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Dr. Bob is Robert Hsiung, MD,
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Posted by ed_uk on October 21, 2005, at 15:38:36
In reply to Beta blockers for anxiety -- interactions with WB?, posted by Racer on October 21, 2005, at 1:26:51
Racie,
Why not try a slightly higher dose of propranolol?
~Ed
Posted by sdb on October 21, 2005, at 15:53:29
In reply to Beta blockers for anxiety -- interactions with WB?, posted by Racer on October 21, 2005, at 1:26:51
Hi Racer!
If the propranolol has too much sideeffects in a higher dosage you can try nadolol. Almost the same but works longer (more than 24h), less sideeffects, hydrophil. Very effective against adrenaline on heart tissue.
Posted by Phillipa on October 21, 2005, at 18:42:13
In reply to Re: Beta blockers for anxiety -- interactions with WB?, posted by sdb on October 21, 2005, at 15:53:29
Beta blockers made me very tired. And heartrate stayed down even while excercising. Fondly, Phillipa
Posted by sdb on October 22, 2005, at 15:45:20
In reply to Re: Beta blockers for anxiety -- interactions with WB?, posted by Phillipa on October 21, 2005, at 18:42:13
Dear Phillipa,
Betablockers only help for physical anxiety for example performance anxiety. They cannot kill the anxiety itself. There are Betablockers you dont have to be tired.
~sdb
Posted by blueberry on October 22, 2005, at 17:32:01
In reply to Beta blockers for anxiety -- interactions with WB?, posted by Racer on October 21, 2005, at 1:26:51
Racer,
Do you feel any anxiety from the wellbutrin or provigil? Even though wellbutrin is famous for causing anxiety side effects, I've seen a few readings here and there that it is actually being used to treat anxiety and panic. If I recall correctly, I think your anxiety existed before using wellbutrin? Anyway, I was just curious to know if wellbutrin has helped ease anxiety at all, or is it neutral, or has it worsened it?
Sorry I'm not much help on your questions. But you did spark my curiosity on how wellbutrin has affected your anxiety levels.
Posted by Phillipa on October 22, 2005, at 18:07:46
In reply to Re: Beta blockers for anxiety -- interactions with WB?, posted by sdb on October 22, 2005, at 15:45:20
Wonder why that pdoc gave me the lopressor. But then again he's the one under investigation. Fondly, Phillipa
Posted by Racer on October 22, 2005, at 19:22:57
In reply to Re: Beta blockers for anxiety -- interactions with WB? » Racer, posted by blueberry on October 22, 2005, at 17:32:01
> Racer,
>
> Do you feel any anxiety from the wellbutrin or provigil? Even though wellbutrin is famous for causing anxiety side effects, I've seen a few readings here and there that it is actually being used to treat anxiety and panic. If I recall correctly, I think your anxiety existed before using wellbutrin? Anyway, I was just curious to know if wellbutrin has helped ease anxiety at all, or is it neutral, or has it worsened it?
>
> Sorry I'm not much help on your questions. But you did spark my curiosity on how wellbutrin has affected your anxiety levels.No problem. Yes, my anxiety is preexisting. As for the effects of WB on it, that's a bit more problematic -- it's hard to tell what I'd feel without it, you know?
Anyway, the basic answer is that when my depression is under control, which is happening with the Cymbalta/Wellbutrin/Provigil combination, then my anxiety is generally lowered. That's consistent for me.
The problem, though, is that when I get hit by anxiety, it tends to be fast and debilitating. It's not related to thinking, just an overwhelming surge of adrenaline, which leaves me physically overwhelmed. That's what I'm trying to find a way to deal with.
Posted by maddy4 on October 24, 2005, at 9:04:09
In reply to Re: Beta blockers for anxiety » blueberry, posted by Racer on October 22, 2005, at 19:22:57
my pdoc cringed when i told him my OB gave me WB for anxiety! (i have only anxiety/panic - no depression) when i tried WB my anxiety was thru the freaking roof - i mean an all day heart attack.
also seems odd to me your pdoc would give you WB since your anorexic. WB is contraindicated for use in people w. or who have had EDs
Posted by Racer on October 24, 2005, at 14:38:21
In reply to Re: Beta blockers for anxiety, posted by maddy4 on October 24, 2005, at 9:04:09
> my pdoc cringed when i told him my OB gave me WB for anxiety! (i have only anxiety/panic - no depression) when i tried WB my anxiety was thru the freaking roof - i mean an all day heart attack.
