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Dr. Bob is Robert Hsiung, MD,
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Posted by ed_uk2010 on December 2, 2013, at 12:09:23
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on December 1, 2013, at 16:12:58
Hello,
I've never heard of rebound akathisia on stopping antihistamines. If you use it for a few weeks, you may notice some vivid dreams on stopping, and possibly some nausea (the 'anticholinergic rebound'). I think this is normally easy to overcome by gradual dose reductions. I suggest limiting treatment to a couple of weeks, by which time you'll hopefully feel better anyway.
The only people who seem to have major problems with diphenhydramine/doxylamine are those who:
a) Take more than the recommended dose because they think it will make it work better, and end up feeling very peculiar.
b) Deliberately take small overdoses to cause an anticholinergic hallucinogenic type effect, using including considerable confusion.
c) Just take it for weeks on end, after which point it's about as much use as a sleep aid as peppermint tea. Probably less. Oh, and then have vivid dreams on withdrawal, encouraging it to be pointlessly restarted.
d) Take it and then go for a drive on the motorway or something. Enough said. It's hardly a concentration booster.
Good luck!
Posted by g_g_g_unit on December 2, 2013, at 21:35:13
In reply to Re: how did I induce akathisia?, posted by ed_uk2010 on December 2, 2013, at 12:09:23
Thanks again for all your help, ed!
No chemists seem to stock the Benadryl sleep preparation (SnuzAid), so I picked up Doxylamine instead.
What dosing schedule would you recommend? 25mg typically makes me feel sedated and bored, yet also completely uninterested in anything, so I'd like to avoid that if possible.
Posted by ed_uk2010 on December 3, 2013, at 3:41:48
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on December 2, 2013, at 21:35:13
>What dosing schedule would you recommend? 25mg typically makes me feel sedated and bored, yet also completely uninterested in anything, so I'd like to avoid that if possible.
I think you should cut the tablet into quarters and take 1, then 1 more after 30-60 mins if necessary. You'll have to play it by ear. I do hope it helps. May need to re-dose after about 8 hours perhaps.
Some tablets are awkward shapes, but the tablet cutting does not need to be accurate.
Posted by g_g_g_unit on December 3, 2013, at 4:05:42
In reply to Re: how did I induce akathisia? » g_g_g_unit, posted by ed_uk2010 on December 3, 2013, at 3:41:48
> I think you should cut the tablet into quarters and take 1, then 1 more after 30-60 mins if necessary. You'll have to play it by ear. I do hope it helps. May need to re-dose after about 8 hours perhaps.
>Thanks, ed. I did end up taking 1/4 this afternoon and didn't feel anything after an hour, so took a further 1/4.
I think it helped the akathisia a bit, but hasn't done anything for the jaw stiffness. I also feel overstimulated on it -- irritable, dysphoric, sensitive to noise etc. I tend to get that stuff the following day after I use Doxylamine for sleep, so maybe the sedation on the higher doses masks it.
Since lowering the dose wouldn't help, what would be the next sensible step? Should I just ask my doctor for a Cogentin script or something?
Feeling angry, worried, frustrated .. it's been 12 days now; wish I'd never taken the Mirtazapine to begin with, *sigh*
Posted by ed_uk2010 on December 3, 2013, at 6:56:03
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on December 3, 2013, at 4:05:42
Sorry to hear it didn't work out for you.
I know you said propranolol drops your blood sugar, have you tried any other beta blockers? You'd (presumably) need one of the lipid soluble beta blockers that enter the brain, but perhaps one of the more selective drugs such as metoprolol could alleviate your restlessness with fewer adverse effects? (Although you are not a rat (!), only lipid soluble beta blockers reduce drug-induced movement disorders in rats. Fortunately, beta-1 selective drugs such as metoprolol still appear to be effective. Atenolol is not lipid soluble, I suspect it wouldn't help. None of this is very evidence-based, I'm just thinking out loud really. Personally, I would dump the propranolol and give metoprolol a shot. It's often used for other 'brain related' disorders such as migraine, so I expect your doctor won't be too averse to trying it.
As far the jaw clenching, perhaps your doctor could prescribe a low dose of a muscle relaxant? I'm unsure what's sold in Australia. I'll look on the Pharmaceutical Benefits Scheme website. Hmm, seems to be even fewer choices than over here. The Americans have millions of muscle relaxants, most of dubious value but at least the choice is there. Diazepam tends to be useful for jaw clenching, do you react paradoxically to all benzos? I believe the differences between the various drugs are greater than is often appreciated. Diazepam is particularly muscle relaxant.
>Should I just ask my doctor for a Cogentin script or something?
