HIGH-DOSE KLONOPIN

[flowerville]

Hello,

I suffer from treatment-resistant PD/GAD/PTSD.  At long last, I found a *wonderful* psychiatrist who is sympathetic to my sufferings.  She has me taking a total daily dose of 4 mg of alprazolam SR (the generic, NOT THE BRAND XANAX XR).  My Medicare Part D insurance is as cheap as can be expected and they will NOT pay for the brand-name Xanax XR, and in my experience, brand-name psychotropics almost always are far superior to generics.

This alprazolam SR therapy is helping a little with the panicky feelings I often get "out of the blue".  I have sustained an enormous, enormous amount of abuse, both emotional and physical, in the past several years.

Unfortunately, alprazolam SR is not taking care of the problem with panic feelings, flashbacks, hyperarousal (PTSD-wise), etc., and I am getting very frightened and HOPELESS about the the thoughts that run through my mind when I'm feeling so nervous and there's nothing around for me to take for it.

.....which leads me to my question:  People love alprazolam SR, and in my opinion during this past week, it's not bad, it's just the dose isn't high enough, and it does not last all day.  Mind you, I am NOT about to ask for a higher dose of alprazolam SR.  alprazolam SR can become a terribly tricky, burdensome medication, and I am NOT in the market to cause those kinds of additional problems with my health - my "plate is full", health-wise, as it is.

I was wondering if I may do better on the Klonopin Wafer alternative (or clonazepam wafers, if Klonopin Wafers are no longer marketed; I don't know).  I hear they work quickly, doctors generally do not have the "angst" with Klonopin as they often do with Xanax.  Best of all, according to the PDR, at least, one can take a very large dose of Klonopin--I have read that the maximum Klonopin dose for the past many years has been 20 mg/day.

I was wondering if it is out of the realm of feasibility to explain to my new p-doc that, although alprazolam SR is helping somewhat, it is not doing a consistent, reliable job, and that I have "breakthrough" panic attacks that *****I JUST CANNOT STAND -- I SUFFER SO NEEDLESSLY FROM THEM*****.

I was wondering if experienced p-docs such as my new one, who works with lots of PD/PTSD clients, sometimes substitute high-dose clonazepam wafers for alprazolam SR if the patient is having an exceptionally hard time with panic anxiety, PTSD-like panic flashbacks, etc., instead of increasing the Xanax.  Again, I know the dangers of high-dose Xanax and I respect it.  Xanax is actually best in low doses for a small percentage of psychiatric patients.

It would be great if my p-doc could just give me the 2-mg clonazepam wafers and let me take 4 or 5 a day to start out with, so I don't always feel like collapsing in public, or else just lying in bed hoping to God I can fall asleep and make the panicky feelings go away.  That SURE is not a route to a productive, happy life!  :(



THANKS for your help.  I'm sure there's people who take high-dose clonazepam wafers.  If the PDR lists the maximum dose to be 20 mg [regardless of whether the indication is epilepsy or anxiety], then that's what the PDR thinks.  The PDR is the PDR is the PDR - just like "Harvard is Harvard is Harvard" :)  They are a conservative source of medical data that all MD's have - it's the "medication Bible".

Again, thanks for your input, and God bless you all.  I am --so-- sick of suffering with my anxiety; it has reduced the quality of my life to ZERO, and I want to go out there again and enjoy the time I have left alive that God so kindly gave me.

Sincerely,

FlowerVille

"where Peace Lilies bloom profusely"

[nursegirl6572]

I DO think if your doc agrees to the Klonopin, that the wafers would be a great choice.  They are much more "exact" in their strength, if that makes any sense?  The wafers are also fantastic when and if you would be tapered down (or up).  The wafers allow for a more exact dose, and they are available in smaller increments than the oral tablet form.

I DO totally get what you're saying about needing a high dose.  You're probably not wrong at all.  BUT, you don't necessarily START at a dose that would knock down a horse!  ;0)

If your doc agrees, and comes to a specific dose...TRULY give that dose a chance for a few days.  Once the Klonopin builds in the plasma, you will REALLY start noticing the effects.  It really isn't the kind of drug to be typically used as a "rescue med".  In other words...it may take you a couple days for it to reach therapeutic levels in your system....before you can attempt Times Square (God love you, btw...that's a panic sufferer's worst nightmare...I shudder thinking about it).

You can also run into trouble trying to use a high dose as a "rescue" med.  So, you take 4 mg, but don't feel a lot different...so you take another 4.  And so on.  SURE, it will cause SOME immediate effects, but due to its VERY long half life...all of those doses aren't going to hit you in the bullseye until 24-48 hrs later, give or take.  That's when you fall over, and someone ends up calling 911.  NOT good.

Before YOU make all the plans....wait and see what your doc says.  Like I said...while you sound extremely intelligent...you're still not a doctor.  At least TRY what he is going to recommend.  Klonopin is NOT at all like it's short-acting benzo cousins, Ativan and Xanax.  Even Xanax ER can't compare to the long acting quality of Klonopin.  It packs one hell of a punch for some people too.

I'll tell you a quick story.  (Ok, I lied, none of my stories are "quick".....well, I digress....)

I have been Rx'd PRN Xanax and Ativan for panic attacks (at different times).  YEARS ago (long time)...my doctor went on some 2 month retreat somewhere (aka....cabin in the woods with his secretary).  So, the "fill in" doctor INSISTED I try Klonopin in place of 0.5mg of Xanax "as needed" (I probably only took a Xanax once or twice a week at that point).  I argued and argued that with Dr. Knowsnotmuch that I didn't need to make any changes...and told him what I knew about Klonopin not being optimal as a prn med.  He wouldn't hear any of it.  I still had plenty of Xanax, so I relented and took the script.  It was for like 10-0.25 mg tabs to be taken "as needed".  I got it filled, and put the Klonopin in with the Xanax.

