Requip XL and depression

[nitewriter]

After I complained about augmentation on Mirapex, my neurologist recently switched me back to Requip (XL version this time). I give the guy huge props for guessing the right dosage for me; the transition didn't affect my sleep much at all. I also take Ultram and Ambien, and the combination usually lets me sleep through the night with minimal augmentation during the day.

Problem is I'm moderately lethargic and depressed during waking hours (not to mention the TMJ). I've cut out alcohol since even a small amount causes several hours of acute depression with suicidal ideation -- an effect not noticed with Mirapex. But my neurologist has been unresponsive to my complaints. He says he doesn't want to add an antidepressant to the delicate mix, which I can understand. I'm also a bit wary of antidepressants since I suspect that high doses of Paxil, Celexa and Lexapro were what brought on (or made noticeable) my RLS.

Has anyone had success combining the Requip-Ultram-Ambien regimen with a chemical or natural antidepressant? Might the depression and lethargy be a simple dosing issue?

[ViewsAskew]

Nitewriter, did you have any RLS symptoms during the day before this all happened? If the Requip change didn't return your symptoms to pre-Mirapex levels, then it might not be a good choice.

To your question, I am sorry but do not have a clue about what to add. I can simply say that from my own experience, each drug dramatically impacts my emotional state...but each in a different way.

Only you can decide if you want to go this route. I would be concerned and want to know if there was a different choice that didn't put me in this state in the first place. I tend to be a bit intolerant of drugs that make me feel lousy, however, and want to be on something that simply helps, not adds to my dilemma. At times, there aren't choices. Then, you have to add something to deal with it. I guess I'm wondering if you're at that place or not.

Welcome to the board. I hope you find what you need here.

[nitewriter]

Thanks for the quick response, VA! I'm about ready to turn in. Ambien is doing its thing, so I might not be completely lucid.

When I first started treatment for RLS using Requip and Ultram, the augmentation and rebounding were unbearable while we ramped up my dosage. Pain, cramping and jitters would start mid-morning. By evening, I'd have developed a stiff walk. I began using a small second dose of both drugs during the day, per my doctor's recommendation. This made me tired and didn't completely remedy the discomfort.

My neurologist switched me to Mirapex and added Ambien to help me sleep. Initially, while ramping up my dosage, I felt better. No rebounding in the a.m., though the augmenting would strike in the evenings. As I increased the dosage, daily augmentation began to get worse. The moderate pain was sufficient enough to make me short-fused and snappish at work, and I never could get the timing of the late-day dosage correct. If I took it too early, I'd lose my way at work due to lethargy. If I took it too late, the pain and cramps would have already set up camp permanently. So I went back to Requip.

Now, with the Requip XL, the augmentation is not much of a problem at all, which is very nice. I guess that's the time-release benefit. However, I wake up lethargic and depressed, and I come home exhausted and angry. My doc prescribed Provigil to assist with the lethargy, and my HMO promptly denied it. Rather than attempt to substitute something else for Provigil, the doc simply threw up his hands. So I've gone back to caffeine for now.

So it looks like I need to choose between tiredness/depression or pain/augmentation -- unless I want to try the neurontin/klonopin router, I guess. Since Requip XL with Ultram and Ambien are at least letting me sleep and reducing the augmentation, they seems like the ideal cocktail makings for now. I'm holding out hope that something further can be done to detoxify that cocktail. Whether that means the addition of an antidepressant or a change in dose I don't know. Unfortunately, my neurologist isn't especially interested in this kind of troubleshooting exercise. The last time I took Requip, the adjustment period took several months, and I've only been on Requip XL for 2-3 months, so maybe I should give it a longer change. Dunno. Would be interested to hear what others in this situation would do.

Sorry for the overlong letter. My internal editor went to bed about an hour ago.

[Neco]

To be honest if you are taking Ultram the Mirapex and Requip should never have been added.. A sufficient amount of Ultram during the day should really take care of your RLS symptoms, and adding Mirapex or Requip which are causing you augmentation are making your current dose of Ultram either ineffective, or severely hindering whatever relief it may provide you.. If you increased your Ultram dose you would eventually reach a point where you would not feel your augmentation symptoms, but again this renders Dopamine Agonists a redundant, and unecesarry medication that is introducing harmful side effects to your quality of life and symptoms resolution.

Your neurologist is right to be wary of adding anti-depressants. If you mix Ultram with SSRI's you increase the seizure risk dangerously.. I experienced a seizure a while after I took the risk of adding Luvox to my regime a couple years ago, and even when quitting the Luvox I have lasting side effects that prevent me from taking Ultram forever. I believe I also have other mild side effects that are permanent..

