Cange from Cetavol (nortriptyline) to Tripta (amitryptyline)

[digital]

(As a follow on from my orignal posts starting back in June starting with perinium pain, then being diagnosed with kidney stones.. the random pains I had contined to a lesser degree,  but I was having very frequent very loose bowel movements, several a day often close together, some weight loss, the rectal discomfort comes and goes, but the pain was now mostly in my left side, although did change sometimes).

 

I eventually went to see a GI specialst as the symptoms were not improving and was diagnosed with IBS, (had stool examination check was clear, had ultrasound twice checking whole abdomen). I am still thinking this still all has something to do with the Cipro antibiotic I took as I had none of these problems before and my Dr also says this may have been the trigger, he did say he thought this would be only a short term problem, although not getting worse it is mostly controlled with the medications altough there has never been a day without any kind of pain or symptom even if mild).

 

19 Aug I was prescribed Dicetel (bowel anti spasmodic) x 3 daily, Cetavol (nortriptyline 10mg  + fluphenazine0.5mg) x 2 daily, Bioflor (probiotic) x2 daily, Rivotril (clonaepam 2mg) x 1 nightly, this reduced my symptoms very quickly.

 

A week later the Dr cut the dose down to Dicetal x2 daily, Cetavol x 1 daily, Rivotril half pill daily. Stopped Bioflor. (but I still drink a probiotic yogurt drink daily).

 

Since then I have been mostly ok, but it has not completely cleared, a few times I increased the Dicetel to 3 x daily for a couple of days when the pain was worse, a few times I tried cutting teh Dicetel  down for a few days but symptoms started to worsen.

 

I have been taking the  medicines now for about 5.5 weeks, The clinic is quite expensive for medications only about 1000 baht every 2 weeks. So this last time I found a Pharmacy that stocked the Dicetel and Rivotril, (small pharmacys did not sell it, pharmacy was not high enough grade) but did not have the Cetavol,  the Pharamcist who spoke good english and was professional (recorded all my details in the book to record the medications etc) said I could substitute the Cetavol (nortriptyline 10mg) for Tripta (amitryptyline) same family very similar. (cost was half that of the Dr's clinic).

 

So on Wednesday night instead of taking my 1 x Cetavol after dinner and my half pill of Rivotril, I just took only the Tripta, all seemed to go ok was a bit groggy the next morning but ok, so Thursday night I did the same but when I woke up on Friday I was very dizzy, had groggy fizzy head, through the day it worse with nausea,body aches,feeling anxious etc,  for a few hours i the middle of the day it was quite bad so I called the Dr thinking it may be because I stopped the Rivotril, they said not because it was to low a dose for to short a time. So Friday night I stpped the Tripta and took the half pill of Rivotril as normal (no Cetavol as ran out), today I woke up a bit better than yesterday but still have headache, mild diziness and aches. I've had several loose bowel movements today so the anxiety is probably cuasing those possible ibs symptoms to worsen again.

 

Sorry for the long post, so to get to the point, is this all due to stopping the Cetavil and/or Rivotril or is it an effect of startig the Tripta ?? a side effect from stopping the old or starting the new, or just something unrelated ?? (my own research agreed with what the pharmacist said about Cetavol & Tripta being very similar).

 

I will go back to the Dr when I can, but won't be until Mon/Tue, so looking for reassurance I am doing the right thing, Thanks.

 

 

 

Edited October 1, 2016 by digital

[Sheryl]

While amitryptilline and nortriptyline are in the same family of drugs and closely related, amitriptylline tends to cause more sedation/grogginess than nortryptiline. Other than that, a switch from one to another at same dosage would usually not be a big issue.

 

However what is of real concenr is (1) the abrupt discontinuation of fluphenazine (the other med contained in Cetavol )and (2) the discontinuation of the clonazepam. Either or both of these things could well explain  your symptoms, and probably does.

 

Fluphenazine is a heavy duty antipsychotic med, though it is also soemtimes used (off label) in combination with nortriptyline for IBS. It is not a good idea to stop it abruptly. Clonazepam is a benzo and highly addictive. As I understand it you were taking it nightly for more than a month, and at a very high high dosage (1 mg - usual dose for sleep would be half that).  Certainly possible then to be having withdrawal symptoms, and benzo withdrawal fits with what you describe. I cannot understand why the doctor dismissed this idea.

