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What Causes Episodes Of Extreme Agitation?
Question: Hello
I am suffering from episodes of extreme agitation. The episodes are so extreme they are like torture. They last for several hours at a time.
I believe the cause of the agitation is down to a side effect of clonidine and/or topiramate that I take. (I was until recently on 1.2mg/day of clonidine and 200mg topiramate.) Agitation is a side effect of both of the drugs, especially clonidine. (I would be interested to know if you agree with me that clonidine is most likely the cause of the agitation.)
What I would like is for you to please list for me some drugs that I could get prescribed by a UK GP / psychiatrist that I could take that would wipe out the extreme agitation when it strikes. For the drugs that you list please ensure that they would work instantly for extreme agitation (and not require weeks to be built up in system) and that they can’t cause dystonia because I had this problem with haloperidol and don’t want to go through the same thing again.
The drugs I have already tried are listed below:
Antidepressants: Mirtazapine, phenelzine, tranylcypromine, dosulepin, amitriptyline, citalopram, escitalopram, fluoxetine, sertraline, venlafaxine, lofepramine
Antipsychotics: Risperidone, olanzapine, quetiapine, aripiprazole, haloperidol
Benzodiazepines: Lorazepam, clonazepam, diazepam, alprazolam
Beta blockers: Propranolol
Anticonvulsants: Sodium valproate
Other: Buspirone
None of the above medications have helped in the past with the exception of the benzodiazepines, which I now have a tolerance to.
Also, I would like advice on how to come off topiramate. I currently am on 150mg. I wish to come off the drug as fast as possible but without incurring any of the severe withdrawal symptoms.
Many thanks
XXXXXXX XXXX
I am suffering from episodes of extreme agitation. The episodes are so extreme they are like torture. They last for several hours at a time.
I believe the cause of the agitation is down to a side effect of clonidine and/or topiramate that I take. (I was until recently on 1.2mg/day of clonidine and 200mg topiramate.) Agitation is a side effect of both of the drugs, especially clonidine. (I would be interested to know if you agree with me that clonidine is most likely the cause of the agitation.)
What I would like is for you to please list for me some drugs that I could get prescribed by a UK GP / psychiatrist that I could take that would wipe out the extreme agitation when it strikes. For the drugs that you list please ensure that they would work instantly for extreme agitation (and not require weeks to be built up in system) and that they can’t cause dystonia because I had this problem with haloperidol and don’t want to go through the same thing again.
The drugs I have already tried are listed below:
Antidepressants: Mirtazapine, phenelzine, tranylcypromine, dosulepin, amitriptyline, citalopram, escitalopram, fluoxetine, sertraline, venlafaxine, lofepramine
Antipsychotics: Risperidone, olanzapine, quetiapine, aripiprazole, haloperidol
Benzodiazepines: Lorazepam, clonazepam, diazepam, alprazolam
Beta blockers: Propranolol
Anticonvulsants: Sodium valproate
Other: Buspirone
None of the above medications have helped in the past with the exception of the benzodiazepines, which I now have a tolerance to.
Also, I would like advice on how to come off topiramate. I currently am on 150mg. I wish to come off the drug as fast as possible but without incurring any of the severe withdrawal symptoms.
Many thanks
XXXXXXX XXXX
Brief Answer:
Carbamazepine or Oxcarbamazepine should be considered
Detailed Answer:
Dear XXXXXXX
Thanks for using Icliniq.
I read your query with keen interest and understand your concerns about the episodic agitation.
First of all I may agree with clonidine causing agitation provided there is temporal relationship between onset of agitation and start/increase dose of clonidine.
If the agitation started long after build up of clonidine I do not think clonidine is likely cause for your agitation.
Regarding topiramate I am not convinced with idea of topiramate causing agitation. In my clinical experience most patients with topiramate feel calmer and there is little evidence of agitation caused by topiramate.
Now regarding the next course of action for agitation in future I must inform you that there is nothing called instant agitation controller. I agree that benzodiazepines, propranolol, typical (older) antispychotics cause some decrease in agitation but this occurs secondary to sedation rather than direct effect.
Considering the fact that you used almost all medications which have role in agitation control I feel mood stabilizers should be the next choice.
In my opinion oxcarmazepine, carbamzepine and lithium should be considered as next option along with propranolol in dose range of 120-160 mg per day.
Regarding topiramate I will request you to decrease the dose by 50 mg for the first week followed by 25 mg every week thus taking around five to six weeks.
I understand that you do not want to linger on while discontinuing but I think we need to act as per the available scientific data rather than creating our own rules for medications.
I hope this helps you.
If you have any further query, I would be glad to help you.
If not, you may close the discussion and if possible you may rate the answer for my future patients.
