Ryan - Please Read

[fd11]

This was sent to me in an email-

"There is no science that backs up the once daily/8-week or twice
daily/4weeks statement. Certainly, some folks metabolize these drugs
faster or slower than other groups, but it is well known that at
approx. 5 half-lives, a drug reaches steady state. This has nothing
to do with number of doses per day."

What do you think?

Also,  I have crosssed over to the valium 3 1/2 weeks ago and I was feeling great at home, but now I went back to work Monday and I am starting to get extreme panic all day.  I take 10MG at night.  I have forced myself to stayed at work the last two days for 5 hours and went home, but on the way home I almost got into a car accident because i started to freeze up.  Should I ask my doctor to increase the valium or should I give it more time?  I feel like this valium isn't doing what it is supposed to do.  I don't even feel like it is taking the edge off when it starts.  Can anyone give me some advice.  I need to be at work and I can't deal with this anymore.  Thanks

[RCA7591]

"but it is well known that at approx. 5 half-lives, a drug reaches steady state. This has nothing to do with number of doses per day."

^quote

Rubbish. For the therapeutic effect of Klonopin to be evident, the drug MUST be dosed *at least* twice daily (if used on a daily basis for the long-term management of panic disorder). First, the duration of action (time frame in which the drug provides a clinical benefit) is 12 hours (18 hours maximum, and only rarely - primarily in the elderly). For the steady-state plasma value to be maintained, and for the therapeutic benefit to be obtained, the drug must be dosed twice daily. The therapeutic range varies from 15-80 ng/mL. A single daily dose cannot produce a plasma value of 15 ng/mL, nor can it produce a steady-state level. Therefore, such a dose would be ineffective, and the duration of such a dose would not provide 24-hr coverage. The plasma value would peak and trough wildly, producing a "rollercoaster effect". Therefore, Roche (the manufacturer of Klonopin) recommends twice daily dosing of their product for maximum efficacy. The only exception to this is if the Klonopin is to be used PRN (as-needed), infrequently (less than 2-3 times/week). In this case, the Wafers are usually given.

So, why the four week statement? Klonopin reaches steady-state in approximately two weeks, and accumulates to 1.5 times that of the steady-state plasma value within approximately two additional weeks (four weeks total from start to finish) - but only when dosed twice daily.

Reducing the dosage every four weeks eliminates the accumulation from the system, leaving only the steady-state value after two weeks. After two weeks, the steady-state value is established, and then begins to decline in proportion to its half-life. The gradual decline of the accumulation and steady-state values prevents or minimizes withdrawal phenomena.

There is no "once a day" Benzodiazepine. ALL of them must be dosed several times/day for the therapeutic benefit to be evident (when used for psychiatric purposes in particular). This includes Librium, Tranxene, and Valium. While the latter three may reach some steady-state value, it will not be therapeutic. This is why I suggested splitting your doses into two equal, divided doses of 5 mg each. The more frequently it is dosed, the greater the accumulation level in the plasma, and the greater the steady-state plasma level. Not only is the plasma level greater (higher), it is more consistent. Consistency is the key for withdrawing these drugs sucessfully. A slow, gradual reduction of the plasma level is critical. Provided that this is done, there is no significant withdrawal. If symptoms manifest, they are related to an underlying disorder.

So, in short, your e-mail message is invalid. The person is not taking into account therapeutic plasma concentration.

To answer your question - Valium has no affinity towards "panic". What Valium is good for is "tension anxiety", musculoskeletal complaints, and Benzodiazepine withdrawal. Valium only binds to a specific sub-sector of GABA, and is useless for panic. Increasing the dosage will not help. The fact that you are experiencing panic at work and not at home suggests panic disorder with agoraphobia. You have three options at this point:

(1) Use the Valium to discontinue Benzodiazepine use and enter cognitive behavior therapy with a psychologist in an attempt to address your issues.

(2) Use the Valium to discontinue Benzodiazepine use, and address the issues on your own (quite difficult to do). You'll need to expose yourself to your fears (exposure therapy). Avoidance behavior fuels panic disorder with agoraphobia, and it would progress over time and with repeated avoidance.

(3) Visit a psychiatrist and request Klonopin at a dosage of 0.5 mg, b.i.d. for the long-term management of panic disorder, or Xanax 0.5 mg as-needed for infrequent attacks.

If, while driving, you experience the following symptoms, go straight to option #3. Do not pass go, and do not collect $200:

(1) Severe shortness of breath or a sensation of smothering
(2) The sensation that you are choking, or cannot swallow
(3) Numbness/tingling over the left portion of your face
(4) Numbness/tingling of the lips, arms, hands, or legs
(5) Clenching of the hands
(6) Severe lightheadedness
(7) Chest pain/constriction with a rapid heart rate

This is hyperventilation, the primary physical feature of panic disorder. Hyperventilation is a false suffocation alarm, due to an overactive sympathetic nervous system (the "fight or flight" response). Overbreathing results in the excessive release (expelling, blowing off) of carbon dioxide. The result is respiratory alkalosis - an acid/base imbalance which presents with neurological symptoms. At its worst, hyperventilation results in tetany (clenching) of the hands, contortion of the mouth, and a feeling of complete paralysis. While this is extremely frightening, it is not dangerous to you physically. It becomes dangerous, however, if it occurs behind the wheel. Should any of this occur, I would urge you to pull off the road.