 

Clonazepam does not treat IBS per se, it treats anxiety and insomnia but its regular use leads to addiction and a host of other problems as you are finding out.

 

Frankly if you really need these psych meds you would be better off under the care of a psychiatrist specializing in anxiety disorders. I would recommend seeing one now to help sort out your meds and hopefully help you wean off the benzo, which needs to be done gradually.

 

You would also do well to see a counsellor regarding your anxiety, this may help reduce the need for medication.

 

[digital]

1 hour ago, Sheryl said:

However what is of real concenr is (1) the abrupt discontinuation of fluphenazine (the other med contained in Cetavol )and (2) the discontinuation of the clonazepam. Either or both of these things could well explain  your symptoms, and probably does.

 

The clonazepam I re-started again last night taking a half pill again, so 1mg. The Cetavol I have not taken since Tuesday (I stopped the clonezepam at the same time), the current symptoms did not start until Friday. The Tripta I only took twice wed/thu night, now stopped completely until I get to the Dr again.

 

1 hour ago, Sheryl said:

Fluphenazine is a heavy duty antipsychotic med, though it is also soemtimes used (off label) in combination with nortriptyline for IBS. It is not a good idea to stop it abruptly. Clonazepam is a benzo and highly addictive. As I understand it you were taking it nightly for more than a month, and at a very high high dosage (1 mg - usual dose for sleep would be half that). 

 

It was written on the dispensing pack of the Cetavol - to help stomach.The  Rivotril was to: help sleep and took it for 1 week at whole pill 2mg and another 4 and a half weeks at half a pill 1mg, I did not realise it was a high dose - Do you think I would be better to take only a quarter pill tonight of the Rivotril (0.5mg)??

 

1 hour ago, Sheryl said:

I cannot understand why the doctor dismissed this idea.

 

It was the pharmacist at the clinic I spoke to on the phone not the Dr, she said it was a low dose. I will go back to see the Dr hopefully on Monday,

 

1 hour ago, Sheryl said:

Frankly if you really need these psych meds you would be better off under the care of a psychiatrist specializing in anxiety disorders. I would recommend seeing one now to help sort out your meds and hopefully help you wean off the benzo, which needs to be done gradually.

 

You would also do well to see a counsellor regarding your anxiety, this may help reduce the need for medication.

 

 

I was anxious and I was worrying about being ill and not knowing what was wrong (and some other things that I won't go into here but nothing major and only started once I started to be ill anyway). I thought it was all treatment for the IBS and the Rivotril was there to help the anxiety, all this started in May if you remember from my older posts with what I thought was a prostate issue, then it turned out to be kidney stones and all these other problems only started after I took Cipro antibiotic. So its been going on a long time. I was doing ok on the meds but now feeling worried about it again. About 2 weeks ago I had also had some kind of spot  just inside my nose that was sore and lasted a while and then I noticed an ulcer in my mouth then by accident I found 2 more very far back in the throat past uvula, not painful though I thought maybe some side effect of meds I will mention this to the Dr also in case of any connection.

 

I am sure (hope) my anxiety is only related to being ill, if this was fixed I would be feeling better. Thanks for you help again Sheryl.

 

Edited October 1, 2016 by digital

[Sheryl]

Actually with IBS the causation is usually in the opposite direction: you are ill (or iller) because of your anxiety. It can become circular of course: anxiety --->IBS, IBS symptoms ---> worse anxiety.

 

Bear in mind IBS is not a disease as such, it is by definition a collection of symptoms for which no physical cause can be found.

 

Now you have a likely benzo addiction and side effects of some pretty serious psych meds thrown into the mix.

 

If I were you I would continue with the GI meds (antispasmodic) and probiotics but otherwise turn to mental health professionals for help in sorting out/weaning off the psych meds and for help with the underlying anxiety .

 

Going back to your question about the rivotril - I would wait until you are under the care of a good psychiatrist and let them guide in the tapering process rather than trying it yourself.  They will usually first switch you to an equivalent dose of valium as this is easier to taper in small increments and its long half life reduces withdrawal symptoms.