You could, but I'm unsure how you'd respond. It may be a little like doxylamine with more dry mouth. It would be ideal if your doctor could give you a prescription for small quantities of a few different meds to try (not all at once!). Eg. Metoprolol, diazepam, Cogentin. What do you think?
Posted by g_g_g_unit on December 3, 2013, at 7:25:42
In reply to Re: how did I induce akathisia? » g_g_g_unit, posted by ed_uk2010 on December 3, 2013, at 6:56:03
> Sorry to hear it didn't work out for you.
>
> I know you said propranolol drops your blood sugar, have you tried any other beta blockers? You'd (presumably) need one of the lipid soluble beta blockers that enter the brain, but perhaps one of the more selective drugs such as metoprolol could alleviate your restlessness with fewer adverse effects? (Although you are not a rat (!), only lipid soluble beta blockers reduce drug-induced movement disorders in rats. Fortunately, beta-1 selective drugs such as metoprolol still appear to be effective. Atenolol is not lipid soluble, I suspect it wouldn't help. None of this is very evidence-based, I'm just thinking out loud really. Personally, I would dump the propranolol and give metoprolol a shot. It's often used for other 'brain related' disorders such as migraine, so I expect your doctor won't be too averse to trying it.Thanks ed! I did indeed drop the propranolol yesterday -- since reinstating Mirtazapine for a night fixed things, I presumed the propranolol wasn't the culprit.
I'll ask my doctor if I could try another beta-blocker .. 20mg of propranolol took the edge off of things, but never hit the core restlessness. Hopefully something else might do the job, though I don't want to end up stuck on another drug. Do other beta blockers tend to mess up sleep like propranolol? I think I read it reduces melatonin production; either way, it made falling asleep difficult.
>
> As far the jaw clenching, perhaps your doctor could prescribe a low dose of a muscle relaxant? I'm unsure what's sold in Australia. I'll look on the Pharmaceutical Benefits Scheme website. Hmm, seems to be even fewer choices than over here. The Americans have millions of muscle relaxants, most of dubious value but at least the choice is there. Diazepam tends to be useful for jaw clenching, do you react paradoxically to all benzos? I believe the differences between the various drugs are greater than is often appreciated. Diazepam is particularly muscle relaxant.
>Good old 'stralia. I have reacted paradoxically to Xanax, Lorazepam and Clonazepam. I tried Valium while I was on Parnate (in an attempt to treat the anxiety) and just recall feeling a little sedated, though still uncomfortable.. it was hard to tell if it was making things better or worse.
Out of desperation, I almost bought a codeine-based painkiller today, since I figured that might help the restlessness and tension, though am I just asking for more trouble?
> >Should I just ask my doctor for a Cogentin script or something?
>
> You could, but I'm unsure how you'd respond. It may be a little like doxylamine with more dry mouth. It would be ideal if your doctor could give you a prescription for small quantities of a few different meds to try (not all at once!). Eg. Metoprolol, diazepam, Cogentin. What do you think?Yeah, after reading up on Cogentin, it doesn't sound ideal.
I'll see what my doctor has to say! You've given me some good ideas, so thank you for all your help.
Posted by ed_uk2010 on December 3, 2013, at 13:22:02
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on December 3, 2013, at 7:25:42
>Do other beta blockers tend to mess up sleep like propranolol?
Propranolol is probably the worst in this respect, and sometimes causes nightmares. Atenolol doesn't affect sleep but probably wouldn't help. I expect metoprolol would be more tolerable than propranolol but there's still a risk of it affecting your sleep.
If you're near a supermarket, you could get some Chamomile tea (German Chamomile seems to be the variety that helps sleep). For sure, it will do you no harm, and avoids caffeine intake - not what you need when tense.
>Valium, it was hard to tell if it was making things better or worse.
I think it might help, but you'd obviously need to be very cautious. Some people find that paradoxical reactions disappear with dose adjustment, either up or down (confusingly). Diazepam has more of a noticeable muscle relaxant effect than other benzos. It is more sleep inducing than Ativan, but this could be appropriate during your current situation, allowing you to get some rest. Diazepam should ideally be limited to about 2 weeks of treatment. After short term use, tapering is rarely difficult (in stark contrast to after long term use).
>Out of desperation, I almost bought a codeine-based painkiller today, since I figured that might help the restlessness and tension, though am I just asking for more trouble?
It certainly might help, but opioids are very addictive. I advise great caution, with no more than 3 days of use - for the jaw tension/pain. For sure, avoid any products which also contain caffeine.
>I'll see what my doctor has to say! You've given me some good ideas, so thank you for all your help.
