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Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 1 to 20 of 20. This is the beginning of the thread.
Posted by jclint on November 6, 2004, at 18:32:04
My doctor wasn't keen on a klonopin route for my social phobia last time I saw him, and I doubt he will have changed his tune next week... ah well. After doing some research this week I found out that Pregabalin, which is praised in studies (and the gradually emerging anecdotes on here) is newly available here in the UK.
How hard do you think this will be to get? I don't want to get my hopes up too early. I don't know anything about doctors' feelings towards this... do you think he would be more comfortable prescribing this than a benzo? It was the dependence issue of the Klonopin he had an issue with, is there any concern about Pregabalin dependence?
Cheers, John :)
Posted by ed_uk on November 6, 2004, at 18:46:24
In reply to Pregabalin (Lyrica) for Social Phobia, posted by jclint on November 6, 2004, at 18:32:04
Hello John...
Here in the UK pregabalin is licensed for the treatment of epilepsy (prevention of partial seizures) and also for the treatment of neuropathic pain. It is not licensed for the treatment of anxiety or social phobia. Since it is still very new, it is quite possible that your doc might not have heard of it!! Despite the fact that it isn't licensed for SP, your doc could still prescribe it if he/she felt that it was suitable.
In terms of benzos, clonazepam is only licensed for the treatment of epilepsy in the UK. Your doc might be more comfortable with the idea of using a different benzo, probably diazepam.
All the best...
Ed.
Posted by pseudonym on November 7, 2004, at 1:34:53
In reply to Pregabalin (Lyrica) for Social Phobia, posted by jclint on November 6, 2004, at 18:32:04
I'm going to attempt to put together a case and present it to my pdoc. Here's something for the arsenal. From the double blind placebo controlled 10 week study seen in: http://www.cnsforum.com/cp/en/CNSforum/literature/trial_reports/reports/958777.html
there was a significant drop in the LSAS at the 600mg/day level. The major side effects which differed from placebo were somnolence and dizziness.
Posted by ed_uk on November 7, 2004, at 6:36:38
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by pseudonym on November 7, 2004, at 1:34:53
The study should definately help... I think a lot of people will be printing it out!
Ed
Posted by SLS on November 7, 2004, at 7:24:28
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by ed_uk on November 7, 2004, at 6:36:38
> The study should definately help... I think a lot of people will be printing it out!
> Ed
I don't know enough about the rating scale to judge the absolute efficacy of pregabalin in this study, but at first look, the results seem disappointing. The placebo response was very high. At a dosage necessary to differ significantly from placebo, side effects became very prominent, with 23% withdrawing from the study.
Side Effect % - Placebo/150mg/600mgSomnolence - 9 10 43
Dizziness - 9 12 40
Headache - 24 29 21
Abnormal thinking - 7 2 21
Asthenia - 7 14 19
Nervousness - 9 0 13
Amblyopia - 0 2 11
Amnesia - 4 2 11
Depersonalisation - 0 5 9
Incoordination - 0 0 9
Insomnia - 13 7 9
Decreased libido - 0 0 9
Nausea - 4 7 9
Withdrew due to adverse events - 9 10 23
Posted by ed_uk on November 7, 2004, at 8:16:31
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by SLS on November 7, 2004, at 7:24:28
Hello Scott!
To be honest, the results were rather disapointing, but the results of most trials of psychotropics are also rather depressing if you actually compare the placebo response to the effect of the drug. In most cases, it seems that the active drug is only slightly more effective than placebo. eg.
Placebo -5.2
Drug X -6.6 p less than 0.05
I just made that up btw!Ed
Posted by jclint on November 7, 2004, at 8:58:24
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by SLS on November 7, 2004, at 7:24:28
Hmm I think I will perhaps wait for a while before trying this. It seems its just too new at the moment, I can only find a handful of anecdotes on the internet. I'm still holding out for it though, it looks like it has real potential, especially if the addiction/tolerance potential is less than benzos'.