In future if you wish to contact me directly, you can use the below mentioned link:
http://doctor.healthcaremagic.com/doctors/dr-ashok-kumar/67386
Thanks and regards.
Carbamazepine or Oxcarbamazepine should be considered
Detailed Answer:
Dear XXXXXXX
Thanks for using Icliniq.
I read your query with keen interest and understand your concerns about the episodic agitation.
First of all I may agree with clonidine causing agitation provided there is temporal relationship between onset of agitation and start/increase dose of clonidine.
If the agitation started long after build up of clonidine I do not think clonidine is likely cause for your agitation.
Regarding topiramate I am not convinced with idea of topiramate causing agitation. In my clinical experience most patients with topiramate feel calmer and there is little evidence of agitation caused by topiramate.
Now regarding the next course of action for agitation in future I must inform you that there is nothing called instant agitation controller. I agree that benzodiazepines, propranolol, typical (older) antispychotics cause some decrease in agitation but this occurs secondary to sedation rather than direct effect.
Considering the fact that you used almost all medications which have role in agitation control I feel mood stabilizers should be the next choice.
In my opinion oxcarmazepine, carbamzepine and lithium should be considered as next option along with propranolol in dose range of 120-160 mg per day.
Regarding topiramate I will request you to decrease the dose by 50 mg for the first week followed by 25 mg every week thus taking around five to six weeks.
I understand that you do not want to linger on while discontinuing but I think we need to act as per the available scientific data rather than creating our own rules for medications.
I hope this helps you.
If you have any further query, I would be glad to help you.
If not, you may close the discussion and if possible you may rate the answer for my future patients.
In future if you wish to contact me directly, you can use the below mentioned link:
http://doctor.healthcaremagic.com/doctors/dr-ashok-kumar/67386
Thanks and regards.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hello
Thank you for your reply.
Please can you answer the following questions for me:
1. Can you name the typical antipsychotics that would be effective in treating extreme agitation instantly when in strikes?
2. Is there any other drug you can think of (excluding propranolol & benzodiazepines) that can be used to treat extreme agitation instantly when in strikes?
3. Have oxcarmazepine, carbamzepine and lithium all been proven to be effective in treating extreme agitation? And how long do each of the three medications would take to build up in your system to an effective level? And what dose of each medication do I need to take? And out of the three which one would you suggest has the best chance of being helpful to me?
4. How effective are divalproex and lithium in treating episodes of extreme agitation?
Thank you for your reply.
Please can you answer the following questions for me:
1. Can you name the typical antipsychotics that would be effective in treating extreme agitation instantly when in strikes?
2. Is there any other drug you can think of (excluding propranolol & benzodiazepines) that can be used to treat extreme agitation instantly when in strikes?
3. Have oxcarmazepine, carbamzepine and lithium all been proven to be effective in treating extreme agitation? And how long do each of the three medications would take to build up in your system to an effective level? And what dose of each medication do I need to take? And out of the three which one would you suggest has the best chance of being helpful to me?
4. How effective are divalproex and lithium in treating episodes of extreme agitation?
Brief Answer:
Follow up
Detailed Answer:
Dear XXXXXXX
Thanks for follow up.
Please find the answer to your questions
1. Haloperidol have the best evidence.
2. Injection Zyprexa have shown to be effective. Seroquel is another option from the same category.
3. Yes they are proven to be effective. Lithium takes around one week while the other two takes two weeks to be effective.
Regarding the dose it varies from person to person.In my clinical experience lithium helps in dose range of 900-1880 mg per day, Carbamazepine in dose range of 600-1200 mg per day and oxcarbamazepine 600-1500 mg per day.
I will prefer lithium as first choice.
4. They are quite effective. For divalproex the dose requirement is generally 1500 mg and more for a adult person.
I hope this assists you further.
Thanks and regards
Follow up
Detailed Answer:
Dear XXXXXXX
Thanks for follow up.
Please find the answer to your questions
1. Haloperidol have the best evidence.
2. Injection Zyprexa have shown to be effective. Seroquel is another option from the same category.
3. Yes they are proven to be effective. Lithium takes around one week while the other two takes two weeks to be effective.
Regarding the dose it varies from person to person.In my clinical experience lithium helps in dose range of 900-1880 mg per day, Carbamazepine in dose range of 600-1200 mg per day and oxcarbamazepine 600-1500 mg per day.
I will prefer lithium as first choice.
4. They are quite effective. For divalproex the dose requirement is generally 1500 mg and more for a adult person.
I hope this assists you further.
Thanks and regards
Above answer was peer-reviewed by :
Dr. Arnab Banerjee
Thank you for your reply.
