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Dr. Bob is Robert Hsiung, MD,
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Posted by ed_uk2010 on December 20, 2013, at 15:02:09
In reply to Re: Smoking cessation ('cold turkey'), posted by sukarno on December 18, 2013, at 14:13:43
Hello.
>The reason why I can't take proton pump inhibitors is because they give me a delayed hypersensitivity reaction which is quite serious. I'll get a high fever along with tachycardia (140-160bpm for 12 hours) and bad bone pain. I tried a few rechallenges and the reaction was more swift and worse.
Were the rechallenges with the same drug or a different PPI? Which drugs specifically caused this reaction? It sounds very unpleasant.
>I am concerned about famotidine at high doses. I recently had an ECG (EKG) and my QTc was 449ms (max is 450ms for a male).
What constitutes a normal QTc interval is a matter of some debate. 449ms is perhaps borderline abnormal, like you say, but not definitely so. It would be good to know what your QTc interval was without famotidine, for the purpose of comparison. Would you be able to stop famotidine for a few days using antacids/alginates etc?
Posted by ed_uk2010 on December 20, 2013, at 15:12:30
In reply to Re: Smoking cessation ('cold turkey'), posted by sukarno on December 18, 2013, at 14:18:17
>I might give diazepam another try.
Bear in mind, the dose of diazepam needed to block alprazolam withdrawal symptoms may be high, and substantially more than you would otherwise need. It is therefore unsurprising that you felt tired.
What happens when you take say 5mg of diazepam while continuing alprazolam? Anything? If it helps, you could reduce alprazolam somewhat and continue with a small dose of diazepam, initially in divided doses then in 1-2 daily doses after a few weeks. Combining benzos is this way is unconventional... but might it help? I don't know, but you can easily find out.
>I wonder if I have bile reflux and not acid reflux? It really doesn't make sense but I've noticed it every time.
Interesting. Have you ever tried a prokinetic such as metoclopramide? (Metoclopramide is generally only suitable for short-term use). Domperidone should be avoided due to your borderline QTc.
Posted by ed_uk2010 on December 20, 2013, at 15:18:14
In reply to Re: Smoking cessation ('cold turkey') » ed_uk2010, posted by SLS on December 18, 2013, at 14:45:09
>Would a beta-blocker be of any use here?
To be honest, I suspect not. Beta blockers do not reduce reflux, nor is there evidence that they reduce the gastro-intestinal symptoms of anxiety. The somatic symptoms best relived by propranolol are cardiac symptoms (racing heart, palpitations etc) and tremor (but not muscle tension). Cardioselective beta blockers such as metoprolol and atenolol may relieve cardiac symptoms but not tremor.
Posted by sukarno on December 30, 2013, at 13:09:52
In reply to Re: Smoking cessation ('cold turkey') » sukarno, posted by ed_uk2010 on December 20, 2013, at 15:02:09
Hi Ed! :-)
I tried lansoprazole first (30mg) and 10 days later had the fever, tachycardia and bone pain for about 12 hours. I tried a rechallenge with it later and the reaction occurred 3 days later. Next time it happened nearly the same day if I remember correctly.
I tried omeprazole 3 years later in small amounts by emptying out a capsule and taking small pieces every hour or so. I started getting sharp pains that would be felt randomly in different parts of the body (in the bones.. ribs, arms, legs.. everywhere there was a bone).
Interestingly, I had the same reaction with diet soda that contained cyclamate and saccharin. Fever, bone pain and tachycardia for about 12 hours.
I found that these drugs are all sulphonamides or sulfur compounds when metabolised.
Maybe I have some sort of hypersensitivity to sulphonamides or substituted benzimidazoles (PPIs), although PPIs also break down into sulfur-like compounds when they reach the stomach.
Posted by sukarno on December 30, 2013, at 13:17:55
In reply to PPIs, posted by sukarno on December 30, 2013, at 13:09:52
I quit Xanax 5 days ago (1mg 4 times daily) and substituted it with diazepam 15mg 4x/day for the first two days, then 10mg 4x/day for a day, 10mg 3x/day for a day and only 10mg twice a day today.