Its a bit confusing, a couple of years back posters were raving about this stuff, now its been released and no-one seems to be mentioning it... :s
I think I'll try the amisulphate route before I try pregabalin. Get me some of that dopamine.
Ps Ed, I read a few of your posts in the archives, am I right in remembering that you are from Birmingham?
Posted by ed_uk on November 7, 2004, at 9:43:09
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by jclint on November 7, 2004, at 8:58:24
Hi jclint,
I'm from West Yorkshire (Huddersfield) not Birmingham. Where do you live? At the moment I'm at the University in Manchester doing Pharmacy. Did you say you had social phobia? I don't remember. Which treatments for anxiety have you tried so far?Hi Scott,
If you look at many clinical studies which examine the efficacy of drugs in treating mental health problems, there are several recurrent themes which tend to emerge...a) The proportion of patients suffering from side effects is frequently high
b) The difference in efficacy between the active drug and placebo is often quite small (as measured by symptom rating scales).
c) Although the difference between the active drug and placebo is often statistically significant, it is very hard to demonstrate that it is clinically significant ie. drug generally provides slightly more symptom relief than placebo but at the expense of adverse effects, withdrawal symptoms and (often) unknown long term efficacy and safety.
d) studies which use an 'active' placebo often fail to show any statistically significant efficacy difference between the psychotropic and the active placebo.
Here is an interesting article....Active placebos versus antidepressants for depression.
Moncrieff J, Wessely S, Hardy R.
Psychiatry, University College London, Warley hospital, Mascalls Lane, Brentwood, Essex, UK, CM14 4TU.
BACKGROUND: Although there is a consensus that antidepressants are effective in depression, placebo effects are also thought to be substantial. Side effects of antidepressants may reveal the identity of medication to participants or investigators and thus may bias the results of conventional trials using inert placebos. Using an 'active' placebo which mimics some of the side effects of antidepressants may help to counteract this potential bias. OBJECTIVES: To investigate the efficacy of antidepressants when compared with 'active' placebos. SEARCH STRATEGY: The Cochrane Collaboration Depression, Anxiety and Neurosis review groups's search strategy was used to search MEDLINE (1966-2000), PsychLIT (1980-2000) and EMBASE (1974-2000) and this was last done in July 2000. Reference lists from relevant articles and textbooks were searched and 12 specialist journals were handsearched up to 1996. SELECTION CRITERIA: Randomised and quasi randomised controlled trials comparing antidepressants with active placebos in people with depression. DATA COLLECTION AND ANALYSIS: Since many different outcome measures were used a standard measure of effect was calculated for each trial. A subgroup analysis of inpatient and outpatient trials was conducted. Two reviewers independently assessed whether each trial met inclusion criteria. MAIN RESULTS: Nine studies involving 751 participants were included. Two of them produced effect sizes which showed a consistent and statistically significant difference in favour of the active drug. Combining all studies produced a pooled estimate of effect of 0.39 standard deviations (confidence interval, 0.24 to 0.54) in favour of the antidepressant measured by improvement in mood. There was high heterogeneity due to one strongly positive trial. Sensitivity analysis omitting this trial reduced the pooled effect to 0.17 (0.00 to 0.34). The pooled effect for inpatient and outpatient trials was highly sensitive to decisions about which combination of data was included but inpatient trials produced the lowest effects. REVIEWER'S CONCLUSIONS: The more conservative estimates from the present analysis found that differences between antidepressants and active placebos were small. This suggests that unblinding effects may inflate the efficacy of antidepressants in trials using inert placebos. Further research into unblinding is warranted.
As you know all too well from personal experience, current psychiatric drugs often leave a lot to be desired!! Which ADs/or combinations of ADs have you not yet tried?
All the best...
Ed
Posted by jclint on November 7, 2004, at 10:18:22
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by ed_uk on November 7, 2004, at 9:43:09
Hmm I remember someone saying they were from Birmingham. I'm from Solihull, just outside brum, hence why I asked.