[digital]

26 minutes ago, Sheryl said:

Actually with IBS the causation is usually in the opposite direction: you are ill (or iller) because of your anxiety. It can become circular of course: anxiety --->IBS, IBS symptoms ---> worse anxiety.

 

Bear in mind IBS is not a disease as such, it is by definition a collection of symptoms for which no physical cause can be found.

 

Now you have a likely benzo addiction and side effects of some pretty serious psych meds thrown into the mix.

 

If I were you I would continue with the GI meds (antispasmodic) and probiotics but otherwise turn to mental health professionals for help in sorting out/weaning off the psych meds and for help with the underlying anxiety .

 

Going back to your question about the rivotril - I would wait until you are under the care of a good psychiatrist and let them guide in the tapering process rather than trying it yourself.  They will usually first switch you to an equivalent dose of valium as this is easier to taper in small increments and its long half life reduces withdrawal symptoms.

 

Thanks again,  Seems so serious to see a psychiatrist and needing help after only 5.5 weeks of use (I am also concerned about costs and have been since this all started). So it sound more likely to be the benzo (Rivotril) problem than the  Cetavol (which i don't have any more of anyway) ?

 

I will continue with the antispasmodic (dicetel) as I have been doing anyway, and will take the 1/2 pill of rivotril until I get more advice. There is one clinic I found in Phuket (natnaiyanaclinic) she seems well qualified from the website, so you think better to go there instead of the GI Clinic I have been visiting ? (I started with 2 different hospitals but then switched to seeing Dr's in private clinics, often same Drs as in the hospitals anyway, found it easier).

[digital]

Hi, last night took the half Rivotril as normal (1mg) around midnight, slept until about 5.45AM when the rain woke me up, and then stayed half asleep until 7.30AM, Woke feeling dizzing and groggy in the head again, also a blocked nose. Took 2 x Paracetamol at 8.00AM and a glass of effervecent KAL-CEE (1000mg vitC etc).

 

Could it be that maybe I just have a cold that happened to come when ending the meds (I feel such an idiot)? have been sneezing a lot this morning also, with headache, fuzzy head, nasal congestion -  it seems a big leap from this though to what Sheryl was suggesting yesterday which to be honest got me quite concerned. I've been back on the Rivotril for the last 2 nights and still have the symptoms so if this was the problem shouldn't I have expected that retaking it would ease the symptoms?

 

My plan now is to go back to the original GI Dr on Monday AM, update him about the IBS symptoms, the mouth sores/ulcers and what has happened since stopping the medicine with a view to weaning off them, I wil see what he has to say and then if not happy will try the psychiatrist route.

 

Does that sound like a good way to start?

 

Just one last thing instead of the paracetamol I may take Decolgen instead, to ease the cold like symptoms, no problem with that right? Thanks.

[Sheryl]

13 hours ago, digital said:

 

Thanks again,  Seems so serious to see a psychiatrist and needing help after only 5.5 weeks of use (I am also concerned about costs and have been since this all started). So it sound more likely to be the benzo (Rivotril) problem than the  Cetavol (which i don't have any more of anyway) ?

 

I will continue with the antispasmodic (dicetel) as I have been doing anyway, and will take the 1/2 pill of rivotril until I get more advice. There is one clinic I found in Phuket (natnaiyanaclinic) she seems well qualified from the website, so you think better to go there instead of the GI Clinic I have been visiting ? (I started with 2 different hospitals but then switched to seeing Dr's in private clinics, often same Drs as in the hospitals anyway, found it easier).

 

I would hardly call it "serious" to see a psychiatrist when you have (or were thought to have) pyschproblems severe enough to require a heavy duty antipsychotic med and large dose of a benzo (and 5 weeks is easily enough time to have developed physical dependency).

 

I don't think changing from on GI doctor to another is going to help and it may confuse matters.

 

Continue to recommend you see a good pyschiatrist and also get some counselling to deal with the anxiety/depression. It will save money in the long run.

 

Only problem re decolgen is it may add to the fogginess/grogginess a bit.

[digital]

2 minutes ago, Sheryl said:

I don't think changing from on GI doctor to another is going to help and it may confuse matters.