Some folks recommend breathing techniques, but I do not. Respiration is an involuntary bodily response, and developing a fixation on your respiration will only worsen the problem. Furthermore, such techniques are only temporary fixes (if they work), and the problem will continue to recur. The body should control the breathing - not the mind.

As for the Valium not doing what it's supposed to do, it most certainly is, it has replaced the Klonopin - avoiding withdrawal phenomena. Your option was to avoid medication and to manage the symptoms on your own. Since Valium has no affinity towards panic, now is the time to manage the symptoms on your own. The Valium is not at fault here, and you are NOT experiencing withdrawal. What you are experiencing is panic. You need to take the information I've presented here and make an informed decision as to what avenue you wish to pursue.

I apologize if I came across as being harsh, but I will never bullsh!t you. These are the facts.

Best to you,

Ryan

[fd11]

Please don't apologize, I WISH YOU WERE MY DOCTOR.  Every time I need an explanation or some facts, you come through.  I was under the assumption that Valium was for Panic Disorder, and I have final come to grips with the fact that I have a Panic Disorder.  

I read the 3 options and the Klonopin made me extremely tired and depressed.  Would you recommend a Lexapro or Zoloft instead?  I tried Paxil and hated it, but are all SSRI's the same.

Also, I told my wife about you and she is very appreciative for the advice you give me, as am I.  I really need to get better and I don't care if I need to stay on a drug for a while, I am at a great risk of losing my job and with just being married and a baby on the way I can’t afford that.  

Also, last night I started to take 7.5MG of the valium at night and 2.5MG in the morning, are you on board with this, I feel sedated and a little out of it.

I truely hope that all is ok with you and as always, Thank you and enjoy your hoilday.  

[fd11]

P.S

I thought that Klonopin and Valium do the same thing, so wouldn’t valium be good for Panic disorder.  I thought the only difference is that Valium is longer lasting.

[michaxx2]

This is my third time on Lexapro....and each time I've used it for a year and a half and came off of it without any problems at all cause I weaned off of it very slowly.......and i love it..it is a wonderful medication..I got back on it a month ago for mild depression and anxiety......and I've been using klonopin as needed too....but by using lexapro you would end up needing less and less klonopin........I have to face and admit that I will always suffer from anxiety...and that I will always rely on those medications..on and off..........if I need it than I need it you know.....I'd rather live happy and anxiety free with medication than living a living hell without them.........that's my opinion!!!!!!!!!  
Good luck!!!!!!!!!!!
Micha

[fd11]

My story started about 17 months ago; I was not taking care of my self like I always would. For a good year I was working 13-16 hours a day 5-6 days a week (while drinking at night so I could do my work, this was 3 months prior to my panic attack I never drank a lot usually once every 3-4 weeks with my wife and/or friends), taking a diet pill (for 2 months), smoking cigarettes (7 years) and doing chewing tobacco (4 years) on top of it. I would get 3-5 hours of sleep a night (for about a year with sleep like this) and then go to the gym in the morning around 5 am.  I also drank 3 cups of coffee a day.  I decided to quit smoking (20 months now without a cigarette) but kept on going with the other nonsense (currently I don't do any of the above stuff for the last 15 months). Then it happen, one night after my in laws left from having dinner and I continued to do work. My chest felt like it was going to explode and I felt like I was going to die. My muscle got so tense that I felt like my muscles were actually getting bigger.  I was rushed to the emergency room where they said that I was having panic attacks and gave me 2 Xanax and sent me home after 4 hours. So a week went by and was feeling a little better, but still not myself.  My primary physician (we did every test you could imagine and I am extremely healthy) decided that I should see a psychiatrist and every psychiatrist I went to wanted to give me a medicine, telling me I have a panic disorder. So I found a doctor I was comfortable with (so I thought); we started to do sessions once a week. I was trying this without the meds and I felt ok but still not my self, so I asked my doctor if I should go on Paxil. He said sure and I started to take Paxil (they give this stuff out like it is candy).  I had to take a 3 month leave of absent from work, I would just lie in bed crying and was afraid to drive and go out of the house because this medicine was driving me crazy.  I took this stuff for 9 months and hated it. The side affects were killing me. I kept telling the doctor that I need to get off this stuff and he said that it wasn’t side affects it was my panic disorder. I was trying to explain to him that this was not anxiety. So he finally said that I could wean off of the Paxil and I asked him if I should take the pill every other day and he said yea lets try that. When I tell you the withdrawal that I went thought was unbearable and I literally just wanted to end my life.  Needless to say I found a new doctor and he took me off the Paxil within 10 days, right before my wedding, the only problem was that he put me on Clonazepam. Now I was on that for a little over 6 months and I want to come off.  Even thought I was only taking .5 MG before bedtime (for 2 months before I started to come down), I fell like this is a nightmare; muscle aches, tension between my eyes, blurred vision, my balance is off, back and neck pain, my legs always week and depression. My doctors told me just to stop taking the medicine and tried that.  Well that was just as bad as the Paxil.  After two days I was feeling good then the withdrawals hit me to the point that my body just froze.  I had no control over my arms and legs.  So I went back on the medicine by myself.  I went back to him and explained to him my story and said that I wanted to wean off the medication.  His response was sure, dry cut the pill ¼ every 10 days until I am off. Well obviously this is too quick and I started to have withdrawals. So I went back up to ¾ of the pill and started to wean off of the Clonazepam again by dry cutting the pill ¼ every 5 weeks and I  was stuck and ¾ of .5 MG for 5 weeks.  I started the water titration and went down from .375 MG to .348 MG.  Then I had a mild panic attack 4 weeks ago (the first one in 11 months) and I decided to go up to .353 and hold there for the last 3 days.  Since that attack, I have not been able to catch my breath (bought those nose strips and it has been better).  So that is why this doctor is saying that my Panic disorder has return.  When the side effects and withdrawals are panic attack, so my question is how they would know?  I truly believe that these meds do more harm then good, your body should be able to heal itself.   So I have found another doctor and I have now crossed over to valium (this doctor has told me that it is nearly impossible to wean off of Klonopin) for the last 18 days at 10MG before bedtime.  Hopefully this will work and make it easier to taper off these horrific drugs that are running my life.  I was just recently married in May of 07 and my wife and I are expecting our first child in February of 08.  I am 29 years old and this is no way to live.  I am unable to drive because of these medicines/or my Panic and my lose my job if I can’t get back to work soon.      