Yeah I have social phobia, with other symptoms, depression and slight ADD. Interested to try a dopamine drug like amisulphide.
I've only been on two drugs so far -
Efexor - helped depression somewhat but not anxiety. Took for 2 years but am kicking it as we speak, I'm tired of no improvements, living a compromised life, putting things 'on hold' until my problems fade away. My old pdoc prescribed Propanolol (beta-blocker) for a short time, but that was a sugar pill for me, really hopeless. I have done hypnotherapy and councelling, and am currently doing CBT. They help me understand myself more, but I can't say they have fixed my symptoms... increasingly I'm coming round to the chemical imbalance way of thinking - I'm pretty eager to see if a dopamogenic drug will help. I've got a feeling it will. The reason I haven't tried many drugs (despite being treated for 3 yrs) is my age - I turned 18 this month so hope to have a bit more autonomy in my decisions. Already I've spoken about my desire to try a MAOI, and my doc is treating me more like an adult. I think he might give me some valium next time which will be a help. But I want to try some alternatives before the MAOI route, amisulphide or pregabalin preferably, although I have no idea how realistic this is. Fingers crossed! lol.
Posted by ed_uk on November 7, 2004, at 10:44:49
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by jclint on November 7, 2004, at 10:18:22
Hello...
Hey, it's good to 'meet' someone near my age (I'm 20 btw).
There are quite a few psycho-babblers who seem to have been helped by amisulpride (Solian) at a dose of 50mg/day. I don't think it's been formally studied in SP though, only in schizophrenia.Personally, I hate propranolol. It doesn't help my anxiety at all. It causes me: fatigue, dry eyes, blurred vision. Feel exhausted when I haven't even done anything.
Do you like diazepam, have you used it before? I've always found it somewhat helpful but only at very high doses- which my pdoc doesn't like to prescribe.
Pregabalin could be helpful for you. It could be worth a try. Your doc might be a lot more familiar with gabapentin though, my pdoc doesn't like prescrbing new drugs.
If none of the above work, it may be time to try an MAOI, probably Nardil. If you want Parnate you might have to threaten your doc at gun point!
Ed
Posted by jclint on November 7, 2004, at 10:58:38
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by ed_uk on November 7, 2004, at 10:44:49
Yea I think our generation is becoming more aware of illnesses like these, and not taking their doc's decision as final. Its a good thing, it breaks my heart when I read of people suffering for 25+ years without even realising they were ill. But I'm pretty focused now, I feel positive about the coming months.
Well I have transfered to a new doc - thought I should move on from my adolescent-specific one. I really wanted Klonopin. He thought benzos would be useful but wanted to see if my CBT would cure me first (argh..!). I've got my next appointment in just over a week. He said diazepam was his prefered treatment so I expect he will prescribe that then - I'm sure it will help me but I know that he doesn't want it as an everyday, long-term thing. And to be honest, I don't either really. Something about me that thinks diazepam < clonazepam.
I'm certainly going to ask about my researched drugs, amisulphide & pregabalin. Will be hard to sell him either... 'there's no research but I know they could help me'... argg. Well I've weaned myself off effexor so if he's open to MAOIs I might give them a whiz, although I think my suggestions are better.
Have you had any real success with meds?
John :)
Posted by ed_uk on November 7, 2004, at 11:33:08
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by jclint on November 7, 2004, at 10:58:38
Hello!
I think I've had some success with meds but it's always impossible to know what I would have been like without them. Maybe I'd have been in better health than I am today!A few of the meds I've taken...