 

No I meant the current GI Dr that prescribed these meds, I dont want to get a different GI Dr involved and have to go through the whole thing again, partly the reason I thought go back to him first, before I try the pyschiatrist. If I do have ibs or some other Gi issue then isn't it the Gi Dr who I should be seeing anyway, even if I end up with both? The psychiatrist I mentioned in the last post has an evening clinic, my current GI Dr is mornings, so if unhappy with what the Gi says I was going to try the other.??

 

6 minutes ago, Sheryl said:

Only problem re decolgen is it may add to the fogginess/grogginess a bit.

 

Maybe better to stick to paracetamol then?

 

Thanks a lot for your help, It really is appreciated to to have someone else to talk to about it. I just need one good understanding  Dr who can sort the whole thing out, but its very trial and error. I sort of think going directly to the specialists myself means I stay within a narrow path of there own specialism, it would be great for a Dr to look at the whole problem and refer me the right people (like a UK GP would do).

 

Thanks again.

[digital]

A quick update...  I went back to the GI Dr this Am.

 

First I explained how my symptoms has have been since the last appointment.

 

Next I discussed the mouth and throat sores which he thought may be caused by acid.

 

Now onto the serious stuff the medications.  I was calm and explained all my concerns clearly. His first reaction was that the dose is very small and only for a short time its no problem,  I Explained I didn't think this was the case and these meds are strong for serious mental health issues and can be highly addictive even at low dosages for a short time, he came back with Thai people don't get addicted or any problem with these medicines (I supect he keeps them on the meds long term so doesn't see the problems), still calm I dismissed this silly argument, bodies are much the same regardless of race.

 

I asked his advice about stopping/reducing the meds if he thinks I have no GI issues but he seems to have lost interest now, only saying he can not guarnatee because you have not hade any scope but he has previously said its all ok. I said I agreed when I was first prescribed the medicine but did not realise how serious these medications were. He still stays with the its because you are not Thai excuse and they are low dose, implying I am to easy to become dependant, but have never had any kind of addiction or dependancy to anything before, I don't drink, have smoked lightly in the past but quit it a long time ago with no problems at all. I suggested maybe I was better to see a Psychiatrist to help get me off the meds if there was no other issue, he agreed. No charge this time, thanked him and left.

 

So I have an appointment this evening with the psychiatrist (although the sound of it is quite daunting), I am hoping she will be able to put me back on the right path.

[xylophone]

1 hour ago, digital said:

I Explained I didn't think this was the case and these meds are strong for serious mental health issues and can be highly addictive even at low dosages for a short time, he came back with Thai people don't get addicted or any problem with these medicines

 

Ahh, the old "we are Thai and we are different" excuse/rollout!

 

And of course you probably caused him some loss of face by questioning his advice and the prescription he gave you. Had a similar thing at Bangkok Phuket Hospital when the levofloxacin I was prescribed caused a couple of tears in and around both Achilles tendons, so I was only able to shuffle along to the next appointment!

 

When I described this situation to the doctor and said that it was a known side effect of fluoroquinolones, he became quite put out, and even worse when I suggested another antibiotic (which he hadn't heard of) he promptly told me that he could do nothing else for me and to go away! So I left his office with a kidney? infection and later sought help at the Phuket International Hospital (although not one of my favourite hospitals for most things apart from a good skin specialist) and was well treated by a doctor there, so now all is fine.

 

Taking that same mindset, I remember speaking to a Thai electrician because I was doing some minor electrical repairs in my house, and commenting on the lack of an earth in the socket outlets and his comment was, "we are Thai, we don't need an earth".

 

Good luck with getting over this and I notice you did take ciprofloxacin at one time and for some people this can cause stomach complaints and it can take some time to get over them, so persevere with the advice that Sheryl has given you and continue with probiotics and prebiotics as well. 

[Sheryl]

I am glad you will see a psychiatrist. Get the psych meds/issued sorted out firty and then if you are still having significant GI symptoms see a different GI doctor, one prepared to do an endoscopy before rushing to he diagnosis of IBS (a diagnosis of exclusion which means other causes must first be excluded which, if you never had a colonoscopy,  they were not). But this only if GI symptoms persist  once your anxiety is under control and you are well off the benzo and antipyschotic med. (There are nonaddictive meds which will treat anxiety and depression).