• Paxil to Klonopin in 10 days -    Ok I was on Paxil (SSRI) for 9 months which targets then serotonin in your brain.  Then I was weaned off of Paxil and crossed over to Clonazepam (Benzo) in 10 days which targets the GABA receptors.  Now I am no doctor, but why would anyone do this?  If you ask me, there has to be a better way to get someone off of Paxil.  Two drugs, two distinct actions. Klonopin is a bad way of masking SSRI withdrawal and vice-versa. The half-life of Klonopin is 50 hours, duration of action is 12 hours for as-needed use, 12-18 hours for single daily use, and 18 hours for twice daily dosing. Paxil targets 5-HT (serotonin) receptor sites, and nine months was a prolonged period of use. Ideally, the Paxil should've been withdrawn very gradually. Of the SSRI's, Paxil carries the highest risk of withdrawal phenomena. Reports indicate that it may be severe. A class-action lawsuit appears to confirm that it is indeed severe.

[michaxx2]

Wow you've been thru alot........I read some of your posts with Ryan's replies to you.......to make a long story short,yes,you did a fast taper with paxil,it should have been done much much slower.......and that by itself affected you big time......now klonopin is a very good drug(In my opinion) for anxiety...but not for depression...it seems that you are depressed with everything you;ve been thru...and it looks too that you are still very anxious....maybe,you chose the wrong path by quitting right now klonopin, cause your symptoms are still there and maybe paxil was not the right drug for you....my dr put me first on zoloft,and I had a terrible side efect from it,than I switched to lexapro combined with klonopin and it was the perfect combination. I remained on them the first time for a year and a half and weaned off very very very slowly.....that;s the key....and had no withdrawals....then a couple of years later I restarted the same regimen and quit the same way....and now ,a month ago restarted lexapro and doing fine with klonopin as needed....which is one or 2 pills a week.....maybe you needed to switch to a different antidepressant and the time? cause klonopin is an awesome antianxiety drug but if you are depressed it will depresses more ....and I think that what happened with you.....I donno...I am just guessing.....maybe you need to fing a different dr too............anxiety and depression suck......I hope you'll find the right way to treat it.......
Micha

[fd11]

Thanks, I don't think I am depressed, maybe I am who knows.  When I was on the Klonopin I was depressed big time until I started weaning down, now I feel like that withe the Valium not as much but still feeling it.  All I know is that I need to get out of this and will most likely go with Ryan's option:

(1) Use the Valium to discontinue Benzodiazepine use and enter cognitive behavior therapy with a psychologist in an attempt to address your issues.

The reason for me going this route is simply that I have been on 4 different meds in almost 2 years, I still feel panic, the only time I rarely felt panic was when I was weaning off the Klonopin.  Then stress took care of that deal, and I then reinstated the Klonopin and shortly crossed to Valium.   I thought this whole time that by talking to someone once a week telling them about my week and venting to them that I was in CBT.  I am just sick of this s#!t.  Thanks again

[michaxx2]

Ryan is awesome......he gives good advices.....I am sure you will benefit a lot from cognitive behavior therapy and feel much much better.....just take your time to wean off from valium..remember it is not a race......keep us posted....would like to hear from you....good luck...I'm sure you'll make it....be positive!!!!!!
Micha

[fd11]

Thanks Micha, I am really going through a hard time like everyone else.  I am trying to be positive.  Thanks bud.