If you are augmenting on both medications, then you need to tell your neurologist to stop making you take them, and either increase your Tramadol to cover your symptoms, or switch to a stronger opiate.. If you switched to Codeine, Hydrocodone, or Oxycodone you would have no problem taking an anti depressant.. Although I would wait a few weeks after stopping Ultram if you do this. You need to give it time to clear your system so you have no risk of a medication interaction from residual amounts of the Ultram.

The Mayo Algorithm is pretty clear that when you augment on two or more DA's, or are otherwise unresponsive to them, the next step is to try another class, opiates, anti-convulsants, or benzos.. I would not reccomend benzos because they are easily more addictive than opiates, and while anti-convulsants (Lyrica or Neurontin) may work, they can make you real tired and increase your lethargy; or may not work at all..

You're already on an opiate, so its pretty clear you should cut out the rest and increase your daily amount, or switch to a stronger one.. When quitting DA's you go through a temporary worsening period that can last a week or two, and most experts agree that a strong opiate should be given during this time..

If there are concerns about addictions or the medication not lasting long enough between doses, look into controlled release meds. Ultram ER, MS Contin, and Oxycontin are your prime candidates. Methadone is also a good candidate if you can't regain control through other opiates. It is a short acting med, but has a LONG half life (72 hours) that can translate to between 10 - 24 hours of relief depending on your dose and how many times a day you take it. Methadone should be considered an absolute last resort. Buprinorphine (Subutex) is an alternative to Methadone that is also very effective. However these meds are very powerful and should be started slowly, with small doses.


I would print out the Mayo Algorithm and take it to your Neuro, and tell him it seems a better choice to cut out the DA's and just stick with an opiate class medication. Always remember, your doc works for you and if you feel he is being unfair for no good reason or refuses to help you further, tries to keep you on meds you decide are not good for you, then you can always find another doctor if it comes down to it.. It's not uncommon for RLS patients to go through many doctors being finding one who truly understands and will do what is necesarry..

Here is a link to the Algorithm.. Read over it yourself, and form your own opinion about what you would suggest to your neuro, regarding treatment changes.

http://www.mayoclinicproceedings.com/co ... l.pdf+html

[ViewsAskew]

NW - I fear that these may not the drug for you. If you augmented and rebounded every time you tried them....you will do so again. As Zach noted, the researchers and RLS experts have determined that once a person augments twice, he or she will just keep doing it and so these meds should no longer be used.

It sounds like you augmented, quickly, too. You case reads much like mine, except in how it was handled. I augmented quickly on three - Mirapex, Requip and Sinemet.

Requip XL and the patch are both thought to lessen augmentation, but I do not know how they work after someone already augmented.

If you feel you have few options and can manage the side effects, it might be worth a try. But, if you feel you have other options and the side effects are unmanageable, then trying to find a drug to resolve the daytime issues may not be the best option.

Of course, only you can decide that. A big part of that decision has to be the doctor, too, and if you think he is going to go down other roads. In my experience, I've had little luck with neurologist going down other roads. But, I'm ever hopeful that we can educate them.

If you haven't look at the algorithm, Zach's link will take you there. Also, take the link in my signature and you'll get to a thread with lots of info. You may not need it, but it may help in some way.

[nitewriter]

Thank you both for the sensible advice and thought-out replies! I've read over the algorithm, and it does seem that the combination of drugs I currently take is unusual: a DA (Requip XL), a benzodiazapene (Ambien) and an opiate (Ultram). Makes me think at least one of them could be eliminated. Combine the RLS with my sleep apnea (threw out my CPAP machine years ago), chronic insomnia, history of moderate depression/anxiety and lifelong allergies, and it's likely a difficult program for the best neurologist to manage. Sounds like I need a specialist who has the time to assess all these. Also sounds like a neurologist is a poor candidate for that role.

Thanks again the terrific links!

[ViewsAskew]

He may well be the wrong candidate. The right candidate may take some work to find. The sleep people tend to do well with the apnea and insomnia, but not so well with the RLS. But, that's not always true, of course.

Let us know what you decide.

[Neco]

Just so you know, Ambien is not a benzo, it's a Hypnotic Sedative.. Although it acts on the same receptors, they bind in different ways and produce totally different results and dependence potentials.

A physicians who addresses all your medical concerns is always a good choice, but remember that you never know who you'll really get.. Many people have gone to so called "RLS experts" and been given completely horrible, sometimes downright bad ineffective advance/drugs that have nothing to do with RLS.

It is really important that you address your sleep apnea problems, especially since you are taking an opiate and a sleep aid. Opiates in particular are CNS depressants and can affect breathing, someone can just as easily die from apnea related complications from dose that normally wouldn't kill them. However this is likely only going to be more important if you ever go into the territory of really strong opiates, but that's an anecdotal opinion at best.