One day, I was having a very bad day...and had a massive panic attack...so I took one of my Xanax sublingually (per my doc's orders....faster absorption).  The NEXT thing I knew...my husband was home from work trying to wake me up.  He said he had called and it sounded like I had drank a fifth of Jack and a case of beer.  I was like "HUH???"  I got accused of being on drugs, blah blah.  WELL, I figured out later that I accidentally took a Klonopin instead of the Xanax.  I know everyone reacts differently to meds, but it wasn't like I was benzo-naive.  That stuff is STRONG.  I had a "hangover" for like 2 days.  I was shocked, looking back in retrospect, that it had worked so fast, being long acting...but the SL route just turbo charged the absorption.  Needless to say, they got flushed.

Just be sure to follow your doctor's recommendations and keep in mind that you'll need to give it at least a few days before making a determination regarding the dose.  Equivalencies will have to be figured in as well, by your doc.  The standard benzo equivalencies are the following: Xanax 0.5mg=Klonopin 0.25 mg=Ativan 1 mg.  Hope that makes sense.  There will be more to figure into the formula to find a comparable dose, being that you were on the "ER" preparation of the Xanax.  Also, equivalencies are not an exact science, as I've already said.  If you were on regular Xanax at 4mg/ daily...you would need 2mg/day Clonazepam to safely cover your dosage.  Just a very basic example.

So, to wrap this up (my I'm long-winded)...let your doctor "doctor"...and TRY to be a patient patient (lol) during the adjustment phase (IF your doc even agrees to this...& that is a big "what if").  

Sounds like your doc is pretty decent, but keep in mind that some docs do not at ALL like ANYONE telling them what to do.  If he is at all like that...find a way to present your info as though you want his input...and then create the illusion that this was all HIS idea.  LOL...seriously, you'd be surprised at the difference in their receptiveness.  LOL.

You're in my thoughts.  I truly hope, whatever it is, your doc comes up with a satisfactory plan that will better manage your anxiety.  Your quality of life is suffering, and that's just not acceptable.

Keep us in the loop!!

[flowerville]

**bless you** for your thoughtful comments.  i'm only trying to find relief from pernicious anxiety in the least obtrusive manner.  we have tried literally everything else non-habituating.

there is a time and a place for a habituating anxiolytic!!

i don't want to get into a big Xanax habit and my new p-doc would not tolerate this in the furst place.

i just want to be able to take an ample amount of clonazepam wafers so I can stop feeling like I am going to collapse in the middle of Times Square, alone, with no one to help.  i just got cleared medically, incidentally, so there are no problems physically, to speak of, to exacerbate the panic, with the possible exception of a slightly low TSH.  My endo and I are in the process of achieving euthyroidism again by skipping a day I take my Synthroid.

i was talking to the pharmacist this evening at a local large chain and he says there are people on 8, 10, 12, 16, etc., mg/day (not all at once, he said, but throughout the day) of the **WAFERS** and this is what I think is best for me, and I'd **love** your feedback, if you would be so kind.

Bless you,

FlowerVille

[....Where Venus Fly Traps Flourish....]

[nursegirl6572]

First of all, I'm sorry you are feeling so lousy.  Having a lifetime's worth of anxiety is just awful, and it sure sounds like you've got the motherload of anxiety.

Well, you've definitely done your research about the Xanax ER and Klonopin.  I think your idea is a reasonable one.  It's certainly worth discussing with your p-doc.  Sometimes, if you don't have TOO severe a problem with cross-tolerance, switching meds may allow you to actually do better on a LOWER comparable dose.  

My main concern is that you keep referencing the "max" dose as per the PDR, I think because you are anticipating needing a higher dose, and worrying about being under-medicated, which I get.  It's not at all reasonable to think your doc would Rx anywhere NEAR that dose.  What I think is reasonable, is for you to ask to be switched to a comparable dose of Klonopin, and give that a try.  You may need some dosage adjustments to get your anxiety to a more manageable level, but like I said, just the change to a different med may allow you to get better relief, even on a lower comparable dose.  Klonopin typically has less issues with tolerance than Xanax ER does, so that would be another possible benefit for you.  You may be easier to "stabilize" on the Klonopin.  Klonopin is usually most
effective when dosed 2-3 times daily, every day.  It allows the Klonopin to build in the plasma properly, which is what is responsible for its efficacy.


It's hard sometimes, to let the doctors be doctors, especially after all the research you've obviously done, but that is really important.  Go in to see your doctor with your research in hand, and explain that this is something you'd like to try.  You need not mention doses, your doctor will be able to calculate the equivalent dose.  THAT being said, calculating a comparable dose is not an exact science either, which os why, like I said, your doc may need to play with the dosage a bit.

The best thing you can do is just tell your doctor what you've told us...that your meds are NOT sufficiently controlling your anxiety, and that you seek a better quality of life.  That's not too much to ask.

What other meds have you tried on your journey?  Have you ever tried an SSRI antidepressant?  Or, any other kind of med to better manage your disorders?  If you haven't, I would discuss that with your doc as well.  It would be great if you could see some success without relying solely on a benzo.  You've found a doc willing to Rx it, but I always worry for people like you, that if you should ever lose your doctor, the likelihood is great that you would have a rough time finding a new doc willing to Rx benzos at high doses.  That's not to say you don't need it, or that it isn't appropriate for you, it's just the reality that SO many docs are less and less willing to prescribe benzos long term anymore.  That's why, it would be great if you could be proactive about finding a med to add to the benzo regimen that would be helpful and lessen your need for the anxiolytic.  I'm sure, with your history, you've probably tried them all.  Just a suggestion.

Best of luck to you...let us know how the pow wow with your doc goes!