meds for fatigue

[Needhelp16]

Are there any other meds for fatigue besides provigil?  The reason I ask is because for the drug interactions for provigil says don't take if you're on beta blockers or amitriptline (sp).  Which of course I'm on both.

Thanks for any suggestions in advance.  I see my pcp on Wednesday, and I want to be ahead of the game!

Laura

[Needhelp16]

Thanks twopack for taking so much time with this.  I really appreciate it.  I actually haven't started the beta blocker yet, because I had knee surgery back on the 4th and I can't start taking it until I'm off the pain meds for my knee.

I take so many meds and supplements now, I think my list is up to 15 or 16.  I hate to be put on another med, but what choice do I have?  I get enough sleep at night, but I'm still exhausted during the day (even with a nap)!

Sorry, but here comes a small rant or pity party.  All of this *****.  I'm 33 yrs old with 3 kids. I have the dreaded MS, ocular migraines, hashimotos hypothyroidism, and knee problems.  I've never been on so many meds in my life!  I can't take my own kids out to play, because my 2 little boys are faster than I am and it's simply not safe!  I walk with a cane...I'm only 33!  I know I've already said that, but it's just mind boggling! I'm trapped in the house most of the time, and if I do go out I'm completely exhausted afterward. I've put so much stress on my family it's ridiculous! All of this ***** a&%!

Sorry for the rant.  I appreciate everyones comments, and I wouldn't mind more if someone has a suggestion on the fatigue. Thanks again twopack for all your input.

Laura

[SarahL2491]

thanks Mary.  I think many of us forget these little details.  I always encounter resistance in the ER when refusing to take some of their "cocktails", they just don't understand we know what works and doesn't work for us.

[twopack]

IMPORTANT INFORMATION for anyone who is STARTING PROVIGIL OR NUVIGIL and ALREADY TAKING OTHER MEDICATION.

Provigil, generic modafinil and Nuvigil are modest inhibitors of the CYP450 2C19 isoenzyme in the liver.  They can cause an INCREASE in the plasma concentration of ANY DRUG that is primarily metabolized by CYP450 2C19.  (**This is similar to the type of reaction we are cautioned about when eating grapefruit while taking some heart medications.)

This is NOT USUALLY APPARENT IMMEDIATELY because plasma levels of any drug that is dependent on the (dwindling) isoenzyme increase gradually.  Less isoenzyme available >> slower metabolism of the secondary drug >> each dose stays in your system longer >> your once therapeutic daily dose now resulting in higher plasma levels >> effects of overdose or toxicity MAY TAKE DAYS TO RECOGNIZE.

This is a COMMON difficulty in today’s pharmacologic world.  The pathways of metabolism in the liver can be inhibited or enhanced by a wide variety of common drugs.  Quixotic1 (a physician!) told us how she ended up gravely ill when a drug she had been taking climbed to toxic levels when she tapered off a separate drug she no longer needed.  That’s when I started learning some things about this and took a closer look in my own medicine cabinet.  

These days I won’t even allow the hospital to substitute their favorite “therapeutic interchange” for what I normally take.  I’ve worked to find the mix that is balanced and works for me at home.  If I can’t avoid a hospital stay I’m plenty willing to carry along whatever drug or supplement the hospital can’t (or won’t) supply.

The ability of drugs to change how others are metabolized is a VITAL side effect to be aware of.  We need to consider it EVERY time we ADD, CHANGE or ELIMINATE a drug from our regimen.  Unfortunately, we are often the ones who end up reminding our doc that a dosage may need to be altered based on the total of our poly-pharmacy status.

Specifically…..

Laura, the CTP450 2C19 isoenzyme provides an ancillary pathway for the metabolism of tricyclic antidepressants (aka, your amitriptyline).  Since Provigil inhibits CTP450 2C19 there is a potential for it to slow down the metabolism of your amitriptyline and therefore increase its plasma level over time.  If you take Provigil your amitriptyline dosage may need to be decreased - but maybe not.  You and your doc just need to be aware of the possible need to rebalance.