You're welcome. Hope you can see your doctor very soon. And I still believe these new symptoms will end fairly soon, even without treatment, it's just a case of getting through the interim period.
Posted by g_g_g_unit on December 3, 2013, at 23:57:28
In reply to Re: how did I induce akathisia? » g_g_g_unit, posted by ed_uk2010 on December 3, 2013, at 13:22:02
Ed, just one final question..
do you think that Prazosin could help? clonidine was actually the most effective anti-akathisia drug I've tried to date, but the sedating effects wear off in about 2 days and thereafter it becomes stimulating (messy receptor affinity, I think). there's no guanfacine available here, so I've been looking for stuff that might work similarly to clonidine.
Posted by ed_uk2010 on December 4, 2013, at 3:31:06
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on December 3, 2013, at 23:57:28
>do you think that Prazosin could help? clonidine was actually the most effective anti-akathisia drug I've tried to date, but the sedating effects wear off in about 2 days and thereafter it becomes stimulating (messy receptor affinity, I think). there's no guanfacine available here, so I've been looking for stuff that might work similarly to clonidine.
I was wondering about clonidine but didn't suggest it because you were on a beta blocker. Clonidine is a bit of an odd one. It seems to change people's emotions, flat at first followed by intensified emotions later (sometimes). That's my impression anyway, probably why both depression and euphoria are listed as side effects.
The muscle relaxant tizanidine is related to clonidine and might help. I looked for it on the Australian PBS yesterday but couldn't find it. Perhaps it's available but not covered? I suspect not though. I don't know how it works in Aus. You could ask at the pharmacy perhaps. You do have baclofen, but it's really more appropriate for severe muscle spasticity in MS and spinal disease, I don't think it would be appropriate.
I really have no idea about prazosin in your case. In psych, it seems most useful for nightmares in PTSD. It might produce some sedation perhaps? I couldn't find any articles on MedLine.
Now I did have one new idea. The drug cyproheptadine (Peractin). It's a unusual antihistamine which blocks certain serotonin receptors. It's been used in akathisia, migraine, insomnia and (formerly) for allergies. It's listed on the PBS as a restricted benefit, whatever that involves. The usual side effect is drowsiness. It's not very anticholinergic. I know several people on p-babble have taken it for various conditions, especially insomnia.
Have you improved at all over the last few days?
Posted by g_g_g_unit on December 4, 2013, at 4:10:07
In reply to Re: how did I induce akathisia? » g_g_g_unit, posted by ed_uk2010 on December 4, 2013, at 3:31:06
Lol, this is turning into a saga ..
> I was wondering about clonidine but didn't suggest it because you were on a beta blocker. Clonidine is a bit of an odd one. It seems to change people's emotions, flat at first followed by intensified emotions later (sometimes). That's my impression anyway, probably why both depression and euphoria are listed as side effects.
Yeah, clonidine definitely intensified (negative) emotion in me, and quickly became stimulating rather than sedating, even when the dose remained stable. FWIW, I'm not taking the Propranolol at the moment .. the side-effects didn't seem to be worth the modest benefits.
>
> I really have no idea about prazosin in your case. In psych, it seems most useful for nightmares in PTSD. It might produce some sedation perhaps? I couldn't find any articles on MedLine.Yeah, I can't find anything either.
>
> Now I did have one new idea. The drug cyproheptadine (Peractin). It's a unusual antihistamine which blocks certain serotonin receptors. It's been used in akathisia, migraine, insomnia and (formerly) for allergies. It's listed on the PBS as a restricted benefit, whatever that involves. The usual side effect is drowsiness. It's not very anticholinergic. I know several people on p-babble have taken it for various conditions, especially insomnia.Sadly, I tried cyproheptadine last night and can't tell if it helped or hindered, but the net effect was more on the stimulating side (which fits my general experience with cyproheptadine). However, today I had a massive relapse in symptoms -- it's happened twice now with cyproheptadine, and was wondering if it was some kind of 5HT2 rebound, given that Mirtazapine works similarly.
It might've helped the akathisia slightly, but the stimulating effect, akin to Doxylamine, was unpleasant.
>
> Have you improved at all over the last few days?
>Not really.. well, I think certain supplements I was trying were making it worse, so my anxiety has dropped off a little, which makes things easier. However, even when I'm calmer, I still can't pay attention or sit still for very long, which is frustrating.
Is akathisia something most doctors are trained to deal with? I haven't been to my own GP in months, and always feel a little uncomfortable seeing him -- I've been meaning to find someone new, but wasn't really sure if this was the kind of issue you could present on a first visit.
