Timing of meds

[Margaret122maryL]

It has been a very tough year but things are looking up. After ten years, I augmented on pramipexole, tapered off. (AWFUL!!!!) I have had consult with Mayo and with local neurologists. (I will leave out the difficulties of all those…Mayo was of course the most satisfying but it was virtual and he cannot prescribe).

Currently on Tramadol 100 mg, Lyrica 150 mg, Ambien 5 mg (I usually cut it in half). I have been playing with the timing of all these drugs and need advice on what might be best. (I was on Tramadol ER 100 and a supplement of 50 mg; the local neuro did not like the Extended rlease, wanted me to taper and I did.)

I take 25 mg of Tramadol in early evening…it seems to wake me up after feeling sleepy all day! I take the Lyrica 150 about 9:00. Then Tramadol 50 and Ambien 2.5 at 10:00. I might get to sleep, I might not. If I do get to sleep, I am wakened by restless legs after an hour or two. Then I take the final 25 mg of Tramadol, do some stretching, play my piano (my husband is deaf) and finally get back to sleep about 1:00. I sleep well until 8:30 or so. Compared to where I was a year ago, I am doing well. Am I asking too much to say I would like to do better? I would like go to sleep at 10:30 PM and wake up refreshed at 6:00. For those who take Lyrica…when is the optimal time to take it?

Another question—The Mayo sleep specialist suggested I get up to Lyrica 300 and then taper off the Tramadol but the neurologist here is not ready to along with that right now. Any ideas about why? Which is ‘worse’…Tramadol or Lyrica?

Thanks.

[Rustsmith]

You are experiencing what we often call "alerting" from the tramadol. Opioids are sedating from most people, but for many of us with RLS, the opioids wake us up. The only way around this is to take it early enough for the alerting to wear off but late enough for it to calm your legs. Honestly, I don't know if that is possible with the fast release form of tramadol.

As for Lyrica, it is sedating for most of us. It helps with calming your legs in about 65% of us, so maybe it will work by itself (without the tramadol) and maybe not. It would be much easier if your doctor would prescribe tramadol ER, but many doctors get very strange ideas when it comes to prescribing opioids.

[Margaret122maryL]

Thank you. Is alert effect more common among rls sufferers?
By the way..the Mayo doctor suggested I cut back on the fast release tramadol rather than the ER. But he is in Minnesota and I am in NY.

[Polar Bear]

Regarding your sleep medication Ambien 2.5mg. The insomnia that comes with RLS is quite specific to RLS and I'm sure I read that sleep medications do not help with our specific RLS insomnia (Although it may help mask the rls symptoms). I'm sorry I don't have any documentation on this.
When I used Ambien I found myself feeling doped up but not sleeping, going to the bathroom I was staggering and bouncing off walls. After trying various sleep medications without success I stopped using them.

[Rustsmith]

As far as I know, alerting is something that is specific to RLS. The listed side effects for opioids all talk about how they are sedating, and this is the opposite. My guess is that it is something that hasn't been studied, but I think it is something that has been described in the reports coming out of the RLS-opioid study that is currently being done by Dr Winkelman at Massachusetts General.

As for tramadol, I have been on tramadol ER on several occasions and would take it at noon to avoid the alerting side effect. It was okay, but the anti-depressant properties would start to kick in after about six months. It didn't help with the depression that I was experiencing then, but it did cause an almost total loss of libido (which made my depression even worse). When I would switch from 200mg tramadol ER back to methadone, my doctor would provide me enough 100mg tramadol ER to last a week. She then provided enough plain tramadol for me to take 100mg (regular) for a week, then 50 mg fro a week, then 25mg for a week and then a week with 25mg every other day. And I was taking my full dose of methadone while doing this. The taper allowed me to come off of the anti-depressant side of tramadol without getting SNRI Withdrawal Syndrome again.

[ViewsAskew]

I take methadone at 4 PM and still fight to go to sleep by 1 AM or so. I had to take is around noon or 1 PM the few times I tried to have a "normal" schedule.

[Margaret122maryL]

Thanks so much to all of you for your input. It is validating. I have been trying various schedules with the Tramadol 50 tablets the doctor has provided (enough for 100 mg a day), along with the Lyrica 150. Tramadol certainly helps the restless legs but doesn’t hold the symptoms for more than four hours. I have cut it in quarters, trying to sustain the effect. I would rather be alert than restless. Lyrica makes me dopey but doesn’t seem to do much for the legs, so at 2AM I am pacing the floor…stumbling and bumbling. I think I need to go back on the Tramadol ER, take it earlier as suggested—IF I can get a prescription for it—and either skip the lyrica or decrease it. There’s no way I am going to get methadone around here. I don’t think I will even be able to get a prescription for the Tramadol ER from the neurologist. It was my GP who ordered it when I asked for it (on your suggestion) but she wanted to pass me off the neuro.

[badnights]

Another question—The Mayo sleep specialist suggested I get up to Lyrica 300 and then taper off the Tramadol but the neurologist here is not ready to along with that right now. Any ideas about why?

Maybe your neuro's thinking is more in line with common wisdom than the specialist's is, in this regard: the anti-convulsants like Lyrica tend not to be effective on their own for people who have augmented.