Dr. Ashok Kumar
Geriatrics
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
I am taking tablets Escitalopram 10 mg and Flupentixol 5 mg for stress. Flupentixol relieves stress, but makes me sleep ten hours daily. I feel dull and tired if I do not take the tablet. It is affecting my professional and family commitments. Please help me.
Hello,
Welcome to icliniq.com.
I suggest you reduce the dose of the tablet Flupentixol to 0.5 mg. The reduction of dose may bring some dullness, but there is a good possibility that it will go away in a few days. If that does not help, I suggest you take the tablet Lorazepam 1 mg or Clonazepam 0.5 mg (consult a specialist doctor, discuss with them, and take medications with their consent).
Patient's Query
Thank you doctor for the reply,
Reducing the dose of the tablet Flupentixol to 0.25 mg has helped me with sedation in the past. However, I feel anxious for no reason. The tablet Escitalopram 15 mg also did not help me. Escitalopram and Flupentixol is a wonderful therapy for me. My treating doctor does not want me to take Benzodiapenes. Is there any other augmentation agent or combination therapy that can help me?
Hello,
Welcome back to icliniq.com.
I suggest you reduce the dose of the tablet Flupentixol to 0.375 mg or take the tablet Escitalopram with Fluoxetine which has a similar mechanism of action and does not cause sedation in most patients (consult a specialist doctor, discuss with them and take medications with their consent).
Patient's Query
Thank you doctor for the reply,
When I presented my stress and anxiety to my current psychiatrist three years ago, I was put on Escitalopram 10 mg. Later the dosage of Escitalopram was hiked to 15 mg. So, Flupentixol 5mg was added, and the stress subsided. Later I was put on Escitalopram 10mg and Flupentixol 5 mg. Even though I got relief from anxiety, I slept for ten hours daily. When the problem of low motivation became unbearable, I consulted my psychiatrist. The problem of stress came back. I silently suffered this for many months as I was under the impression that there was no other replacement medicine for Flupentixol and worried about side effects. Two months back, I again went to my psychiatrist, and he put me on Escitalopram 10 mg daily. As of now, I have this oversleeping problem. I must mention that I do not have to wait for two to four weeks to get relief. Escitalopram and Flupentixol combination gives me relief the same day itself.
Can I replace the tablet Flupentixol 5 mg with Buspirone? Is Escitalopram 10 mg and Buspirone 10 mg a good option for long-term treatment? What about the side effects of Buspirone? Can I take the tablet Flupentixol 25 mg and Buspirone 5 mg? What about atypical antipsychotics? Can you recommend a good augmentation agent on which I can stay for the long term?
Hello,
Welcome back to icliniq.com.
Regarding your first question, my answer would be no, because the tablet Buspirone is completely different from Flupentixol and does not have any matching. Buspirone is exclusively an anti-anxiety medication and has no role in sleep and other things. In addition, Buspirone needs to be taken three times a day. I do not think that will be easy for you. My experience with the use of Buspirone is not much positive. Regarding the second question, I feel the answer remains the same. Buspirone is unlikely to target depressive symptoms such as low motivation and increased sleep due to the use of Flupentixol. Regarding your third question, I feel they can be used as a replacement for Flupentixol.
Patient's Query
Thank you doctor for the reply,
What is your opinion on Benzodiazepines such as Clonazepam 5 mg as adjunctive therapy and escitalopram 10 mg? Can it be used in the long term? What are its side effects if it is used in the long term? Does it cause cognitive issues and sedation? I read about a supplement called Lithium orotate 5 mg. Is it of any use?
Hello,
Welcome back to icliniq.com.
Benzodiazepines are excellent options for the short term but not a good choice for the long term. There is a good chance of developing tolerance and dependence after using Clonazepam. The list of side effects is lengthy, but dependence and loss of effect after years of use result in dose increase. I never used this molecule, and the existing literature does not support the claims made by various persons.
Patient's Query
Thank you doctor for the reply,
I was just curious about the medications and my medical condition. Which one is better for stress, Risperidone or Flupentixol? Does treatment-resistant depression or stress mean an overactive dopaminergic and serotoninergic system? Is it true that SSRIs and atypical anti-psychotics are most commonly used for treating anxiety? Is there a chance that my condition will get better over the years and I can come out of this situation?