I can feel the effects of diazepam increasing despite the dose reduction, which is probably because of the long half-life of diazepam.
I had no withdrawal symptoms during the transition except for a few "adrenaline rushes" which led to mild panic attacks on two occasions.
My stomach feels so much better that I forgot to take my famotidine. Usually my stomach is so sour and like there's a lit match inside it that I have to take famotidine around the clock. Failure to do that can result in nausea and a lot of gastritis.
Anyway, wow.. my stomach feels so "calm" and settled despite only two famotidine tablets taken today.
I did read an old medical abstract that claimed diazepam reduces gastric acid production, but I find that difficult to believe.
I suppose diazepam reduces stress or relaxes muscles near the stomach so there's less acid being produced.
Maybe it's functional dyspepsia which means it is psychological or psychogenic.
I guess I should have an endoscopy one of these days.
Posted by ed_uk2010 on December 30, 2013, at 13:23:29
In reply to Valium settles the stomach, posted by sukarno on December 30, 2013, at 13:17:55
Hi!
That's great news. I don't think you'll necessarily find diazepam so sedating this time. Sedation might simply mean that the dose is too high. The pharmacokinetics of diazepam are complex and may necessitate successive dosage adjustments over the next few weeks.
Let us know how you do.
Posted by sukarno on December 30, 2013, at 13:42:38
In reply to Re: Valium settles the stomach » sukarno, posted by ed_uk2010 on December 30, 2013, at 13:23:29
I don't really know why, but diazepam consistently (no matter how long I take it) produces a good subjective sense of sedation in me along with a lot of muscle relaxation whereas alprazolam did neither appreciably.
Being on alprazolam was like being emotionally numb and apathetic with very little sense of sedation.
Right now I feel "buzzed" pretty deeply on diazepam. One dose lasts at least 12 hours and the whole time I feel doped.
I'm sure that will go away in a few days but I remember years ago when I was on 5mg 4x/day as maintenance for panic attacks, I always felt a "buzz" in the morning when I'd take that first 5mg tablet before breakfast.
Diazepam always felt stronger than alprazolam but alprazolam prevented almost all panic attacks.
On a few occasions, despite subjective sedation, I experienced panic attacks on a long term maintenance dose of diazepam but never (or very rarely) on alprazolam.
Either way I'm not a big fan of alprazolam because of the withdrawal symptoms should I lose my pills. Scary.. what a nightmare (or medical emergency) that would be.
I think diazepam is much easier to taper off but I've been on BZDs for 23 years now so I suppose I should allow 2 years of tapering at the very minimum to avoid withdrawal symptoms.
I definitely don't like being on BZDs. Life just seems to float by.. time passes by very fast on these drugs. Don't get me wrong though, they are very useful and the downsides may be a lot better than having a full blown panic attack.
Panic attacks are the scariest thing I have ever experienced in my life.
Posted by SLS on December 30, 2013, at 16:12:48
In reply to Re: Valium settles the stomach, posted by sukarno on December 30, 2013, at 13:42:38
Thyroid stuff?
Have you ever tried amitriptyline?
Shots in the dark.
- Scott
Posted by Phillipa on December 30, 2013, at 21:03:21
In reply to Re: Valium settles the stomach, posted by sukarno on December 30, 2013, at 13:42:38
I so agree with you on the panic attacks. You also have been on benzos a long time as have I. I don't think will ever be off them. Phillipa
Posted by sukarno on December 30, 2013, at 23:45:38
In reply to Re: Valium settles the stomach » sukarno, posted by SLS on December 30, 2013, at 16:12:48
My aunt has hyperthyroidism and grandfather has hypothyroidism. I should have a blood test to get it checked again.. haven't checked it in almost 10 years. I remember my TSH or one of those values was near the borderline (if it was below that it would have been hyperthyroidism).
I don't think I can take TCAs anymore. I had tried imipramine but my heart began to beat too fast and irregularly one night about a month into treatment. My pdoc then switched me to nortriptyline which had less side effects (apart from elevated blood pressure).