Posted by ed_uk2010 on December 4, 2013, at 9:05:05
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on December 4, 2013, at 4:10:07
>Is akathisia something most doctors are trained to deal with?
Not really, only psychiatrists. I would discuss it as restlessness, tension, jaw clenching and anxiety, rather than akathisia. And of course mention the recently stopped mirtazapine, which I suppose they may encourage you to restart.
On the other hand, a GP may be willing to give you a few diazepam tablets to see you through the next week. It doesn't sound like you had any clear paradoxical reaction to it before. You'll just need to mention which benzos you definitely can't take so they don't try to prescribe any of those.
Do you have a psych you can see?
Posted by g_g_g_unit on December 5, 2013, at 1:36:06
In reply to Re: how did I induce akathisia? » g_g_g_unit, posted by ed_uk2010 on December 4, 2013, at 9:05:05
>
> Do you have a psych you can see?Hi ed,
No, I don't have a psychiatrist at the moment. I ended up seeing my GP, though it was a little bizarre. I explained what was going on, and he's familiar with akathisia .. however, he commented that I didn't look very restless at the time. I explained I had taken 20mg of propanolol, otherwise I wouldn't have been able to drive there.
Then he just kept looking at me and remarking how I didn't look very restless, and I kept saying "but I took the propranolol". Maybe he thought I was drug-seeking .. I have no idea. Finally, he relented and prescribed Cogentin (0.5mg once a day).
So I'll see how that goes, but it confirmed it's probably time for a new GP.
Posted by g_g_g_unit on December 5, 2013, at 6:27:00
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on December 5, 2013, at 1:36:06
After about 2.5 hours, the Cogentin kicked in and I could distinctly feel that inner tension unwinding. It hasn't completely abated -- maybe 0.5mg is too low.. but I'll cut out everything else and see how I fare over the next couple of days.
Ed, as an anticholinergic, can Cogentin add to anxiety/overstimulation (which is distinct from akathisia)? Would it be best to take it in the a.m.?
Posted by ed_uk2010 on December 5, 2013, at 16:58:20
In reply to Re: how did I induce akathisia? » g_g_g_unit, posted by g_g_g_unit on December 5, 2013, at 6:27:00
>Ed, as an anticholinergic, can Cogentin add to anxiety/overstimulation (which is distinct from akathisia)? Would it be best to take it in the a.m.?
Great that it helped! I think you'll have to experiment to be honest. It can be stimulating for some, but can also cause an antihistamine-type drowsiness in others. Let us know how it goes.
Posted by phidippus on December 5, 2013, at 17:40:07
In reply to how did I induce akathisia?, posted by g_g_g_unit on November 29, 2013, at 9:02:52
Its the Mirtazapine.
Really, talk your doc into letting you take Tiagabine 12 mg for anxiety and insomnia. It works really well and there's plenty of literature on the net supporting it.
Eric
Posted by g_g_g_unit on December 6, 2013, at 6:55:58
In reply to Re: how did I induce akathisia? » g_g_g_unit, posted by ed_uk2010 on December 5, 2013, at 16:58:20
> Great that it helped! I think you'll have to experiment to be honest. It can be stimulating for some, but can also cause an antihistamine-type drowsiness in others. Let us know how it goes.
>Will do. Trying not to obsess about it so will report back in a few days.
Posted by g_g_g_unit on December 6, 2013, at 6:56:56
In reply to Re: how did I induce akathisia? » g_g_g_unit, posted by phidippus on December 5, 2013, at 17:40:07
> Its the Mirtazapine.
>
> Really, talk your doc into letting you take Tiagabine 12 mg for anxiety and insomnia. It works really well and there's plenty of literature on the net supporting it.
>
> EricCool, thanks, I'll make a note.
Posted by ed_uk2010 on December 6, 2013, at 13:51:07
In reply to Re: how did I induce akathisia? » ed_uk2010, posted by g_g_g_unit on December 6, 2013, at 6:55:58
>Will do. Trying not to obsess about it so will report back in a few days.
Cogentin's a long-acting med. After the first few days, it probably won't make a great deal of difference what time of day you take it. Personally, I'd stick with a fairly low dose. Best of luck!
Posted by jono_in_adelaide on December 6, 2013, at 21:57:52
In reply to Re: how did I induce akathisia? » g_g_g_unit, posted by ed_uk2010 on December 6, 2013, at 13:51:07
Try Phenergan 10mg in the morning and the afternoon, and 10-20mg half an hour before bedtime
Its OTC, not habit forming and has been in use since 1949, so they know its safe
Posted by g_g_g_unit on December 9, 2013, at 2:24:59
In reply to Re: how did I induce akathisia? » g_g_g_unit, posted by ed_uk2010 on December 6, 2013, at 13:51:07
> Cogentin's a long-acting med. After the first few days, it probably won't make a great deal of difference what time of day you take it. Personally, I'd stick with a fairly low dose. Best of luck!