Hello,
Welcome back to icliniq.com.
Both are equally effective as per the available data. In other words, the response varies from patient to patient, and any of them may be superior or inferior to the other. There is also a chance that both may have the same response for a person. Even depression means the same. There is a disturbance in the dopamine and serotonin neurotransmitter system. Treatment-resistant means at least two modalities(different medications used for adequate time) failed to yield response for the person. It is not applicable to you as the first modality had some response. Yes, it is true. If a single medication is not helping properly, then we need to add something and low-dose antipsychotics are the most common additions. The response depends on the patient for the individual patient, and statistically speaking, the response is the same for the population.
Patient's Query
Thank you doctor for the reply,
Is the sedation due to anti-psychotics antagonism at off-targets? Is it true that I am sensitive to sedation, and almost everyone does not feel sedation at low doses? What is your opinion on Lithium carbonate as an augmentation agent with Escitalopram 10 mg? What is your opinion on Oxcarbazepine as an augmentation agent with Escitalopram 10 mg?
Hello,
Welcome back to icloniq.com.
Mostly it is due to the antagonism of cholinergic and histaminergic targets. Newer antipsychotics have fewer chances of causing sedation compared to the old ones. Risperidone 0.5 mg or Aripiprazole 2 mg can be a good substitute for Flupentixol. However, response varies from person to person and can not be generalized. Therefore, I do not feel your symptom profile will be targeted with the addition of lithium.
Patient's Query
Thank you doctor for the reply,
May I know your opinion on Duloxetine for stress or anxiety? Can I stay on it for the long term? May I know the general duration of Nexito 10 mg and Clonazepam 5 mg for which a person can stay without dependence? May I know the basic mechanism of action of tricyclic antidepressants? Are the antagonism actions of tricyclic antidepressants off target, which cause side effects? I understand that there are different kinds of anxiety. May I know the kind of anxiety that I have?
Hello,
Welcome back to icliniq.com.
Duloxetine has equal potential to Nexito and can be used as an alternative. However, response varies from individual to individual, and we must wait for a response. If the dose remains the same, the chance of addiction is very low. If there is decreased response over time (common with benzodiazepines), the risk is high for addiction. Addiction has been reported even after a few months of use, and on the other side, addiction did not develop after years of use. So, the duration varies from person to person. Generally, it takes a few months. They inhibit the reuptake of serotonin and norepinephrine, leading to increased levels for both neurotransmitters.
Patient's Query
Thank you doctor for the reply,
Duloxetine has reuptake inhibition at serotonin and norepinephrine receptors. Does that mean it is more effective than Escitalopram for stress and anxiety? Is it possible to add a third agent to the tablet Escitalopram 10 mg and Flupentixol 25 mg so that I do not get sedation? Atypical anti-psychotics have antagonism at some serotonin and dopamine receptors, whereas SSRIs increase the amount of serotonin at the synaptic cleft with augmentation therapy. Does that mean that there are different types of receptors for serotonin and a combination of reuptake at some serotoninergic receptors and antagonism at some serotoninergic receptors brings mood stabilization?
Hello,
Welcome back to icliniq.com.
Duloxetine has a dual mechanism, but it is similarly effective to Escitalopram. However, this is population data and does not mean anything to the individual patient. Yes, there are different types of serotonin receptors, and antidepressants do not oppose the action of others.
Patient's Query
Thank you doctor for the reply,
Escitalopram 20 mg has not made me sleepy in the past, but my libido has become very low. We are trying for a baby. I have tested my semen sample and found that it is healthy. If I start taking the tablet Escitalopram 20 mg, will it affect sperm quality? May I know your thought and what the medical literature say?
Hello,
Welcome back to icliniq.com.
There is no harm in trying Escitalopram 20 mg because the effective dose of Escitalopram is 10 to 20 mg, and the effective dose in your case may be 15 mg or 20 mg. I am also not convinced about decreasing the dose of Escitalopram to 10 mg immediately after stabilization as it takes time to stabilize the neurotransmitter. As per the available literature, no adverse effect on semen quality was noted.
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