1. Lorazepam (Ativan)- helps anxiety up to a point
2. Diazepam (Valium)-similar to Ativan but it's got a zonkier feel to it
3. Paroxetine (Seroxat/Paxil)- helped anxiety, didn't help depression. Made me very lazy and sleepy.
4. Fluoxetine (Prozac)- placebo?
5. Venlafaxine (Effexor)- no better than an SSRI
6. Moclobemide (Manerix)- another placebo?
7. Citalopram (Cipramil/Celexa)- similar to Paxil for anxiety, less drowsiness.
8. Chlorpromazine (Thorazine/Largactil)- within a hour of taking the dose I wished I was dead, most awful/terrifying experince of my life
9. Hydroxyzine (Atarax)- didn't help at all, made me extremely tired and dizzy
10. Lofepramine (Gamanil)- seems to help my depression
11. Amitriptyline (Elavin)- only took one dose, nearly lost consciousness I was so drowsy.
12. Dothiepin (Prothiaden)- ditto amitriptyline
13. Clonazepam (Rivotril/Klonopin)- for me, it was just another benzo to be honest
14. Clobazam (Frisium)- an unusually ineffective benzo
15. Diphenhydramine (Nytol/Benadryl)- helps me sleep, rarely use it these days. Wake up feeling hungover.
16. Promethazine (Phenergan)- like Nytol with a really bad hang-over
17. Prochlorperazine (Stemetil)- only took a tiny dose thankfully, if i had taken more it would have been like chlorpromazine but worse!Ed
Posted by Iansf on November 7, 2004, at 13:19:19
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by ed_uk on November 7, 2004, at 6:36:38
> The study should definately help... I think a lot of people will be printing it out!
> EdI think the side effect profile looks extraordinarily bleak. 40 out of 46 at 600mg/d experiencing somnolence? That's an astonishing percentage, especially since these generally short-term studies typically undermeasure side effects. Dizziness, headaches, confused thinking - all had generally high percentages compared to the figures for most drugs. Pregabalin doesn't seem very promising to me.
John Mc
Posted by ed_uk on November 7, 2004, at 13:58:27
In reply to Re: Pregabalin (Lyrica) for Social Phobia » ed_uk, posted by Iansf on November 7, 2004, at 13:19:19
Hello everyone... :-)
I'm starting to regret saying that 'the study should definately help'. I thought that the study would interest doctors who had not yet heard of the anxiolytic potential of pregabalin- that's why I said that some people may print it out. Basically, I was just trying to thank pseudonym for kindly providing the link to the study. I agree that the results are not impressive. At a dose of 600mg, 43% of patients experienced somnolence, 40% experienced dizziness and 21% had abnormal thinking. Pregabalin did not improve QOL. My opinion of pregabalin is the same as it always has been: it's just gabapentin(Neurontin) in disguise :-(
Perhaps a few people will prefer it to gabapentin, but many others will probably find that there's little to choose between them. For me, Neurontin was like a placebo so I'm not in a hurry to try Lyrica!
Ed
Posted by jclint on November 7, 2004, at 14:29:39
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by ed_uk on November 7, 2004, at 11:33:08
That's quite a hefty list for someone so young :) I'm impressed you were able to get things like clonazepam here. You must have a good doc.
I wish I hadn't spent so much time on effexor. Until researching on places like this, I didn't realise that it wasn't really a great med for my symptoms. I accepted that I was being treated and this was it. I've got quite a few new options now though, no more mediocre treatment I hope :s
Posted by ed_uk on November 7, 2004, at 14:48:38
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by jclint on November 7, 2004, at 14:29:39
Hi!
Although clonazepam isn't licensed for anxiety in the UK there are plenty of other benzos which are. Here is a list of the benzos which are approved for the treatment of anxiety in England:
1. Diazepam (Valium)
2. Chlordiazepoxide (Librium)
3. Lorazepam (Ativan)
4. Oxazepam (Serax)
(The brand name drugs are not available on the NHS, generics are always dispensed).
Alprazolam (Xanax) is available on private prescription only- you cannot get it on the NHS.Do you think you'll try amisulpride (Solian) next?
Ed
Posted by jclint on November 7, 2004, at 15:02:55
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by ed_uk on November 7, 2004, at 14:48:38
> Do you think you'll try amisulpride (Solian) next?