While I do have an anxiety disorder, the depression is more of an issue. The bottom line is that Wellbutrin XL addresses my depression without side effects that create other problems, so that's what I take. It's a drug that I wouldn't give up, by the way, because of how helpful it is to me -- despite the anxiety problems, which it does not make worse. Another of those 'everyone's different' things, but I'm also on Cymbalta, which is a bit more sedating/anxiolytic.
>
> also seems odd to me your pdoc would give you WB since your anorexic. WB is contraindicated for use in people w. or who have had EDsThe eating disorder thing with WB is a bit less clear than that. It's related to the seizure risk, and is probably a function of electrolyte imbalances caused by purging. Since I'm a restricting-only anorexic, and being treated for it with nutritional counseling as well as therapy, my doctor was willing to use WB XL. At that time, there had been no reports of the XL being related to seizures, which has since changed.
Whatever else I can say, I'm just so relieved that he was willing to prescribe it. (For what it's worth, it was first prescribed to me in the hospital after a suicide attempt. At that time, I simply wasn't eating -- picky eater, lousy food -- and yet the doctor put me on the regular WB. I think there's a pretty wide window of what doctors think is appropriate with this drug...)
Thanks for your input.
Posted by maddy4 on October 24, 2005, at 15:25:37
In reply to Re: Beta blockers for anxiety » maddy4, posted by Racer on October 24, 2005, at 14:38:21
> > my pdoc cringed when i told him my OB gave me WB for anxiety! (i have only anxiety/panic - no depression) when i tried WB my anxiety was thru the freaking roof - i mean an all day heart attack.
>
> While I do have an anxiety disorder, the depression is more of an issue. The bottom line is that Wellbutrin XL addresses my depression without side effects that create other problems, so that's what I take. It's a drug that I wouldn't give up, by the way, because of how helpful it is to me -- despite the anxiety problems, which it does not make worse. Another of those 'everyone's different' things, but I'm also on Cymbalta, which is a bit more sedating/anxiolytic.
>
> >
> > also seems odd to me your pdoc would give you WB since your anorexic. WB is contraindicated for use in people w. or who have had EDs
>
> The eating disorder thing with WB is a bit less clear than that. It's related to the seizure risk, and is probably a function of electrolyte imbalances caused by purging. Since I'm a restricting-only anorexic, and being treated for it with nutritional counseling as well as therapy, my doctor was willing to use WB XL. At that time, there had been no reports of the XL being related to seizures, which has since changed.
>
> Whatever else I can say, I'm just so relieved that he was willing to prescribe it. (For what it's worth, it was first prescribed to me in the hospital after a suicide attempt. At that time, I simply wasn't eating -- picky eater, lousy food -- and yet the doctor put me on the regular WB. I think there's a pretty wide window of what doctors think is appropriate with this drug...)
>
> Thanks for your input.so many pdos add WB to an SSRI cocktail to conteract weight gain - b.c WB has the reputation for weight loss - so it seemed to me that that was the contraindication.
i also see your point abt the electrolyte imbalance being an issue - but even w. restricting cant that throw your electrolytes out of whack?
has the WB made you lose weight and decreased your app? i guess that was my main concern i was pointing out to you.
at any rate - i am glad you have found smthg that is working!
im still working on that! :)
Posted by grammy on October 27, 2005, at 22:32:48
In reply to Re: Beta blockers for anxiety » maddy4, posted by Racer on October 24, 2005, at 14:38:21
I am on Coreg for high blood pressure twice a day and it is not helping with anxiety. The doc put me on Tranxene which is helping a little but I need something stronger.
Posted by Bowtie Bob on October 28, 2005, at 7:16:23
In reply to Re: Beta blockers for anxiety -- interactions with WB? » sdb, posted by Phillipa on October 22, 2005, at 18:07:46
> Wonder why that pdoc gave me the lopressor. But then again he's the one under investigation. Fondly, Phillipa
Good Morning Phillipa. How much Lopressor did your pdoc give you? Should be a much lower dose than that used for hypertension.
