akathisia driving me crazy

[doctordog]

I've had akathisia for the last 2 weeks since stopping a low-dose of Mirtazapine (~3mg per night). I have constant headaches because my jaw is so stiff, my legs are restless, and I haven't been able to sit still long enough to watch a half-hour TV show during that entire period. The only way I'm coping is by staying on the move and annoying everyone in my household.

Melatonin helps (but can only be taken before bed, obviously), Vitamin E helps a little. Antihistamines stop the inner tension, but replace it with a different kind of anxiety.

Propranolol (20mg) cuts out the anxiety so I can sit for a while, but doesn't eliminate the inner tension/discomfort.

My GP didn't actually believe I had akathisia because I wasn't writhing around, even though I explained to him that I'd taken 20mg of propanolol just so that I could drive over to see him -- he's kind of a moron (also sent me home after I'd been vomiting for 8 hours straight and basically crawled into his office because I was so weak from hypoglycemia; I was later hospitalized that afternoon).

Anyway, he did give me Cogentin (0.5mg) a day .. I was told it can take several days to work .. today is day#3 and I do notice the inner tension lessens after I take it, but the Cogentin seems to be stimulating in and of itself .. I get tachycardia, become more ruminative/obsessive and kind of scatterbrained. I read it's a DRI, so that would make sense.

Clonidine helps the akathisia too, but I find that drug stimulates me as well.

I'll probably be finding a new GP next week, so any ideas?

 

[gingerbaker]

Well shit, I was going to recommend an anti-cholinergic like Cogentin or something like Clonidine... I'm curious what you mean by stimulation (regarding clonidine). Is it the same sympathetic stimulation (because that would seem paradoxical, but obviously not impossible)?

If you don't find benadryl to be too stimulating you could try that since it has some anticholinergic properties to it. I know you said they give you some anxiety but maybe that's the most comfortable compromise you could find. Also, I'm pretty sure DXM also has some weak anticholinergic effects too.

Good luck man, I've had that before from Seroquel and that shit is beyond uncomfortable. Benzos might help make you more comfortable and less anxious at least :/

 

[doctordog]

Umm, maybe it's more of a rebound effect with clonidine actually .. I'd use it for insomnia and noticed I was always more revved up the next day. When I first take clonidine, it's a miracle for anxiety for about a day or two, then tolerance will set in to the sedative properties and it starts behaving weirdly. I've read it can be a bit weird in terms of receptor affinity and some people do get stimulated from it .. it did get worse the higher in dose I went, and started to induce rage above 0.2mg.

Since I wouldn't be using it for sleep though, maybe I could get away with just staying on a lower dose like 0.05mg.

I can't find diphenhydramine in Australia .. they've removed it from the OTC benadryl syrup I believe. Maybe I'll look for DXM.

Benzos give me paradoxical anxiety unfortunately (I know, I'm quite the disaster case..)

I wonder if a higher dose of a beta-blocker would work ..

 

[gingerbaker]

Ohhh, well that definitely makes much more sense (it's common). I always was taking it TID (.2mg po TID) so I can't comment on rebound anxiety the following day, but I did notice rebound effects starting around 12-18hrs after my last dose. I honestly would recommend clonidine over a β-blocker. If you have enough to last, you might as well take that twice a day (.05-.1mg each dose) because that will definitely help with your symptoms and won't interfere with the nature of withdrawal (ie. it won't prolong your W/Ds or result in protracted symptoms from Mirtazapine).

I always am surprised at countries that have diphen as a Rx only substance since it is in practically everything here in the states. I'm not even sure what other anti-histamines have as much anti-cholinergic activity but I'm guessing 2nd gens don't as much as other 1st gens.

 

[doctordog]

I actually ran out of clonidine a while ago, so unfortunately can't take any right now ..

do you happen to know much about Cogentin, i.e. at what point it should kick in? there's something slightly physically calming about it, but it just isn't nailing the restlessness .. I might try raise the dose on Monday and if that doesn't work go see a GP about clonidine or something.

 

[gingerbaker]

What do you mean what point it should kick in? Dose would depend on the individual (especially with you lol, no offense). Usually 1hr was around the time when I felt the dose really starting to have an effect.

Dosing-wise I would use about .5mg to 1mg depending on if it was time to sleep or not.

 

[doctordog]

Sorry, are you referring to Clonidine or Cogentin there?

I mean with Cogentin .. when should it start to help akathisia .. a pharmacist said it could take several days to help, though I don't really understand why.

 

[gingerbaker]

I had a doctor prescribe it for the exact same thing and he told me it would help with the akathisia (and other symtoms) "within an couple hours".

 

[paranoid android]

I would suggest finding a better doctor for starters cause this one seems like the type that does more harm then good. I have never known anyone to get akathesia from withdrawal of mirtazapine but i know people that have gotten it from anti-psychotic treatment. Abit of lorazepam and some gabapentin stopped it for a friend of mine who had bad akathesia from haldol.

Benzotropine is basically a strong anti-cholinergic with dopamine reuptake inhibitor properties and is often prescribed right along anti-psychotics to stop the movement disorders caused by anti-psychotics. I would honestly say go see a different doctor. As for clonidine abrupt withdrawal from that can cause life threatening hypertension and i'm sure restlessness would also be a side effect.

 

[88dood88]

Magnesium is great for muscle clenching and restless legs. I was mirtazapine for awhile and I remember the first time I took it the restless legs were unbearable, when starting the medication and stopping. Magnesium ended that very quickly though.