Can you please answer the following questions:
1. Is there a typical antipsychotic that does not cause dystonia as a side effect (or at least is very low risk for causing it) that is proven to be effective in treating extreme agitation instantly? (The reason I came off haloperidol was because I developed dystonia.)
2. Is there a drug apart from propranolol, antipsychotics and benzodiazepines that is effective in treating extreme agitation instantly?
3. You mention taking olanzapine by injection is this simply because it acts quicker than taking it orally?
4. What injection dose of olanzapine would you take to control extreme agitation instantly? And the same question for seroquel?
5. If taking the dose of olanzapine orally, what dose would you take to control extreme agitation instanty? And the same question for seroquel? (Do you take a very large dose to control extreme agitation instantly?)
6. Would you recommend I try lithium before trying divalproex?
7. Is there any difference in terms of effectiveness in treating extreme agitation instantly between divalproex and epilim?
8. When I have been suffering from an episode of extreme agitation in the past and I have taken haloperidol, I did not notice any benefit, can you offer an explanation why this was?
Can you please answer the following questions:
1. Is there a typical antipsychotic that does not cause dystonia as a side effect (or at least is very low risk for causing it) that is proven to be effective in treating extreme agitation instantly? (The reason I came off haloperidol was because I developed dystonia.)
2. Is there a drug apart from propranolol, antipsychotics and benzodiazepines that is effective in treating extreme agitation instantly?
3. You mention taking olanzapine by injection is this simply because it acts quicker than taking it orally?
4. What injection dose of olanzapine would you take to control extreme agitation instantly? And the same question for seroquel?
5. If taking the dose of olanzapine orally, what dose would you take to control extreme agitation instanty? And the same question for seroquel? (Do you take a very large dose to control extreme agitation instantly?)
6. Would you recommend I try lithium before trying divalproex?
7. Is there any difference in terms of effectiveness in treating extreme agitation instantly between divalproex and epilim?
8. When I have been suffering from an episode of extreme agitation in the past and I have taken haloperidol, I did not notice any benefit, can you offer an explanation why this was?
Brief Answer:
Follow up
Detailed Answer:
Dear XXXXXXX
Thanks for having thoughtful questions.
My answer to your questions are as follows
1. There is none. Although Olanzapine have very low chance.
2. Mood stabilizers but not for instant action.
3. Yes it is true
4. 10 mg. I do not think seroquel have injectable form and largely not useful for extreme agitation. There are some trials of 200 mg with mixed results.
5. Not applicable
6. Yes. I think I communicated about it in last answer.
7. Not much. They are simply same molecules in terms of effectiveness.
8. No medicine is effective for 100% population. There are various factors in causation of agitation and same is applicable for effect or no effect of medication.
I hope this answers you.
Thanks again.
Follow up
Detailed Answer:
Dear XXXXXXX
Thanks for having thoughtful questions.
My answer to your questions are as follows
1. There is none. Although Olanzapine have very low chance.
2. Mood stabilizers but not for instant action.
3. Yes it is true
4. 10 mg. I do not think seroquel have injectable form and largely not useful for extreme agitation. There are some trials of 200 mg with mixed results.
5. Not applicable
6. Yes. I think I communicated about it in last answer.
7. Not much. They are simply same molecules in terms of effectiveness.
8. No medicine is effective for 100% population. There are various factors in causation of agitation and same is applicable for effect or no effect of medication.
I hope this answers you.
Thanks again.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you for your reply.
For your answer to question five you wrote "Not applicable", are you saying that an oral dose of olanzapine would be ineffective for controlling extreme agitation instantly?
I have already tried olanzapine orally in the past and found it did not help me with my agitation when it was at a constant low-level, could it be effective at controlling it instantly when it's at its worst (when it's extreme)?
Does the fact that I would be taking olanzapine 10mg via injection rather than orally make a difference to whether the drug works on me or not?
Does the fact that haloperidol did not help me with my agitation mean that for controlling extreme agitation instantly, all typical antipsychotics are unlikely to be effective on me?
Would you recommend I try one of the barbiturate type medications to control my extreme agitation instantly when it next strikes?
What is your opinion of the following medications for controlling extreme agitation instantly when it strikes: Meprobamate, Promethazine and Phenobarbital? Would you recommend I try any of these? And if so in what order of preference and at what doses?
For your answer to question five you wrote "Not applicable", are you saying that an oral dose of olanzapine would be ineffective for controlling extreme agitation instantly?
I have already tried olanzapine orally in the past and found it did not help me with my agitation when it was at a constant low-level, could it be effective at controlling it instantly when it's at its worst (when it's extreme)?
Does the fact that I would be taking olanzapine 10mg via injection rather than orally make a difference to whether the drug works on me or not?