BTB
Posted by Phillipa on October 28, 2005, at 18:38:42
In reply to Re: Beta blockers for anxiety -- interactions with WB?, posted by Bowtie Bob on October 28, 2005, at 7:16:23
Bow Tie I think it was 50mg. It certainly made me tired. Fondly, Phillipa
Posted by BowTie Bob on October 29, 2005, at 13:03:23
In reply to Re: Beta blockers for anxiety -- interactions with WB? » Bowtie Bob, posted by Phillipa on October 28, 2005, at 18:38:42
> Bow Tie I think it was 50mg. It certainly made me tired. Fondly, Phillipa
Phillipa...did it help at all? The Lopressor can also be broken down into 25mg. The branded tabs are scored...? BTB
Posted by SLS on October 29, 2005, at 18:28:28
In reply to Re: Beta blockers for anxiety -- interactions with WB? » Bowtie Bob, posted by Phillipa on October 28, 2005, at 18:38:42
I don't really know, but doesn't a beta-blocker have to cross the blood-brain barrier to have the desired anti-anxiety effect?
The ones being discussed are more cardioselective and might not have the desired effect on the sympathetic nervous system as a whole.
Can someone clear this up for me?
Thanks.
- Scott
Posted by ed_uk on October 30, 2005, at 10:11:11
In reply to Re: Beta blockers for anxiety -- interactions with WB?, posted by SLS on October 29, 2005, at 18:28:28
Hi Scott,
>I don't really know, but doesn't a beta-blocker have to cross the blood-brain barrier to have the desired anti-anxiety effect?
No. Beta blockers are not anti-anxiety as such. They can be effective in relieving *some* of the peripheral manifestations of anxiety - which can in turn reduce psychological distress. Cardioselective beta blockers (eg. atenolol, metoprolol) are only effective in relieving cardiac symptoms..... tachycardia, chest discomfort, palpitations etc. Cardioselective beta blockers do not relieve tremor. Non-cardioselective beta blockers eg. nadolol can relieve tremor as well as cardiac symptoms. Beta blockers do not relieve muscle tension, there is no evidence that they decrease sweating. In fact, tremor and cardiac symptoms are usually the only symptoms which are relieved. My experience of beta blockers suggests that the large majority of peripheral symptoms of anxiety are not affected.
Propranolol (Inderal) crosses the blood brain barrier. Nadolol, an non-cardioselective beta blocker which does not cross the BBB might be equally effective with less side effects. Beta blockers which cross the BBB can cause sleep disturbances, most frequently nightmares.
The term 'cardioselective' implies that the drug is beta-1 selective eg. atenolol. Some 'cardioselective' beta blockers cross the BBB eg. metoprolol, bisoprolol, whereas others do not eg. atenolol.
'Non-cardioselective' implies that the drug acts as an antagonist at beta-1 *and* beta-2 receptors. Some 'non-cardioselective' beta blockers cross the BBB eg. propranolol, whereas others do not eg. nadolol.
Some beta-blockers are lipid soluble and some are water soluble. Atenolol, celiprolol, nadolol, and sotalol are the most water-soluble. Water soluable beta blocker cause less sleep disturbances and nightmares than other beta blockers....... because they penetrate the BBB only to a limited extent.
Water-soluble beta-blockers are excreted by the kidneys.... they accumulate in patients with renal impairment and dosage reduction is necessary.
Which beta blocker to choose????????????
Cardiac symptoms of anxiety: atenolol
Tremor due to anxiety: nadolol, propranolol
Tremor + cardiac symptoms of anxiety: nadolol, propranolol
Hypertension: atenolol, bisoprolol, metoprolol
Angina: atenolol, bisoprolol, metoprolol
Chronic stable heart failure: bisoprolol (in countries where low dose formulations are available), carvedilol
Relief of symptoms of thyrotoxicosis: propranolol
Intravenous use in patients suffering from acute myocardiac infarction or acute coronary syndrome: atenolol, metoprolol, esmolol
Situations in which a short-acting IV beta blocker is necessary: esmolol
Prophylaxis following myocardial infarction: metoprolol, bisoprolol, timolol, propranolol
Hypertensive crisis: labetalol
Hypertension in pregnancy: labetalol
Prophylaxis of recurrent migraine: propranolol
Topical treatment of gluacoma: timolol, betaxolol, carteolol, levobunolol, metipranolol
Situations in which a class III anti-arrhythmic is required: sotalol. Warning - sotalol is *only* indicated for the treatment and prophylaxis of serious cardiac arrhythmias
Patients with stable well-controlled asthma who require a beta blocker for the treatment of angina: bisoprolol, atenolol, metoprolol. All beta blockers are contra-indicated in severe or unstable asthma. Non-cardioselective beta blockers are always contra-indicated in asthma, even mild asthma.
Patients with asthma who require a beta blocker for the treatment of hypertension only: nebivolol
Diabetic patients who require a beta blocker: atenolol, bisoprolol, metoprolol.
