Up and Down...why?

[hanshan]

Hi Utah49er - It's good to hear that you are feeling better. I have to say I tried paroxetine some time back, and the initial side effects really were intolerable for me. However, many people take it, so it's clearly a case of how it affects each individual. I switched to mirtazapine, which was a much easier start-up for me.

My pregabalin costs me about A$3.50 (US$4.50) a day for 600 mg (it's not Australian government-subsidised for anxiety, but some of this can be recouped from private health insurance that includes pharmaceuticals). Fortunately, I can afford it and consider it money well spent - about the cost of a bus fare or cup of coffee, which most people wouldn't think twice about paying.

[Utah49er]

Handshan, thanks for your comments. I actually suggested Mirtazapine to my doc instead of Paxil, it seems it is not used as much here in the states (probably due to its lack of FDA approval for any anxiety disorders, much like pregabalin unfortunately, honestly we are behind the rest of the world in many instances such as these). He wanted to try low dose Paxil 1st, simply due to its FDA indications for all anxiety disorders. Hopefully low dose start of Paxil is better for me than the trials of Zoloft and Lexapro (tolerated Zoloft well during startup 8 years ago, off for 4 months, then sent me for this crazy ride the last 4 months this time). Paxil is supposed to be the least activating of the SSRIs so I am hopeful. I'll keep you posted, unfortunately my Pregabalin is a little more than double your $4 a day, still totally worth it at this point as it seems to be helping, but I have to think I will do well on an SSRI again as I barely thought about anxiety the last 8 years I was on Zoloft.

---------- Post added at 20:43 ---------- Previous post was at 19:32 ----------

Handshan, were you on pregabalin when you tried the paroxotine? If not do you think you could have got through the startups with pregabalin?

[hanshan]

No, it was at the start of a very bad anxiety period some years back, and I was given paroxetine - but within a day or so I'd developed nausea, diarrhea, a jaw tremor and anorgasmia - really terrible (I don't want to put you or anyone off it, as many people find it okay). The doctor switched to diazepam, then mirtazapine. The pregabalin was added a year or so later.

It's funny that the pricing for pregabalin should be different, as I assume its the same brand - Lyrica - from Pfizer. Does the US allow you to import either Lyrica or generic pregabalin from a cheaper country?

[Utah49er]

Handshan,

I just did my 2nd night of Paxil, woke up at 5:15 and couldn't really go back to sleep. I didn't feel any anxiety, which was nice, but I did this early waking for the 3 months I was trying Zoloft and Lexapro and to be honest, I am not wanting to do it again. Thinking of asking for a switch to Mirtazapine. How long after you started Mirtazapine did you start to feel better? I am getting desperate, the Pregabalin has helped a lot, but I don't think I want to do the Paxil trial.

[panic_down_under]

I just did my 2nd night of Paxil, woke up at 5:15 and couldn't really go back to sleep. I didn't feel any anxiety, which was nice, but I did this early waking for the 3 months I was trying Zoloft and Lexapro and to be honest, I am not wanting to do it again. Thinking of asking for a switch to Mirtazapine

How about just adding a small dose of mirtazapine at night to help you sleep. SSRI induced insomnia is a fairly common at the beginning, but it usually does resolve after a while. The mirtazapine may also slightly speed up Paxil kick-in too.

[Utah49er]

Panic, I didn't know you could take Mirtazapine and Paxil together, isn't there a risk of serotonin syndrome? I have never taken a "cocktail" of meds, only psych med I have ever taken before 4 months ago was the Zoloft I took for years, so being already on 600MGs of Lyrica, and now 10mgs of Paxil...I guess I am scared to add yet ANOTHER drug to the mix. I don't want to be someone who needs a whole mouthful of meds to function, as that has never been the case. Though your advice is probably sound, I guess I am just scared, but I have anxiety so I am always scared of something haha!

I am continuing with the Paxil for now, and am going to try in the AM to see if that help the insomnia.

[panic_down_under]

Panic, I didn't know you could take Mirtazapine and Paxil together, isn't there a risk of serotonin syndrome?

No, because while mirtazapine is classified as an antidepressant, it is mostly just a potent antihistamine with only a very weak affect on serotonin. To quote arguably the world's leading serotonin syndrome/toxicity (SS/ST) expert, Dr Ken Gillman:

As I have pointed out before, drugs like bupropion and mirtazapine, that have no significant serotonergic activity, are no more likely to cause ST than is vitamin C. This scenario has already been enacted, over a decade, with the antidepressant mirtazapine, which was claimed, erroneously, to have serotonergic activity. Many poor quality case reports of ST with mirtazapine were published. This probably led to misdirected treatment of overdoses, some of which may have caused morbidity. It took several reviews to correct this error and establish that mirtazapine cannot cause ST.

