Question:
im looking for creative approaches to pharmacological treatment of panic
disorder for a woman who has had a lot of trouble with side effects of the
various drugs
answers to any of the following will be enormously appreciated.
1-aside from tricyclics,MAOIs and SSRIS in the antidpressant world, and
valium,ativan,xanax,klonopin and other benzos in the tranquillizer universe any
other drugs work for anybody???
2-anybody get around side effects with real low doses?
how low?
of what drugs?
how gradual the buildup?
3-has anybody tried any of the estrogen derivatives for panic?
Answer:
It's hard to answer that one without knowing what meds were tried, what dosages
caused the problems and what the specific problems were. I'm a 'medication
sensitive' patient and don't dare jump on any given antidepressant at the typical
recommended starting dosage without significant problems. And as in any case,
individual results are going to vary. Some side effects can be so overwhelming -
even at low dosages - that it's hard to suggest continuing a trial at all. In any
event starting at half the recommend dose is a good idea, maybe even less it the
patient has become sensitized to expect adverse side effects.
In my personal - and I underscore personal - use of different meds to treat my pd
and gad:
1.) Imipramine. Constipation and dizziness upon bending over or arising too
quickly. The constipation will lessen over time but can still cycle up every time
the dosage is increased. I had to take fiber supplements to control the problem
over the term of using this med. No way around it in my case. The
dizziness/lightheadedness was the most extreme in the first week or so of going on
the med and again, cycled up and then leveled off every time the dosage was stepped
up.
Both these side effects "settled in" once the dosage was stabilized but they never
disappeared. One has to be constantly vigilant about not getting up or bending over
too quickly to avoid a rush of dizziness. This one depends on what the patient is
willing to tolerate. Overall, the side effects were the most uncomfortable when
starting the med - even at low dosages. When the dosage was stepped up the side
effects would again become worse but not like the first time around before leveling
out again.
FWIW: Through discussion with several other people taking Imipramine we discovered
that we all had trouble with rectal bleeding. The MD's were attributing it to
straining from the constipation. (I was even having internal hemorrhoids cauterized
all the time.) Once discontinuing Imipramine the rectal bleeding stopped in all
cases. I could find no mention of this as a possible side effect in the literature.
Not everyone had constipation or hemorrhoid problems but we all experienced rectal
bleeding Not a scientific study but worth noting.
Imipramine is still quite effective for some people and the dosage can be stepped
up very slowly as there are a wide variety of dosages available. (Starting at
10mg?) So the dose stepping can be stretched out over months if need be while your
patient adjusts to the side effects as they level out.
2.) Paxil. I tried - really tried - to adjust to this drug. But even at low dosages
I was a walking PDR of side effects. Without even trying to step up the dosage
beyond 25mg I was overwhelmed with side effects that did not subside after 21 days.
Other people do fine on this drug. Me? I got depressed, lethargic, hypo-nytremia,
difficulty breathing, and on and on. No lessening of symptoms over the 21 day
trial. It wasn't a matter of one or two minor side effects - I got just about every
one you can and none of them lessened. I wouldn't expect anyone to adjust to a med
presenting this many problems right at the onset and not lessening over a
reasonable trial period. So it all depends on where your patient is on the sliding
scale of side effects.
3.) And yet - Zoloft. Same family of meds but... Again, being medication
sensitive, my MD wanted to double my dosage from only 25mg to 50mg. I went hypo
manic for two weeks. Got a lot done around the house but I obviously couldn't keep
up with that pace! Had to drop the med back to 25mg for 3 weeks and the hypo
mania disappeared. Then began slowly increasing the dose up to 50 mg and had no
further problem. This is what I did with my MD's approval:
25 mg per day for one week,
cycles of 25, 25, 37.5 mg's for the next week.
cycle of alternating 25 and 37.5 mg's the next week.
cycles of 37.5, 37.5, 25 the next week.
37.5 mg's per day for one week.
cycle of 37.5, 37.5, 50mg's for the next week etc. following the same basic pattern
until I was taking 50mg per day.
This kind of sloooow dosage stepping is only gonna work if the patient is capable
of dealing with it. Splitting 50mg Zoloft tabs into quarters when needed is no
picnic. I'd do it but not everyone will. I also have a vested interested in it,
knowing what problems I have when I don't slow step dosages on some meds.
Weekly/monthly pill box and a pill splitter are mandatory equipment, laying out a
cycle of several weeks all at once to eliminate confusion.
Zoloft, in my case presented a different kind of GI problem - loose bowels. My
cardinal rule was to never take it on an empty stomach or I would certainly be in
trouble. Had to keep anti diahhreal's around just in case. Tolerable for me but not
necessarily for everyone. Severity of problem lessens over time after the Zoloft
dose is stabilized but it never went away.
FWIW: I could never take more than 50mg of Zoloft without symptoms actually getting
worse. Through attempting to move the dosage from 50 to 75 and up to a "normal"
100mg dose I felt profoundly depressed and even looked it. Sitting up was becoming
a real effort at times. Dropping the dose back to 50mg curtailed the unpleasant
side effects.
The point being, recommended dosages from pharmaceutical companies are not set in
stone. And you will find that the recommended dosage for the same med used to
treat PD is typically a lot lower than the recommend dose to treat depression. This
can become a point of confusion and I have had to insist that my doctor re-check
the PDR to correct his "off the top of his head" info about certain drugs. More
often than not, he was prescribing based on the recommended dosage to treat
depression instead of PD. As I said, in the case of Zoloft dosages over 50mg made
me depressed and didn't improve the state of my PD.
3.) Buspar. Never could get used to the chronic stomach upset each time I took it.
Taking it with food or after food didn't seem to help. Discontinued after a two
week trial. It was something like having stomach acid from hell.
4.) Prozac presents it's own special problems for a sensitive patient. Since it's a
capsule it can't be divided and the only alternative to obtain low level dosages
that can be stepped is the liquid form. Patient compliance can them be a problem -
requiring droppers (that need cleaning all the time) to measure the dosage. If GI
problems show up taking it 'straight' then it needs to be diluted by mixing it in
something palatable. I found ginger ale to be the best at masking the taste. If I
ran out of ginger ale I skipped doses and would eventually quit Prozac altogether.
Beyond 3ml - even with diluting - I had nausea, which required splitting the dose,
diluting it twice per day and cleaning up twice per day. Double the nuisance
factor. Didn't work for me but it might for someone else.