Does the fact that haloperidol did not help me with my agitation mean that for controlling extreme agitation instantly, all typical antipsychotics are unlikely to be effective on me?
Would you recommend I try one of the barbiturate type medications to control my extreme agitation instantly when it next strikes?
What is your opinion of the following medications for controlling extreme agitation instantly when it strikes: Meprobamate, Promethazine and Phenobarbital? Would you recommend I try any of these? And if so in what order of preference and at what doses?
Brief Answer:
Follow up
Detailed Answer:
Dear XXXXXXX
Thanks for follow up.
Yes. You interpreted it right.
The odds of action still remains there. Not all agitations stem from same pathology and it is possible that you may respond in future.
As stated in my first answer the help in agitation is delivered by other effects like sedation and that is the reason injection may be helpful despite the fact oral did not work for you.
It does not hold true. There is nothing called cross resistance among antipsychotics.
I never recommend barbiturates other than the seizures. I will prefer benzos over barbiturates.
Promethazine could be a option but that too along with haloperidol. I am sure that it will not be sufficient to act alone in case of extreme agitation.
I hope this answers you further.
If you have any further query, I would be glad to help you.
In future if you wish to ask any more questions , you can use the below mentioned link to contact me.
http://doctor.healthcaremagic.com/doctors/dr-ashok-kumar/67386
Thanks and regards.
Follow up
Detailed Answer:
Dear XXXXXXX
Thanks for follow up.
Yes. You interpreted it right.
The odds of action still remains there. Not all agitations stem from same pathology and it is possible that you may respond in future.
As stated in my first answer the help in agitation is delivered by other effects like sedation and that is the reason injection may be helpful despite the fact oral did not work for you.
It does not hold true. There is nothing called cross resistance among antipsychotics.
I never recommend barbiturates other than the seizures. I will prefer benzos over barbiturates.
Promethazine could be a option but that too along with haloperidol. I am sure that it will not be sufficient to act alone in case of extreme agitation.
I hope this answers you further.
If you have any further query, I would be glad to help you.
In future if you wish to ask any more questions , you can use the below mentioned link to contact me.
http://doctor.healthcaremagic.com/doctors/dr-ashok-kumar/67386
Thanks and regards.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you for your reply.
I did not understand this sentence: "The odds of action still remains there. Not all agitations stem from same pathology and it is possible that you may respond in future." Could you please explain what you are trying to say in a different way?
Do barbiturates cause loss of inihibitons and memory loss in the same way that benzodiazepines do? And if you have a tolerance to benzodiazepines will barbiturates work on you?
Is there any antihistamine that would provide a strong enough sedative effect that it would effective by itself to treat extreme agitation instantly?
Would any of these medications be effective in treating extreme agitation instantly: Meprobamate, Chloral hydrate and Sodium oxybate? And are these medications still prescribed now?
I did not understand this sentence: "The odds of action still remains there. Not all agitations stem from same pathology and it is possible that you may respond in future." Could you please explain what you are trying to say in a different way?
Do barbiturates cause loss of inihibitons and memory loss in the same way that benzodiazepines do? And if you have a tolerance to benzodiazepines will barbiturates work on you?
Is there any antihistamine that would provide a strong enough sedative effect that it would effective by itself to treat extreme agitation instantly?
Would any of these medications be effective in treating extreme agitation instantly: Meprobamate, Chloral hydrate and Sodium oxybate? And are these medications still prescribed now?
Brief Answer:
Follow up
Detailed Answer:
Dear XXXXXXX
I mean to say that the chance of effect are always there despite multiple failures in fast. This happens because agitation is contributed by multiple factors and you never know when a medicine can show its effectiveness.
Barbiturates aremore prone to cause memory loss and inhibitions in compare to benzos.
Yes they will act as the mechanism of action and receptors for them (barbiturates and benzos) are completely different.
Diphenhydramine and promethazine are one but again short of clear anti agitation effects.
I have no experience with these three medicines and not available in my home country where I practice. I am sure that you need practical knowledge as theoretical knowledge is available everywhere.
Thanks again.
Follow up
Detailed Answer:
Dear XXXXXXX
I mean to say that the chance of effect are always there despite multiple failures in fast. This happens because agitation is contributed by multiple factors and you never know when a medicine can show its effectiveness.
Barbiturates aremore prone to cause memory loss and inhibitions in compare to benzos.
Yes they will act as the mechanism of action and receptors for them (barbiturates and benzos) are completely different.
Diphenhydramine and promethazine are one but again short of clear anti agitation effects.
I have no experience with these three medicines and not available in my home country where I practice. I am sure that you need practical knowledge as theoretical knowledge is available everywhere.
Thanks again.
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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