 

Don't forget the counselling angle, psychiatrist will help only with meds. As I gather you are in Phuket, might try here  http://balancegroup.asia/services/counselling-services/

 

(I have no specific feedback on that place, it is just the only resource I find listed for Phuket - if anyone has other suggestions, please post them here)

[digital]

Thanks for the support/advice and feedback.

 

Ok I went to the Psychiatrist, she seemed just OK.

 

I had previously emailed her a basic history of what has been happening. She listened to what we had to say, asked about anxiety in the past and also asked my wife about my anxiety in the past and how I dealt with it, she did not seem to think I had much of a problem until this series of heath episodes which caused the anxiety.

 

She did also say that the dosages I was taking were not that high but she did agree that there needed to be a plan to come off them safely as there can be dependancy over a short time.  For the Cetavol which I have stopped since mid last week, she did not say that we needed to do anything, she said I may continue with symptoms for a while but should pass soon.

We have come up with a plan to stop the Rivotril, starting tonight I will reduce to 0.5mg for a week starting tonight  and then for the next week 0.25mg, then should be able to stop, again she said may get some minor symptoms but this reduction should be ok for the dose and length of time I have have been taking the medicine. this is a quicker reduction than I seen in my own Internet research but to be fair most of those were for people who had taken the Clonezepam for years and bigger doses.

 

She thought the mouth/throat sores were more likely due to just being run down, and didn't reommend I take omeprazole for acid at this moment, just to wait until things settled down. Much the same advice regarding the Gi issues (as Sheryl advised also) wait and see what happens after I am clear of these meds, but only choice if I don't want to see this GI Dr is to go to a hospital. She did agree that the original cause of my GI problems could well have been from the Cipro antibiotic, which in turn caused this circular anxiety-ibs problem.

 

One thing I haven't mentioned before is an increasingly worsening pain in the lower right rib, this started a few days ago and feels like a bruise or muscular pain, but through the day yesterday it got quite bad and is very painful on moving. I mentioned it and she said its normal (I also mentioned it to the Gi Dr but he didn;t say or didn;t want to say any more about this). This morning I stil have this pain very strong even with the smallest of movements, and woke again with the hangover fuzzy groggy head feeling again. I have taken ibuprofen but am trying to put the pain to the back of my mind, I don't want another worry adding to the anxiety.

[Sheryl]

It is possible to become hyper-sensative to bodily sensations, and when one is, there will always be a "symptom" somewhere. Then the more you worry about it, the worse it gets and  the more new sensations arise elsewhere, it is a never-ending cycle.

 

And one that can lead to unnecessary medications and medical treatments, which can lead to side effects and new medical problems....you get the idea.

 

I don't usually say this but in your case, paying less attention to passing aches, pains and other symptoms may be the wisest course of action. You need to get off this particular merry-go-round.

 

If you are so inclined, a course of Vipassana meditation - which works directly at the mind-body interface - may be helpful. www.dhamma.org

[digital]

On 10/4/2016 at 11:58 AM, Sheryl said:

It is possible to become hyper-sensative to bodily sensations, and when one is, there will always be a "symptom" somewhere. Then the more you worry about it, the worse it gets and  the more new sensations arise elsewhere, it is a never-ending cycle.

 

And one that can lead to unnecessary medications and medical treatments, which can lead to side effects and new medical problems....you get the idea.

 

I don't usually say this but in your case, paying less attention to passing aches, pains and other symptoms may be the wisest course of action. You need to get off this particular merry-go-round.

 

Yes I completely agree with this, I am trying. My right bottom/under rib problem is still there and actually is pretty painful, I am trying to put to the back of mind as much as I can. I have stopped the ibs (Dicetel) meds for a couple of days now, I am having more frequent loose movements but its manageable. I do have a general unsettled feeling mainly in the stomach .

 

After reducing the rivotril last night,  I got to sleep ok and slept well, my head does feel a bit clearer and less grogginess this morning

 

I had some anxiety last evening out of the blue whilst watching a movie, nothing major but just kept thinking back to how I was speaking at my appointment with the GI Dr. But I think its expected to have some rebound after stopping the Cetavol. My wife is a great support.