Hey ed, wikipedia lists the half-life of Cogentin as 12-24 hours .. I'm a bit confused, because people most commonly seem to be dosing b.i.d.
I read it acts as a DRI at the 'nerve terminals', and have no idea what that means; but I've actually noticed some psychoactive effects that I thought might be consistent with a DRI .. namely, I've been hyperfocusing far more, my obsessive thoughts are much 'louder' and distracting, and my sleep is disturbed (I take it at 6pm and find it calming for about 3 hours, before stimulation takes over) though I'm still alert and focused during the day. I feel less 'stressed'.
The akathisia is better, and my jaw has loosened up, but it's been replaced by a different kind of anxiety/overstimulation.
Anyway, this is day 5, so I wasn't sure if blood levels have stabilized yet. Anyway, I'm seeing a new doctor at a private practice tomorrow -- more expensive, but better care, I imagine -- so hopefully they have some ideas.
Posted by g_g_g_unit on December 10, 2013, at 0:55:49
In reply to Re: how did I induce akathisia?, posted by jono_in_adelaide on December 6, 2013, at 21:57:52
> Try Phenergan 10mg in the morning and the afternoon, and 10-20mg half an hour before bedtime
>
> Its OTC, not habit forming and has been in use since 1949, so they know its safeI'm pretty sure it's a D2 antagonist, isn't it? I imagine that would make things worse.
Posted by g_g_g_unit on December 10, 2013, at 0:56:36
In reply to Re: how did I induce akathisia? » jono_in_adelaide, posted by g_g_g_unit on December 10, 2013, at 0:55:49
New doctor was nice enough, though a little confused by the situation. She suggested I stop Cogentin and gave me a script for Atenolol in case it returns.
Posted by ed_uk2010 on December 10, 2013, at 14:22:05
In reply to Re: how did I induce akathisia? » jono_in_adelaide, posted by g_g_g_unit on December 10, 2013, at 0:55:49
>I'm pretty sure it's a D2 antagonist, isn't it?
It is, yes.
Posted by ed_uk2010 on December 10, 2013, at 14:32:22
In reply to cogentin » ed_uk2010, posted by g_g_g_unit on December 9, 2013, at 2:24:59
>Hey ed, wikipedia lists the half-life of Cogentin as 12-24 hours .. I'm a bit confused, because people most commonly seem to be dosing b.i.d.
Can be taken once or twice a day, depending on response. Half lives vary between individuals so perhaps it was wrong of me to suggest that the timing of the dose won't matter after a few days.
>I read it acts as a DRI at the 'nerve terminals', and have no idea what that means; but I've actually noticed some psychoactive effects that I thought might be consistent with a DRI .. namely, I've been hyperfocusing far more, my obsessive thoughts are much 'louder' and distracting, and my sleep is disturbed (I take it at 6pm and find it calming for about 3 hours, before stimulation takes over) though I'm still alert and focused during the day. I feel less 'stressed'.
Yes, I believe it is a weak DRI. Would it be worth trying a different anticholinergic? In Aus you have benzhexol (Artane) and biperiden (Akineton). Artane has a reputation for being stimulating. Biperiden might be more suitable.
Have you tried the atenolol yet?
Posted by g_g_g_unit on December 11, 2013, at 4:04:48
In reply to Akineton » g_g_g_unit, posted by ed_uk2010 on December 10, 2013, at 14:32:22
> Can be taken once or twice a day, depending on response. Half lives vary between individuals so perhaps it was wrong of me to suggest that the timing of the dose won't matter after a few days.
Ah, maybe I'll experiment with taking it in the morning if the need arises.
>
> Yes, I believe it is a weak DRI.I wonder why Australia hasn't regulated it *eyeroll*
>Would it be worth trying a different >anticholinergic? In Aus you have benzhexol >Artane) and biperiden (Akineton). Artane has a >reputation for being stimulating. Biperiden >might be more suitable.
Thanks, I'll make a note if Biperiden! I did notice some of the symptoms returning since stopping the Cogentin last night, though not as forcefully. I'll see how it goes the next couple of days. My sleep was better last night, though.
>
> Have you tried the atenolol yet?Not yet, I was going to see what happens over the next two days.
Thanks for all your help, ed! I really do appreciate it.
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