If you address all your sleep problems, you will likely sleep better and more restful as a result. As far as your allergies, Fexafenadine (Allegra) and Loratidine (Claritin) both tend to be very RLS friendly.. They will not severely aggravate your RLS like Benadryl (Diphenhydramine) or other OTC or some prescription allergy medications... If you ARE currently taking Benadryl unknowingly, stop immediately and your RLS may diminish in severity..

As for your depression issue.. As I said you can't mix Tramadol (or Methadone for that matter) with SSRI's and some other anti-depressants. Or you'll likely have seizures (or in Methadones case, mixing can causes fatalities). Most well-known anti-depressants also can severely aggravate RLS just like allergy meds.. There are a few like Well-Butrin that have been tagged as more RLS friendly, but everyone is different so there is no way of telling.. The good news is if you badly need meds for depression, you can likely overcome the increased symptoms with a sufficient dose of opiates, or at the very least reduce symptoms by a lot.


I'm curious how much Ultram you are on, and if you've noticed any effect on your mood? Myself and others have noticed some anti-depressant anxyolitic properties from Ultram that are rather unique vs other meds. Though this unfortunately can make it a little harder to stop as a result.

[ViewsAskew]

Technically, Zach is right the Ambien is not a benzo - but they both fall under the sedative hypnotics according to the Hening, Buchfurer, Lee book. So, they fall in the same category in treating RLS. According to the book, they primarily should be used for the same function: to help you sleep. The other categories, are better used for stopping the RLS.

I'm guessing that he just meant he was taking meds from three categories of RLS drugs.

[nitewriter]

Ann's right: I meant to communicate that I'm taking multiple, perhaps redundant, drugs from the different classes mentioned in the algorithm.

Quick rehash of my RLS history: I started on neurontin, I think, and did okay on that for a few weeks. It had been prescribed by my neurologist's PA, who appeared to be experimenting with meds himself (or suffering a nervous breakdown at any rate). The actual neurologist switched me to Requip and Ultram simultaneously. So I haven't tried Ultram alone. I now take 100mg of Ultram in the morning and 100mg at night. Due to a back injury, I've been taking it in the afternoon recently, too. It makes me generally pleasant for a few hours. Brings on a mild headache and sensitive stomach, but I do get relief from the blues. Ambien was added several months later. Seems I have a 26-hour circadian cycle, and the Ambien helps me keep a normal rhythm provided I can remember to take it on-time. Other meds on-board right now are minocycline (for acne), Zyrtec (allergies) and Zicam spray (nasal congestion). Did I mention 60mg iron in the morning along with a multivitamin and cup of coffee? Finally, I smoke crystal meth on breaks at work because my job is very stressful. Just kidding about that last part.

If I can figure out how to taper down on the Requip XL (the 2mg tablets don't look like they can be split), I could try seeing how I do without the DA. Short of grinding them up, anyone have any suggestions?

As for my sleep apnea, I expressed a strong concern to my neurologist that the respiratory depressive effects of most of these drugs are well known. He downplayed the interaction and said, "Let me know if things get worse.' So far, the apnea is relatively mild. I had given up my CPAP and learned to side-sleep several years ago. So that's where I'm at.

I wonder if there are physicians who specialize in managing drug menus. Folks who can work with a patient to carefully report the symptoms, side effects, and user satisfaction levels -- and then communicate that effectively to the prescribing specialists. I'll do some poking around my HMO's site and see if I come up with anything.

Glad I found this board! Some of the sticky topics are super helpful.

[SquirmingSusan]

If you have questions about drug interactions, your best best is to talk to a pharmacist. There are MDs who specialize in mixing meds, usually they are psychiatrist or neurologists, who have taken additional training in pharmacology. I know that there is one locally in MN who is a "neuropsychopharmacologist." Those doctors are few and far between, though.

It seems that tramadol does have some mild antidepressant effects of its own. And it sounds like it helps you feel better overall. I don't know why a doctor would put you on that as well as a DA, especially if you have to keep increasing the dosage of the DA to cover the augmentation from the DA. A lot of people take tramadol by itself for RLS.

As for quitting the DA, according to Dr. B, you can just stop taking it without tapering. But if you're having augmentation issues already, stopping it can cause more issues.

In your list of what you take, there are a couple things that can aggravate RLS - Zyrtec is on the list of meds that can make RLS worse. (Dr. B's list in one of his books). I haven't personally noticed that it does, for me, but apparently other people have. Also, coffee is notorious for worsening RLS.