PK Gillman, 2010 PDF

Moreover, mirtazapine is a moderate serotonin 5-HT2a receptor antagonist (blocker). The recommended treatments for severe serotonin syndrome are the more potent 5-HT2a receptor antagonists cyproheptadine and chlorpromazine. 5-HT2a antagonists prevent the body temperature spike which does the damage in SS.

I have never taken a "cocktail" of meds, only psych med I have ever taken before 4 months ago was the Zoloft I took for years, so being already on 600MGs of Lyrica, and now 10mgs of Paxil...I guess I am scared to add yet ANOTHER drug to the mix.

I'm not a fan of poly pharmacy either. I'm only suggesting mirtazapine as a temporary sleep aid, not as a therapeutic agent, and now that it has registered you're in America, not Britain, I'm recommending immediate-release trazodone (Desyrel) instead. At low doses, 25-75mg it acts only as a very sedating antihistamine, just like mirtazapine, but it has a much shorter half-life, 3-4 hours compared to 20-40 h for mirtazapine, so it is less likely to cause daytime sedation.

I assume the intention is to wean off the pregabalin once the paroxetine kicks-in, in which case you'll soon be back to one med anyway if it works.

[Utah49er]

Panic,

Yes that Is the plan to wean off the pregabalin when I am stable, though at the point that feels an impossibility. In your opinion is the Paxil a good option, even though I failed on the Zoloft and Lexapro? I don't know what is going on as I was completely stable on Zoloft for such a long time, and this time this SSRIs are not kicking in, and I feel they have made me worse. Can the 10mgs of Paxil be an effective dose? Or do you think I will need more? Do you take meds for anxiety? Sorry for all the question, just seem like you know a lot about this stuff and I am relatively naive, as I simply started Zoloft 8 years ago after a rough year of anxiety, and I just started to feel better as I went along. Each week was better than the last, until I eventually felt like my old self again (albeit with some anxiety blips a couple of times a year that would last a week or two). I didn't really have to know about other meds, or combos, as it just simply worked...this time I have certainly not been as fortunate.

---------- Post added at 10:31 ---------- Previous post was at 10:09 ----------

Also, skipped the Paxil (3rd one) dose last night, took it this morning. Did not have early morning awakening, which was good, but woke up with more anxiety...I just can't figure this out...haha.

[panic_down_under]

In your opinion is the Paxil a good option, even though I failed on the Zoloft and Lexapro?

It may not be. Generally if two SSRIs have failed the likelihood of a third working is pretty low. Usually, a dual action SNRI (which rules out venlafaxine (Effexor) and desvenlafaxine (Pristiq), btw, as they are really only SSRIs), or TCA would be the better bet. However, Paxil also a reasonably effective norepinephrine, aka noradrenaline reuptake inhibitor which might just be enough to make a difference.

I don't know what is going on as I was completely stable on Zoloft for such a long time, and this time this SSRIs are not kicking in, and I feel they have made me worse.

How much Zoloft were you on, and if it was less than the recommended maximum 200mg dose did you try increasing it up to that?

Can the 10mgs of Paxil be an effective dose? Or do you think I will need more?

10mg is a sub therapeutic dose for most so should not be taken for long periods as it may increase the risk of the med pooping-out. You should take at least 20mg, and my guess is you'll need more given the other SSRIs failed.

Do you take meds for anxiety?

I've been on antidepressants pretty much continuously since March 1987 and have been on 225mg dosulepin, aka dothiepin, for the last 21 years.

Also, skipped the Paxil (3rd one) dose last night, took it this morning. Did not have early morning awakening, which was good, but woke up with more anxiety...I just can't figure this out...haha.

After about 5 days paroxetine plasma levels will stabilize to a steady-state and then not vary much across 24 hours so it won't matter much when you take it.

[Utah49er]

There was a time I was on a higher dose, 100-150mgs of Zoloft, but I started fish oil supplements and got healthier and my dose for the last 5 years was 50mgs. I got off it in November as I felt I was great and no longer needed it. Had a little anxiety blip in January, nothing bad that I didn't deal with from time to time on the Zoloft. I thought I would be proactive and just get back on the Zoloft, anxiety went through the roof , and I have felt terrible ever since through a trial of Zoloft and then Lexapro. I never got higher than the 50mgs on the trial as even the lose doses were sending my anxiety through the roof, got up to 10 MGs on Kexapro.

I don't know if it is the start on Paxil, or increasing pregabalin to 600mgs, but my anxiety is so bad right now, I honestly can't take it anymore! After 5 months of anxiety hell, I am just done. I feel I will never get back to myself, my kids will never get their Dad back and my Wife will probably leave me. This has just been too much, and it is simply not getting better!