That's my current plan. Although last week I was planning on parnate, so who knows what I'll go for. I think I'll bring up pregabalin but I don'y expect I'll get it. Amisulpride seems more realistic though. Last time my doc said he prefered valium, so hopefully I'll get a script for some of them (for emergencies). I just hope he's not put off by the 'antipsycotic' label of solian, it could scare him off if he's not aware of its use in depression/anxiety. I'll try and get some clinical research to show him.
Posted by pseudonym on November 7, 2004, at 18:29:35
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by SLS on November 7, 2004, at 7:24:28
Scott,
I agree that the results of the pregabalin study are not the greatest (Ocinaplon from Dov fared far better and I sure as #$#$ wish they'd start the phase III trial).
I was disappointed ultimately by duloxetine, as you were, but am happy knowing that these type of drugs, SSRIs, SNRIs, simply do not work well for my social anxiety. Maybe Lyrica will work, maybe EMSAM will work. Selegiline seems very promising, just not in oral form.
Posted by SLS on November 8, 2004, at 7:25:54
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by pseudonym on November 7, 2004, at 18:29:35
> Scott,
>
> I agree that the results of the pregabalin study are not the greatest (Ocinaplon from Dov fared far better and I sure as #$#$ wish they'd start the phase III trial).
>
> I was disappointed ultimately by duloxetine, as you were, but am happy knowing that these type of drugs, SSRIs, SNRIs, simply do not work well for my social anxiety. Maybe Lyrica will work, maybe EMSAM will work. Selegiline seems very promising, just not in oral form.
Cymbalta pretty much left me high and dry. I have added riluzole and a small amount of imipramine:Lamictal 300mg
Cymbalta 60mg
imipramine 100mg
Abilify 10mg
riluzole 100mg
I will continue with the riluzole for a few weeks. I have been on it for 6 days. Nothing yet.Regarding selegiline, it is amazing some of the reports of how much better the transdermal patch works for depression compared to the oral preparation.
I am thinking of trying pregabalin when it comes out. Neurontin had a passing antidepressant effect for me. I'll want to see how people react to it first. Pregabalin is considerably more potent than Neurontin as a ligand at calcium channels. Hopefully, this will allow people to gain a therapeutic effect at dosages lower than what produces cognitive side effects.
- Scott
Posted by Sydney on November 9, 2004, at 11:34:01
In reply to Re: Pregabalin (Lyrica) for Social Phobia, posted by SLS on November 8, 2004, at 7:25:54
In the December 2003 journal of PAIN, Chesler EJ, Ritchie J, Kokayeff A, Lariviere WR, Wilson SG and Mogil JS studied and observed significantly different responses to Pregabalin which depended upon which strain of mice were used. They argue this shows sensitivity to Pregabalin is heritable.
>>Abstract available at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14659515<<;
So, hypothetically, one could pick three strains of mice, strain "A" being proven responders, and strains "B" amd "C" being proven non-responders. A double-blind survey of such mice would show little to no response- overall- despite clear, a priori evidence that pregabalin yielded a positive response amongst strain "A".
To state the point in reverse, all the data in the world didn't help me respond to Paxil, Prozac, Effexor, Cymbalta, etc... Yet pregablin's pre-cursor, Neurontin, prescribed to me following back-surgery, had the serendipitous effect of strongly- but fleetingly- relieving my anxiety. Likewise, even at high doses I experienced zero side-effects despite many complaints by others.
In other words, it is clear that some medications which are intolerable to some and without effect for others will provide god-sent relief to others. We may not know enough about the mind to predict who will benefit from a drug and who won't, but accepting generalized results as dogma risks throwing the baby out with the bathwater.
For treatment resistant individuals such as myself, we are forced to look beyond the generic conclusions and instead attempt to discern the *possibility* that a medication will provide some relief. So... Pregablin *may* be a waste of time for most people, but for those who have exhausted the more obvious possibilities, it's weak but demonstratable efficacy in treating anxiety still provides a compelling reason for a personal trial.Fortunately with Pregabalin, it looks like efficacy and tolerability take about a week to show themselves.
This is the end of the thread.
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