Adjunct in the treatment of severe depression: pindolol
Patients who require a beta blocker with intrinsic sympathomimetic activity: oxprenolol, pindolol, acebutolol, celiprolol
~Ed
Posted by SLS on October 30, 2005, at 11:15:33
In reply to Beta blockers » SLS, posted by ed_uk on October 30, 2005, at 10:11:11
Hi Ed.
Thanks for your thorough post.
It's great that so many different beta-blockers are available. I had no idea.
My grandmother gets substantial relief from her CHF using carvedilol. It is supposed to have the added property of being an afterload reducer via alpha-1 blockade. It does help her with exertion breathlessness more than the others she's tried.
Do you know which of the ARBs is indicated when there is renal insufficiency? My grandmother can't take losartan because it causes her to become hyperkalemic.
So that this thread doesn't go too far off track, I guess the psychiatric question I have for you is whether or not you have personally seen pindolol used successfully as an augmentor of antidepressants?
Thanks.
- Scott
Posted by bowtie bob on October 30, 2005, at 11:24:57
In reply to Re: Beta blockers » ed_uk, posted by SLS on October 30, 2005, at 11:15:33
> Hi Ed.
>
> Thanks for your thorough post.
>
> It's great that so many different beta-blockers are available. I had no idea.
>
> My grandmother gets substantial relief from her CHF using carvedilol. It is supposed to have the added property of being an afterload reducer via alpha-1 blockade. It does help her with exertion breathlessness more than the others she's tried.
>
> Do you know which of the ARBs is indicated when there is renal insufficiency? My grandmother can't take losartan because it causes her to become hyperkalemic.
>
> So that this thread doesn't go too far off track, I guess the psychiatric question I have for you is whether or not you have personally seen pindolol used successfully as an augmentor of antidepressants?
>
> Thanks.
>
>
> - ScottHey Scott. Here is an ARB that, apparently, can be used in people with renal insuffiency. Hyperkalemia seems to be more prevalent with ACE Inhibitors.
http://www.pharma.us.novartis.com/product/pi/pdf/diovan_hct.pdf
BTB
Posted by SLS on October 30, 2005, at 11:42:04
In reply to Re: Beta blockers, posted by bowtie bob on October 30, 2005, at 11:24:57
Hi BTB.
> Hey Scott. Here is an ARB that, apparently, can be used in people with renal insuffiency. Hyperkalemia seems to be more prevalent with ACE Inhibitors.
> http://www.pharma.us.novartis.com/product/pi/pdf/diovan_hct.pdf
>
> BTB
Thanks, Bob. I really appreciate it.Are you the guy with the Chevy truck?
- Scott
Posted by ed_uk on October 30, 2005, at 11:57:05
In reply to Re: Beta blockers » ed_uk, posted by SLS on October 30, 2005, at 11:15:33
Hi Scott,
>It's great that so many different beta-blockers are available.
14 oral beta blockers are marketed in the UK.
>My grandmother can't take losartan because it causes her to become hyperkalemic.
All ARBs can cause hyperkaemia. The hyperkalemia may be reduced by potassium-wasting diuretics such as furosemide (Lasix).
>So that this thread doesn't go too far off track, I guess the psychiatric question I have for you is whether or not you have personally seen pindolol used successfully as an augmentor of antidepressants?
No, I don't know anyone who's tried it.
Ed
Posted by ed_uk on October 30, 2005, at 12:53:53
In reply to Re: Beta blockers, posted by SLS on October 30, 2005, at 11:42:04
Hi Scott,
What medication/doses is your grandmother taking at the moment?
Ed
Posted by SLS on October 30, 2005, at 14:10:26
In reply to Re: Beta blockers » SLS, posted by ed_uk on October 30, 2005, at 12:53:53
> What medication/doses is your grandmother taking at the moment?
Hi Ed.
How's this for a cocktail:
Coreg (carvedilol)
Cozaar (losartan)
Folgard (folate, B6, B12)
Hydralazine
Imdur (isosorbide)
Lasix (furosemide)
Protonix (pantoprazole)
Quinine sulfa
Levoxyl (T4 thyroid)
Aspirin
Celebrex (celecoxib)
Flonase (fluticasone)
Advair 100/50I can't figure out where all the potassium is coming from in her diet. I guess it's unavoidable. She has only one kidney. She had been able to handle Cozaar 100mg without her potassium becoming dangerously high. She was stable. Then, a new cardiologist removed the Cozaar because he got spooked by the potassium numbers, which were actually acceptable. Once the Cozaar was restarted, it seems that her system was less able eliminate the potassium. He should have left things alone. Now, at Cozaar 25mg, she is hyperkalemic to the point that her EKG shows a spike on the T wave. We will probably have to discontinue the Cozaar.