I remember the pdoc took my BP after being on nortriptyline for a while and said my BP was up so I should get exercise. I ended up exercising regularly and felt great with a resting pulse of 58. Before I took up exercise I used to have tachycardia of 90 or so on the nortriptyline.
I'm not sure if it was the nortriptyline which helped me so much or the regular, brisk 5 mile walks 3 to 4 times a week (or a combination of the two).That was the best I had ever felt in my life.
Posted by sukarno on December 30, 2013, at 23:48:56
In reply to Re: Valium settles the stomach » sukarno, posted by Phillipa on December 30, 2013, at 21:03:21
> I so agree with you on the panic attacks. You also have been on benzos a long time as have I. I don't think will ever be off them. Phillipa
Hi Phillipa. :-)
Yeah, I somehow think I'll never be off them. It's just been too long. The best I can do is to be on the minimum dose that will keep the anxiety at bay.
Posted by sukarno on December 31, 2013, at 0:46:07
In reply to Re: Valium settles the stomach, posted by sukarno on December 30, 2013, at 23:48:56
I'm not sure if it is good to quit it cold turkey but I woke up this morning (12 to 24 hours after last taking famotidine) and my stomach felt fine.. no acidic feeling.
Is it okay to stop just like that?
Thanks in advance.
I've been on famotidine for almost 9 years.
Posted by SLS on December 31, 2013, at 2:12:37
In reply to Re: Valium settles the stomach, posted by sukarno on December 30, 2013, at 23:45:38
> I used to have tachycardia of 90 or so on the nortriptyline.
Did anyone think to tell you that this is a normal reaction to nortriptyline, and that 90 bpm is by no means tachycardia? Your doctor should have known this. I believe the current standard for diagnosing tachycardia is having a resting heart rate of 130 bpm.
Perhaps you should revisit nortriptyline.
- Scott
Posted by sukarno on December 31, 2013, at 2:17:36
In reply to Re: Valium settles the stomach » sukarno, posted by SLS on December 31, 2013, at 2:12:37
Oh, if that's normal then I'm all for it. Sometimes it caused some "skipped beats" along with a palpitation after that but nothing serious.
I was on a low dose of 10 to 25mg/night.
I got 4.0 grades in high school on nortriptyline.
I remember feeling interested and highly motivated in all subjects.
Imagine the total opposite of the benzodiazepine experience along with no panic attacks.
My pdoc said they don't have nortriptyline here.
Maybe I can import it and take it under his approval/supervision in a very low dose and have an EKG done before it and during treatment along with BP tests.
Posted by SLS on December 31, 2013, at 5:55:36
In reply to Re: Valium settles the stomach, posted by sukarno on December 31, 2013, at 2:17:36
> Oh, if that's normal then I'm all for it. Sometimes it caused some "skipped beats" along with a palpitation after that but nothing serious.
>
> I was on a low dose of 10 to 25mg/night.
>
> I got 4.0 grades in high school on nortriptyline.
>
> I remember feeling interested and highly motivated in all subjects.
>
> Imagine the total opposite of the benzodiazepine experience along with no panic attacks.
>
> My pdoc said they don't have nortriptyline here.
> Maybe I can import it and take it under his approval/supervision in a very low dose and have an EKG done before it and during treatment along with BP tests.That is a very rational approach.
- Scott
Posted by Phillipa on December 31, 2013, at 20:19:15
In reply to Re: Valium settles the stomach, posted by sukarno on December 30, 2013, at 23:45:38
Taccycardia heart rate over l00 beats per minute. Phillipa
Posted by sukarno on January 3, 2014, at 9:41:47
In reply to Quit famotidine, posted by sukarno on December 31, 2013, at 0:46:07
Have any of you quit an H2 blocker abruptly?
I quit famotidine a few days ago and my stomach feels fine and no GERD or anything but I've noticed:
*tiny itchy raised spot like eczema on my right hand
*tightness in the upper chest including the
soft spot just below the trachea.I wonder if upping the cetirizine (H1 antihistamine) would help offset that at all or if I should just wait it out?
