pain
-darvocet-- 100/650 (?)-- 1-2 pills every 4-6hrs
-vicodin ES-- 1-2 pills every 4-6 hrs
(note: i don't take percocet, darvocet, and vicodin all at once; i usually pick which one to take according to pain severity and need for cognitive clarity)
-reglan-- 10-15mg four times a day (bad nausea and also for GI motility)
-propranolol as needed-- tremors and muscle twitches from lithium
-ortho-cyclen (current dc'd till mood stabilizes)i think those are all. as for the other stuff, i don't touch NSAIDs because of a bleeding problem, i'm not on any blood pressure meds (except propranolol), never taken diuretics. kidney function tests are at the upper extreme of reference range, but if you factor in weight (45 kg) for things like creatinine clearance, a serum creatinine of 1.4 could be significant, i don't know. electrolytes were just a little off-- no huge sodium or potassium abnormalities to account for such a big change in lithium level. i can't remember if you had other questions, but that's all i can think of for now. thanks again!!!!
Posted by ed_uk on October 31, 2004, at 12:21:48
In reply to re: lithium, ECT, etc. » ed_uk, posted by CareBear04 on October 31, 2004, at 10:33:57
Hello!
I think you will find psychobabble helpful, but only once people understand enough about you to make some sensible suggestions.Just a few more questions, hope you don't mind..
1. Why are you taking three benzos all at once? Were they all prescribed by different doctors?
You might be better off just taking one benzo on its own but at a higher dose. Some people find that benzos make them more depressed, is this a problem for you? You definately need to make sure that all your doctors know what the other docs have prescribed. That way they can check for drug interactions.2. Did your contraceptive pill worsen your mood?
3. Were you taking any other meds at the time your lithium level went through the roof? If you were there could have been an interaction.
A few suggestions....
1. Have you ever had a creatinine clearance test to evaluate your kidney function? Perhaps it would be helpful to have one if you haven't already. If it was normal your pdoc might be willing to start you back on a low dose of lithium (with frequent monitoring of blood levels of course). I get the impression the lithium was really helping, am I right? Since lithium itself can impair kidney function when the blood concentration is high this may explain why your Li level went up even though your dose had been reduced. If your kidney function was impaired, the Li may have been accumulating in your body despite the decrease in dose. Although Li sometimes causes permanent damage to the kidneys this is not likely to have occured in your case. Your kidney function has probably returned to normal now that you've been off the Li for a while. If so, you might be able to tolerate a small dose of Li well. Just be sure to keep your blood Li level well below 1 mmol/litre. Some people do well with Li levels as low as 0.4. It's very important to determine the optimum Li level for each individual patient. Some people need much higher/lower levels than others to get the best effect.
2. Please be really careful not to overdose on your pain meds. Be sure never to take more than 4g (4000mg) of acetaminophen/paracetamol/APAP in any 24 hour period. Never take more that 1g (1000mg) of acetaminophen at once and make sure you leave at least four hours between doses. I was worried that you might be taking doses of vicodin, darvocet and percocet at the same time. So long as you take care not to overdose you should be fine.
3. Hydroxyzine (Vistaril) is commonly used for anxiety, itchy skin or for the relief of nausea/vomiting.
4. Bear in mind Reglan occasionally causes restlessness and emotional distress as side effects.
5. Propranolol sometimes causes depression. Do you find this to be a problem for you?
6. I think it's a bit early to consider ECT. Sadly, some people do report permanent memory loss as a side effect. The antidepressant effect of ECT usually wears off about 4 weeks after the last session. I tend to see ECT as a last resort, the Lamictal could be more helpful in the long run.
Ed
Posted by chailatte on November 2, 2004, at 21:13:44
In reply to re: lithium, ECT, etc., posted by ed_uk on October 31, 2004, at 12:21:48
I have always had a lot of trouble with my Lithium level spiking despite avoiding things that cause that and montoring the level consistently. I am concerned about the level at which you are being medicated. It seems like you are being overmedicated. I am not talking about the number of medicines, but about the overlap of 3 benzos for anxiety. It is understandable why you take Adderall for energy in addition to your ADHD. I think it is more effective to take one benzo at an appropriate dose. Hopefully, you will feel better soon and can go off some of these meds for your medical condition. Right now there are just so many interactions occuring which might make you worse and require additional meds. Good luck with the Lamictal.
Katie
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