I would like to see her thyroxine increased a bit. Hypothyroidism can throw off potassium clearance, especially under exertion. Her TSH is around 5.0. Free T4 and T3 are OK, but I tend to trust more the TSH number when it comes to thyroid efficiency. I'd like to see it closer to 2.0.
- Scott
Posted by ed_uk on October 30, 2005, at 14:59:49
In reply to Re: Beta blockers » ed_uk, posted by SLS on October 30, 2005, at 14:10:26
Hi Scott
Carvedilol can cause mild hyperkalemia.
Celecoxib is generally contra-indicated in heart failure, especially in patients with renal impairment. Celecoxib has been associated with fluid retention, renal impairment, hypertension and thrombo-embolic events. For what condition is she taking celecoxib?
>I'd like to see it closer to 2.0.
Me too.
>We will probably have to discontinue the Cozaar.
If she suffers from edema, despite her current treatment, perhaps an increased dose of furosemide would eliminate the excess potassium. How bad is her edema?
>Imdur
For heart failure or angina?
>Advair 100/50
For asthma? Carvedilol can aggravate asthma, it's not cardioselective. Has she tried bisoprolol or metoprolol XR? She could add an alpha blocker if necessary.
>losartan
Losartan is my least favourite ARB because it doesn't consistently last 24 hours (if given as a single daily dose). It's probably best given in two divided doses. Candesartan (Atacand) is a long-acting ARB which is approved for the treatment of heart failure.
Ed
Posted by SLS on October 30, 2005, at 15:40:24
In reply to Re: Beta blockers » SLS, posted by ed_uk on October 30, 2005, at 14:59:49
Hi Ed.
> Celecoxib is generally contra-indicated in heart failure,
At age 96, we're not worried about theoretical long-term effects. Celecoxib is contra-indicated for almost anyone with a cardiovascular disease. It is hard to get my grandmother to try anything new. I don't blame her. I would rather she take Advil with a proton-pump inhibitor.
> especially in patients with renal impairment. Celecoxib has been associated with fluid retention, renal impairment, hypertension and thrombo-embolic events.
Yes. We follow-up with a nephrologist to guage her kidney function while she takes these drugs.
> For what condition is she taking celecoxib?
Severe osteoarthritis.
> >We will probably have to discontinue the Cozaar.
>
> If she suffers from edema, despite her current treatment, perhaps an increased dose of furosemide would eliminate the excess potassium.Actually, she suffers from very little edema at this point. She takes 40mg on a regular basis and 80mg on days where edema appears. Her lungs are quite clear. I am disappointed that her cardiologist defines HF as being congestive. There are presentations of HF that do not display much fluid retention, but for which exertion breathlessness and fatigue manifest. Her ejection fraction is too low and she has hypertrophy of the left ventricle. Sometimes, doctors really...
My grandmother has a hint of emphysema and perhaps other contributors to pulmonary insufficiency. It is really not too big a deal though - not compared to the HF - although her cardiologist would like to think otherwise. Along with the other antihypertensives, the higher dosages of Coreg and Cozaar very much remedied her exertion breathlessness. Too much potassium. Her case is a bit complicated.
Just to add a psychiatric point of interest:
My grandmother has no history of depression. However, she became very much depressed when she was given clonidine to treat hypertension.
- Scott
Posted by ed_uk on October 31, 2005, at 14:26:03
In reply to Re: Beta blockers » ed_uk, posted by SLS on October 30, 2005, at 15:40:24
Hi Scott,
>At age 96, we're not worried about theoretical long-term effects.
I was thinking about the short term effects mainly. Celecoxib might increase the risk of hyperkalemia with ARBs (or ACE inhibitors). Traditional NSAIDs (such as Advil) produce similar effects.
The hemodynamic effects of opioids are generally beneficial in heart failure. Acetaminophen/opioid combinations can often provide useful pain relief in osteoarthritis
>I am disappointed that her cardiologist defines HF as being congestive.
I was under the impression that the term 'congestive heart failure' was obsolete. Cardiologists don't seem to use it much anymore.
Kind regards
Ed
This is the end of the thread.
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