I feel pretty relaxed on the diazepam but can't help worrying.
Maybe it's psychosomatic..
Posted by ed_uk2010 on January 5, 2014, at 13:48:58
In reply to Re: Quit famotidine, posted by sukarno on January 3, 2014, at 9:41:47
>I quit famotidine a few days ago and my stomach feels fine and no GERD or anything but I've noticed....
Why not just take say 20mg twice a day for one week then 20mg daily for one week then stop?
It's interesting what you say about diazepam being noticeable after you take your morning dose. Diazepam is absorbed faster than any other med I've ever taken. The likes of lorazepam take ages to work in comparison (oral or sublingual), and I frankly don't find it very effective. Diazepam is the only med I would want to take for an acute panic attack. It stops it within 10 minutes.
Posted by ed_uk2010 on January 5, 2014, at 14:20:33
In reply to Absorption of diazepam » sukarno, posted by ed_uk2010 on January 5, 2014, at 13:48:58
Also, although I think diazepam causes more muscle relaxation and drowsiness than most anxiolytic benzos, I find it causes less amnesia and a generally better state of mind.
Posted by sukarno on January 5, 2014, at 15:44:02
In reply to Benzos » ed_uk2010, posted by ed_uk2010 on January 5, 2014, at 14:20:33
> Also, although I think diazepam causes more muscle relaxation and drowsiness than most anxiolytic benzos, I find it causes less amnesia and a generally better state of mind.
Hi Ed. :-)
It affects me the same way. I feel quite drowsy
but have a cup or two of green tea to help me
through the day.My muscles feel relaxed and
my mood is more steady..much more on an
even keel than the alprazolam experience
(e.g. interdose anxiety or apprehension or even irritability between doses).
Interestingly, despite the sedation, I feel
more motivation and my libido has increased
(although it is probably lower than
average for my age if I had to guess).
Diazepam just feels less "mind numbing"
and there's less apathy.I can remember the names of my friends much
more easily.Sadly, on alprazolam, I would forget the simplest
of things at times and rarely would feel disoriented
as to time and place. That happened 20 years ago
on alprazolam on two occasions but never happened
on diazepam.I agree with you too about the onset of action.
Diazepam is of very rapid onset.The British National Formula (BNF) which I
read in 2002 said diazepam is the most
rapid-acting benzodiazepine.I can feel the effects of diazepam in 10 minutes.
Alprazolam would take 20 minutes minimum, so
I think for a panic attack, diazepam would be
a better choice to abort the attack.
Posted by sukarno on January 5, 2014, at 15:47:11
In reply to Re: Benzos » ed_uk2010, posted by sukarno on January 5, 2014, at 15:44:02
Posted by sukarno on January 5, 2014, at 15:48:02
In reply to Re: Benzos (nm), posted by sukarno on January 5, 2014, at 15:47:11
Typo...meant to say British National Formulary.. :-)
Posted by sukarno on January 5, 2014, at 16:04:13
In reply to Absorption of diazepam » sukarno, posted by ed_uk2010 on January 5, 2014, at 13:48:58
> >I quit famotidine a few days ago and my stomach feels fine and no GERD or anything but I've noticed....
>
> Why not just take say 20mg twice a day for one week then 20mg daily for one week then stop?
>
> It's interesting what you say about diazepam being noticeable after you take your morning dose. Diazepam is absorbed faster than any other med I've ever taken. The likes of lorazepam take ages to work in comparison (oral or sublingual), and I frankly don't find it very effective. Diazepam is the only med I would want to take for an acute panic attack. It stops it within 10 minutes.I'm finally feeling better now although
your strategy would have worked better.
I was just too scared of the 449ms QTc
and read some articles that claimed high
doses (dialysis patients in particular..of
course they would have the potential to
have very high levels accumulating in
their body) prolong QTc and have
induced TdP in some people.Lorazepam took forever to take effect.
I remember waiting 45 to 60 minutes
for it to work (as a short term sleep aid
prescribed by my pdoc) and I was sure
I fell asleep long before the drug took effect.The next day I felt sleepy and was hearing
music playing repeatedly in my head..
