Using Xanax and Klonopin–is that safe???

It’s nice when things go smoothly, isn’t it . . . Now, personally, I can’t remember a time when things DID go smoothly.  It always seems that something is cropping up and disturbing the day.  Stress from home.  Stress from work.  The kids.  Traffic.  And then . . . once again, you are in panic mode and you have to get yourself back to baseline before being able to take on even the mundane tasks of life. . . and I don’t have a panic disorder!!!  For those of you who DO suffer with ongoing anxiety symptoms and intrusive panic attacks, even mild increases in stress (or sometimes no stress at all) can bring about dramatic and crippling anxiety symptoms.

My hope when I treat anxiety is to take the anxiety away.  I’m not aiming for numb and sedated.  Just not overwhelmed with anxiety.  Klonopin, as many of you know, is one common tool used to address this and, when it works well, is great.  It can prevent the onset of anxiety and keep you moving along in your day getting done what needs to get done.  As the old saying goes, “an ounce of prevention is worth a pound of cure”.  But those of you who struggle with anxiety know that breakthrough anxiety is just all too common. So, what is the best way to address it?

Of course, the best, when possible, is to use one of the antidepressants that work on anxiety.  These tend to be effective, are non-addictive and have fewer sedating side effects.  They are not without their problems, however.  I have covered that sufficiently in other blarticles so I won’t cover that here.  I will suppose that either the antidepressants don’t work well enough or you don’t tolerate them.  The use of Klonopin in these cases can be very helpful.  When breakthrough anxiety occurs, there are several different approaches.  Whenever possible, I use higher doses of Klonopin.  Again, this goes back to the “ounce of prevention” statement made above.  But there are limits here.  Sometimes, you go up on the Klonopin and all you get is tired and fuzzy.  Sometimes, even going up does not seem to capture the breakthrough.  In these cases, use of a rescue medicine can be very, very, VERY helpful.  In years past, I tried to avoid the use of Xanax for breakthrough anxiety because of it’s higher abuse potential.  My patients have found Ativan (another short acting benzo) not as helpful, however, leading me back to using Xanax.  It has a very quick onset of action, so relief comes quickly.  It tends to provide relief without making you overly sedated.  It is short acting so that the side effects that do occur do not hang around for a long time.

There are no studies showing that use of different agents in this benzodiazepine class can be used together safely.  They have been widely used in combination for many years without evidence of difficulty, so it has become a standard of practice.  It is important to be cautious about the potential for sedation.   Xanax will be more sedating when used in combination with Klonopin compared with use of Xanax alone.  Caution should be exercised, especially when you are tired or when you are first using the combination together.

As always, you should not take more Xanax or Klonopin than you are prescribed.  You should never combine them with alcohol, and you should contact your doctor if you continue to have breakthrough anxiety. 

–Dan Hartman, MD

Meridia and antidepressants–Part I and Part II

PART I 

Last week a patient came in with question regarding the use of antidepressants while taking the weight loss drug Meridia.  Seems her family doc took her off the two antidepressants I had her on to treat her depression (Lexapro and Wellbutrin if my memory serves me), and gave her Meridia to treat her weight issue.  While somewhat overweight, this lady was far from obese, so I would not consider this change an emergency.  My patient’s question was . . . “can I still take something to treat my depression?”

In a word . . . “NO”.

At least not with standard antidepressants.  The reason boils down to the mechanism of action.  Frequent fliers on this site will remember that all of the antidepressants increase the levels of one or more of the main neurotransmitters involved in mood.  This includes serotonin, norepinephrine and dopamine.  Most of the antidepressants do this by re-uptake inhibition.  Re-uptake inhibition is the process of blocking the main recycling pathway the body uses to conserve the neurotransmitters after firing them off from one nerve cell to another. Well, it turns out that the mechanism of action of Meridia is also re-uptake inhibition of these neurotranmitters.  Not only does it block re-uptake, it blocks re-uptake of all three neurotransmitters (tho’ the re-uptake of dopamine is much less than that of serotonin and norepinephrine).  The risk here is that the combination of multiple medications that increase serotonin levels puts a patient at risk of something called Serotonin Syndrome which is a potentially deadly physiologic reaction to an over-abundance of serotonin in the brain (look for that in another blarticle).  A reasonable question here is whether or not Meridia can function as an antidepressant since it has a similar mechanism of action as the antidepressants.  My patient certainly did not get profoundly depressed when switched over to Meridia.  By my reading of the information on it, however, there does not seem to be clinical studies showing either benefits or lack of benefits.  The jury is still out.  I suspect that there are studies going on somewhere about this.  Especially since any medication that acts on all three neurotransmitters is like the “Holy Grail” of psychopharmacology . . . a medicine that is triple action (remember Cymbalta’s big claim to fame is that it acts on two receptor systems–norepi and serotonin).