Once in a while someone reports that taking antibiotics drives their RLS nuts as well.

(BTW, I've never heard that methadone interacts negatively with antidepressants. Anything is possible, but there sure are a lot of us who take both. My pain doctor was never concerned about my taking Lexapro or Effexor along with methadone.)

Anyway, your best bet in figuring out how to manage your RLS is to read the Mayo Clinic Algorithm, along with some of Dr. B's books. The more you know, the better you'll be able to advocate for yourself. And if you have questions about drugs and interactions, talk to a pharmacist or your doctor. We do have a couple of pharmacists who post now and again in the discussion board, but the rest of us are not trained to answer those questions.

[Neco]

Here is an HTML version of a PDF

http://74.125.95.132/search?q=cache:TYc ... lang_en#14

There are several kinds of interactions with Methadone.. Some alter the way it is metabolised, others decrease serum methadone levels, and others may increase serum methadone levels. An interaction from any of these categories could result in possible death, lowering of efficacy, or increasing of efficacy, per dose.. They usually give this sheet out to MMT patients I think..

As per anti-depressants, from the Altered Metabolism / Unpredictable Interaction colum..

TCAs
amitriptyline♥,
desipramine♥,
imipramine♥,
nortriptyline♥,
protriptyline♥
Elavil, Norpramin,
Tofranil, Pamelor,
Trimipramine,
Sinequan, Vivactil,
and other brands

Tricyclic
antidepressants
(TCAs).

Combination with methadone increases TCA toxicity
(DeMaria 2003; Maany et al. 1989; Quinn et al. 1997;
Richelson 1997). Mixed reports of methadone increase or
decrease (Eap et al. 2002; Moolchan et al. 2001; Strang
1999; Venkatakrishnan et al. 1998). Caution might be
advised when using the drugs in combination with methadone
due to possible proarrhythmic effects.

St. Johns wart is listed as decreasing SML as well.. Which I take to mean it makes a given dose less effective or some such. I know many people routinely take this, so thought I would throw that out there..

From the increased SML table

Warning: Acute increases in serum methadone concentration may produce significant signs/symptoms of methadone overmedication,
possibly resulting in overdose. Recent data suggest that in susceptible individuals acutely elevated methadone levels – alone or, more
commonly, in combination with other drugs and/or cardiac risk factors – may influence cardiac rhythm disturbances (prolonged QTc
interval and/or torsade de pointes; see Leavitt and Krantz 2003).

Here are the SSRI's under the same table

SSRIs

fluoxetine♥,
fluvoxamine,
paroxetine♥,
nefazodone,
sertraline♥
Prozac, Luvox, Paxil,
Serzone, Zoloft

Treatment of
depression and
compulsive disorders.

Possible mild elevations of SML due to variable
inhibition of CYP450 enzymes (Begre et al. 2002;
Batki et al. 1993; Bertschy 1996; Eap et al. 2002;
Hamilton et al. 1988, 2000; Levy et al. 2000;
Richelson 1997). Strongest effect seen with
fluvoxamine (Alderman and Frith 1999;
Bertschy et al. 1994; DeMaria and Serota 1999;
Eap et al. 1997)

Not all SSRI's or TCA's are on the list, but many of the popular ones are.. Including Luvox dissapointingly.. I really thought it was helpful to me but after my Tramadol incident I am very afraid of adding anything that could have possible interactions leading to another seizure or accidental overdose.

Other notables on the list are Tagamet, Dextromethorphan, Hydrocodone, and of course Grape Fruit Juice.. As you all know I routinely mix Methadone with Dextromethorphan and get a significant duration and efficacy boost and haven't died yet.. Some some interactions can be taken with a grain of salt.. I've taken Tagamet as well, which over time causes a few minor problems but didn't seem to be life threatening in any case..

Here is a nice, cleanly formatted PDF version, suitable for printouts.. Which make it good to take the list to your doc and stick in your chart for prescription references against interactions that may be harmful.. It lists the type of interaction as well in most cases, so the doc should be able to make a qualified guess...

But when it comes to Benzo's and AD's I would just flat out not take anything on the list.

http://pain-topics.org/pdf/Methadone-Drug_Intx_2006.pdf

[ViewsAskew]

NW - I think we had a recent conversation about doctors who handle drug interactions...hopefully Aiken or Sojourner will remember (I say him because I remember them participating...I think). Just can't pull the info out of my brain...

[Sojourner]

ann, i don't recall mentioning a name. think i suggested asking a pharmacist to check them in the hopes they have a more sophisticated drug interaction program. don't know if i'm on the right track here or not.

[ViewsAskew]

Oops....wrong memory. There was a conversation...now I'll have to go search just to see how off I was...