I just couldn't focus on any tasks at all.I wasn't sure if I was in a state of withdrawal
or a state of intoxication as both were rather similar..
a very amnestic effect and not very effective at all
for my anxiety when I did try it for a brief time as
a daytime anxiolytic years ago.I'm not sure why lorazepam is so popular in the US.
Perhaps it is the slow onset of action which deters
drug seekers and the lack of a "buzz" means less
abuse liability.Oxazepam was the same in that it was so slow
to take effect and when it did it didn't do much.
I experienced no amnestic effects with oxazepam though.
I was given it once in the ER for panic attacks
but it took an hour to take effect so it didn't
stop my attacks at the time.One pdoc I met said "diazepam is tried and true"
and thought of all the other benzodiazepines
as just a bunch of fancy marketing tactics and not
superior to diazepam. With all the decades of use
and millions (or billions) of prescriptions for diazepam,
what is known about it is probably very well known by now.
Posted by ed_uk2010 on January 6, 2014, at 15:31:58
In reply to lorazepam » ed_uk2010, posted by sukarno on January 5, 2014, at 16:04:13
I dislike lorazepam. It causes less drowsiness than diazepam but I just find it pointless. It takes far too long to work to be effective for a panic attack. I do not have an hour to spare in this situation. And when it does work, it's crap, fuzzy head but still panicking, and no relief of muscle tension. Sublingual absorption is no more rapid than oral absorption - the alleged advantages of this route are a myth. At least it doesn't taste of anything. Oh, and I do not need amnesia thank you very much! Unlike diazepam, lorazepam has a relatively consistent duration of action of several hours, which is potentially useful in the elderly because diazepam tends to accumulate after a few days. Unfortunately, lorazepam causes withdrawal symptoms more readily than diazepam. The potential for misuse may be lower, however.
Clonazepam is another med I dislike. Tonnes of amnesia, negative mood, odd feelings of discomfort and anxiety, no relief of muscle tension.... and blah. Yuck.
Diazepam. Immensely rapid acting after an adequate dose eg. 10mg for an acute panic attack. Wears off extremely (and surprisingly) fast after single isolated doses, requiring frequent re-dosing every few hours. After regular use for a week or two, accumulation occurs and it becomes long-acting, you can then dose infrequently and taper the dose. Most doctors think diazepam is long-acting right from the start, which is generally incorrect, except perhaps for the very elderly or those with extremely low body weight. Diazepam is very highly lipid soluble. It's absorbed quickly, it penetrates the blood brain barrier quickly, but it's also redistributed to adipose tissue (fat) very quickly, terminating most of its effects. Only once accumulation has occurred does it become long-acting. Although diazepam has a long elimination half-life (as does its main metabolite), this only refers to elimination from the body. In reality, a single dose is redistributed to fat stores within a few hours and the sedative effect therefore disappears quickly, apart from a slight residual effect. Just because it's still in the body does not mean it's in the right place (ie. the brain)!
Temazepam. 20mg seems to start working after about 20 mins, and is (for me) an entirely reasonable hypnotic for short-term use ie. 1-2 weeks or PRN. Lower doses are not very sleep-inducing (but may be suitable for the elderly), higher doses tend to cause some next day drowsiness. Like diazepam, temazepam appears to produce muscle relaxation and relief of physical tension. It is sedating but in more of an anxiolytic manner like diazepam, as opposed to causing the nasty fatigued sensation than some meds do. Think trazodone or anything else that creates a next day 'run over by a bus' sensation.
Posted by sukarno on January 6, 2014, at 18:46:27
In reply to Benzos » sukarno, posted by ed_uk2010 on January 6, 2014, at 15:31:58
The first time my pdoc gave me diazepam I noticed almost nothing the first few hours after taking it but the next morning I could barely get out of bed as I was so sleepy and sedated. It was like a delayed effect.
With repeated dosing after a week or two I could feel its effects consistently around the clock and it felt a lot stronger despite maintaining the same dosage.
Have you ever tried chlordiazepoxide? Is it any longer acting right from the start?
This is the end of the thread.
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