 

[doctordog]

I would suggest finding a better doctor for starters cause this one seems like the type that does more harm then good. I have never known anyone to get akathesia from withdrawal of mirtazapine but i know people that have gotten it from anti-psychotic treatment. Abit of lorazepam and some gabapentin stopped it for a friend of mine who had bad akathesia from haldol.

Yeah, he sees like a million patients a day, so maybe just doesn't have the time to attend to things properly. You have bulk-billing (free) doctors here and private ones .. the bulk-billing ones generally try cram patients in. I guess I'll just bite the bullet and pay to see a decent one.

I can't come across anything regarding Mirtazapine withdrawal and akathisia, but it is recommended as a treatment for akathisia, so maybe not impossible that it could cause it upon cessation.

Benzotropine is basically a strong anti-cholinergic with dopamine reuptake inhibitor properties and is often prescribed right along anti-psychotics to stop the movement disorders caused by anti-psychotics. I would honestly say go see a different doctor. As for clonidine abrupt withdrawal from that can cause life threatening hypertension and i'm sure restlessness would also be a side effect.

Yeah, I guess blood levels haven't stabilized, but the benzotropine is making me feel more activated each day; I was totally wired until 3am last night and caved and took some Doxylamine. I'm actually finding a higher dose of Vitamin E (500IU twice a day) to have a good effect, so maybe if I just keep taking that and wait it out it'll get better. I'll see how things are in a day or two, and then go see a decent GP next week.

 

[doctordog]

Magnesium is great for muscle clenching and restless legs. I was mirtazapine for awhile and I remember the first time I took it the restless legs were unbearable, when starting the medication and stopping. Magnesium ended that very quickly though.

Unfortunately, magnesium stimulates me and messes with my sleep -- I think it's an NMDA antagonist and they all tend to have that effect on me.

 

[paranoid android]

The benzotropine could be doing more harm then good at this point. Not to mention that akathesia caused by mirtazapine withdrawal may not be through the same mechanisms as anti-psychotic treatment at all.

 

[doctordog]

The benzotropine could be doing more harm then good at this point.

Out of curiosity, what makes you say that? The reason I ask is because I read benzotropine is a DRI at 'nerve terminals', though wasn't sure if that meant it had psychoactive properties as well ..

Anyway, it *does* clear up the akathisia to some extent and I will feel calmer for about 3-4 hours after taking it. But it's also causing insomnia, worsened stereotypy (I have OCD and e.g. can't pull myself away from the internet .. I'm also picking my scalp more), my ruminations are more intense, I have mild tachycardia and the akathisia is replaced by a different kind of overstimulation. It's not as intense as like an NRI, but I definitely feel something.. and I guess I'd take this over akathisia ..

I wish I could just use klonopin or something temporarily .. life would be so much easier if I could tolerate benzos.

 

[paranoid android]

Akathesia and restlessness in general is a common side effect of anti-cholinergics so yeah it does have a potential to make things worse.

 

[doctordog]

I think it's dose-dependent.. Benadryl in low-doses can help akathisia, but higher doses will exacerbate the problem. The Cogentin dose is low (0.5mg a day), but I do tend to be sensitive to medications.

I've made an appointment to see a new doctor at a private practice, so hopefully they can help .. it'll cost more, but the standard of care is probably higher. Is there anything you'd recommend I ask about? All I can think of is a beta-blocker other than propranolol (too depressive). Is it possible an alpha-1 antagonist like Prazosin could help?

 

[Intenselife]

What exactly do you mean by if i could "tolerate benzos"? As in do you find them too strong? Because having a prescription of a small amount of benzos at a low dose can help you, if your symptoms are that bad especially.

I would say like a 0.5 of ativan as needed with just a small quantity, would help you out a lot with your symptoms. It also would help with your constant thinking, racing thoughts, and overstimulation aka your anxiety. That is the best cure i'd recommend, but just as you need it and only for a weeks till your withdrawal subsides, it will feel like the best cure and isn't as hard to get as some other benzos, or isn't as hard to tolerate. Even 5mg valium as needed might be a good one too.

 

[doctordog]

What exactly do you mean by if i could "tolerate benzos"? As in do you find them too strong? Because having a prescription of a small amount of benzos at a low dose can help you, if your symptoms are that bad especially.

I would say like a 0.5 of ativan as needed with just a small quantity, would help you out a lot with your symptoms. It also would help with your constant thinking, racing thoughts, and overstimulation aka your anxiety. That is the best cure i'd recommend, but just as you need it and only for a weeks till your withdrawal subsides, it will feel like the best cure and isn't as hard to get as some other benzos, or isn't as hard to tolerate. Even 5mg valium as needed might be a good one too.

No, I react paradoxically to benzodiazepines, unfortunately.. they make me more anxious, agitated and revved up. I've tried Ativan, Xanax, Clonazepam and Valium and my reaction was the same. I think I read somewhere that Oxazepam may be less likely to produce paradoxical reactions, but I'm not sure.

 

[paranoid android]

^ I would suggest trying a hypnotic benzo such as temazepam or nitrazepam. I have seen very few paradoxical reactions from either.

 

[doctordog]

Yeah, I think Temazepam was fine, and I don't react paradoxically to Ambien (though it makes me hallucinate, which I enjoy).

I presume what I was experiencing is something similar to this -- http://www.ncbi.nlm.nih.gov/pubmed/9031996 -- since Mirtazapine is also an anti-serotonergic.

The doctor I saw seemed a little confused by the whole thing and I wasn't in a good state due to barely sleeping the past few nights, but she suggested I discontinue the Cogentin and see how things are; I asked if I could have a beta-blocker script in case it returns and she gave me Atenolol, though looking now it seems that the lipid-base beta-blockers are best, which Atenolol isn't.