Deb, I suspect Provigil actually increases your plasma level of propanolol.  This doesn’t mean you can’t take them together.  It does mean you needed to be monitored when you started the Provigil and need to be aware again if you change your dose or stop using Provigil.

Sorry all!!  I thought I could make this a short and sweet heads-up.  It was not to be I guess.  I needed a sit down activity but this one has consumed a huge hunk of time.  Sure hope it helps someone.

Medicating to treat multiple diseases or multiple symptoms of one disease (multiple sclerosis) is a multiple PIA (Pain In the - proverbial and always MH censored - A**).  Keep yourselves safe.

Mary

[twopack]

Sorry you're having such a hard go of things and I hope you get some potential solutions going at that appointment.

Antidepressants are sometimes a necessary and helpful therapy for treating MS symptoms.  They also tend to complicate other drug therapies because they have a high incidence of adverse interactions with other pharmaceuticals - very high.  Beta blockers are nearly as famous for risk of undesirable interactions but far fewer of them are classed as major.

You’ll definitely need to talk this over with a physician.  For what it’s worth, some PCP’s will require your neuro to prescribe a drug like Provigil (generic modafinil).  Your benefits provider may also be more inclined to cover the cost of certain drugs if a specialist prescribes and monitors them.

I doubt amantadine would be used with the amitriptyline as both drugs have anticholinergic properties.  You probably don’t want to risk a cumulative parasympathetic effect in your effort to battle fatigue.

I suspect one concern about adding Provigil to a beta blocker might be the possibility of an additional drop in your BP or a change (increase) in heart rate.  Your b-blocker and amitriptyline combo probably already potentiate each other but I assume you’re stable at your present doses.  It would certainly need to be considered by a physician who knows your personal health history and could monitor progress - adjusting doses when necessary.

You may want to consider supplementing with carnitine, an amino acid derivative that is important to energy production.  It is generally easily tolerated and some PwMS have found it helpful in their fight against fatigue.  Several carnitine compounds are available.  Acetyl-L-carnitine is usually considered the easiest to absorb and most efficient at crossing the blood-brain barrier (a plus for MS fatigue, imo).  I didn’t find it to be a quick fix but have seen definite improvement over time, especially when taken with alpha lipoic acid (a fatty acid antioxidant).

Of course any supplements you consider should also be discussed and approved by your treating physicians.  Dietary supplements help so much because they are powerful agents from nature and/or synthetic processes.  They can have the same potential for interactions as the drugs produced by pharmaceutical companies.  Hopefully your doc is familiar enough with supplements to know how to advise you.

I’m going to write up something separate about Provigil and why it has the potential to change the way many other drugs do their jobs in our bodies.  It is info that needs to stand alone.

You might be interested in taking a look at what Guitar_grrrl wrote today.  It isn’t specific for fatigue but she had lots of good info to share.  In case it gets lost in the recent post shuffle, go to >>>
http://www.medhelp.org/posts/Multiple-Sclerosis/Scientific-vs-Anecdotal-Evidence/show/1743062

[saucygrl]

My neuro prescribed Amantadine for me because my insurance won't pay for Provigil unless you've tried it first.  I've been really happy with it.  He prescribed the liquid so I could figure out what dosage worked best for me.  It tastes icky, but if I take a divided dose in the morning and afternoon it totally helps me get through the day.

Chris

[torikat32]

there is a drug called Amantadine they do use that for fatigue though my neuro doesnt prescribe it any more for that use she feels provigil  is the best

Kat

[Deb61]

I take propanolol and the generic Provigil which I've done for years.  The propanolol increases the Provigil in the blood.  I only take 100 mg. of Provigil.  I have tried other medicines for fatigue and they don't work for me.  I don't have any adverse effect and it actually makes me feel human.  Typically, the medicines used for attention deficit disorder or ADHD are used to combat fatigue.  

[SarahL2491]

darn, I took Inderal for years and provigil at the same time
go figure