So, for now Ms. H, if you choose to stay on Meridia, you cannot take antidepressants.  We will just have to keep an eye on you and balance the benefits you get from it with the pattern of your mood symptoms which may or may not get worse.

PART II

How unreasonable is it for me to expect that I am consulted or at least INFORMED when another physician changes the medicine I have prescribed for a serious and potentially deadly illness (Major Depression)? My patient has had a very difficult year with a variety of significant stresses.  Her mood disorder is long-standing and has, at times, been quite serious.  The family doc in question did not call and consult me nor inform me that the medication that I thought quite important to this patient was being stopped.  If I went around adjusting medication for blood pressure of diabetes without letting the prescribing physician know, I would be called on the carpet and flogged (figuratively, of course).  Now, I am hopeful that all will go well.  If things do not go well, how much responsibility will this doc take? 

My message to all reading this is as follows:  If you are receiving treatment for a condition by a specialist, make sure that your family doctor communicates with the specialist if he or she makes changes to the medicine prescribed by the specialist.  This is especially true when dramatic changes take place (like stopping a medicine).  There is a reason you are going to a specialist and there is a reason the specialist is a specialist . . . certain conditions are intrinsically more difficult to manage and the input of a specialist can be vitally important.  To take them out of the loop when decisions are being made is to potentially put you at greater risk.

Rant and rave over . . . have a good day.

–Dan Hartman, MD

Teddy–a tribute to someone I didn’t really know but wish I did

I met Teddy earlier this year when our kids were involved in an activity together.  As in most activities like this, the kids do and the adults watch . . . but not Ted.  He was right there, and I mean RIGHT THERE.  As close as he could get to being right with the kids, his arms up yelling, making a HUGE fuss about his kid and giving a high-five to everyone he could after it was done.  I’m all for cheering for your kid, but this was over the top . . . to the point where he had to be talked to and told to keep it down, move to the side, etc.  Over the next few months, I had other brief contacts with him, mostly at these events.  He continued to be loud and boisterous in his cheering (you could always tell where he was during an event), but he did moderate somewhat after the first “talking to”.  I was more a witness to conversations with him than actually in conversations with him.  Even in everyday life he seemed over the top and too intense (tho’ always in a pleasant and happy way). 

Teddy was hit by a car last week as he crossed the Boulevard on his way to pick up his son from practice.  He made sure someone took care of his dog (who always accompanied him in his backpack), lapsed into a coma, and never regained consciousness.

We went to the Funeral Mass last Friday and I was, once again, reminded how superficial my casual interpretations of others can be at times.   The receiving line for Teddy’s family stretched to the front door of the church.  Along the way down the aisle, the family had constructed posters with pictures showing snap-shots of Ted’s life from his earliest days to the present.  Proud moments as a kid, summers down the shore, the births of his children, moments with family and  friends . . . a full and rich life marked not so much by grand achievement and monetary gain as by . . . love.  The brief moments I spent with him and observing him did not capture the complexity and depth of this man’s life.  Despite his tendency to make “mistakes” in what he did and what he said, this was a man who touched people’s lives in a good and positive way.  From the way he went out of his way to help others, his skill as a cabinet maker, his over-the-top devotion to his kids, his clear enjoyment of others.  Ted brough a sense of festivity to casual conversation.  And those mistakes?  From what I learned, he was quite willing to admit them, apologize for them, and move on.  He had a humble understanding of himself and seemed to have accepted himself more than most of us have.  And, it seems, he accepted us, too, more than we accepted him for who he was.

My ”knowing” of Teddy was superficial at best.  My understanding of him since the celebration of his life last Friday is much greater.  I will miss him at the next show.  I will think of him . . . often I hope.  For with every thought of him, I smile.  And wish that, in some ways, I could be a bit more like him.

Rest in peace, good man.

–Dan Hartman, MD