 

On 10/4/2016 at 11:58 AM, Sheryl said:

If you are so inclined, a course of Vipassana meditation - which works directly at the mind-body interface - may be helpful. www.dhamma.org

 

I would be interested in something like this I will look into it more - thanks, the councelling Sheryl mentioned before is fine but at 2,500 a session its not a consideration for me, and I dont feel I need it at the moment. I have also seen a few apps for relaxation, might give them a try.

 

I want to seee what happens after all these meds are cleared from my system in a few weeks then re-evaluate everything. All I am taking in addition to the reducing Rivotril, is ibuprofen/paracetamol, the effervecent CAL-CEE Vit C supplement, Bioflor Probiotic (just for the next 10 days because I am not taking the probiotic yogurt drink during the vegetarian time). But  I would be interested in some kind of non-addictive or dependency forming anti anxiety/depression medications (which Sheryl mentioned in an earlier post) after this time if I felt I still needed some help, I don't know what you think about other alternative supplements, but things like Ginseng with Ginkgo, Khi Lek(cassia Siamea) a thai herb, Vit B are all things I have read may be good alternative treatments.

 

Thanks again.

Edited October 5, 2016 by digital

[Sheryl]

You can certainly try various herbs and the like (valerian being the one most often used for anxiety) but in my experience the effects are too mild to help with a real anxiety disorder, though they will often help induce a slight relaxation in people without an anxiety disorder.

 

The non-addictive meds for anxiety and depression are things like venlafaxine (do not self-prescribe! Just for your information). You might need to come to Bangkok to see a good western-trained psychiatrist to get proper evaluation and treatment but likely worth the flight and once stablilized can get the meds locally. Medical expertise in Phuket is limited.

 

The Vipassana courses are free of charge, donation basis only, but need to  consider iwhether you are stable enough to manage a 10 day course without severe anxiety erupting, which can happen in some cases. Best to get off the psych meds to the extent possible and get a professional assessment of whether you are fit to undergo it (the course organizers may require such a letter from a doctor in any case, given your history and meds).

 

If you can do it successfully, it will definitely help.

[digital]

Again... thanks Sheryl,

 

I dont want to mess around adding new meds or supplements too much at the moment until I see the result after the Rivotril has ended, but I am going to take Turmeric today (as we have it anyway), I have read its good for digestive disorders and there is some benefit for anxiety/depression (although if you look hard enough you can find good / bad thigs for almost anything on the Internet - a habit I need to break).

 

I do think I have anxiety rather than depression, but not entirely clear on the diffference, I still feel if I knew for sure I was ok with my other health concerns my anxiety would improve, Maybe I have lost faith in Thai Dr's.

 

I would consider going to Bangkok (even better if they could first do an email consulation before travelling), but its the same problem of not knowing exatly what type of Dr I need to see. Bangkok Phuket Hospital does have a seeming very good Professor Art Hiranyakas with western experience http://www.phukethospital.com/Doctor/Curriculum-Vitae.php?doctor_id=193  As Ibs and anxiety seem closely linked he may be a good option, As I said before I want someone who will look at the whole problem, outside of there own specialisation also if neccessary.

 

Today head is clearer on waking again, still a bit unsettled in the stomach, not much appetite with loose BM, but manageable. Still have the pain under right rib, not sure the 1xibuprofen+1paraetamol twice daily is making a lot of difference.

[Sheryl]

Indeed, from your posts it does very much sound to me like you have an anxiety disorder.

 

While you may feel that the anxiety would disappear if you could only get your health concerns resolved it is more likely IMO that the anxiety is the cause of your health concerns.

 

Anxiety feels like (and physically behaves like, in our bodies) fear.  There is a natural tendency to try to locate an objective cause for fear when you feel that, but in many cases the feeling came first and the mind atttributes the cause afterwards.

 

There is a type of anxiety disorder  called Somatic Symptom Disorder.  The diagnostic criteria are:

 

• You have one or more somatic (physical) symptoms that are distressing or result in problems with your daily life
• You have excessive and persistent thoughts about the seriousness of your symptoms, you have a persistently high level of anxiety about your health or symptoms, or you devote too much time and energy to your symptoms or health concerns
• You continue to have symptoms that concern you, typically for more than six months, even though the symptoms may vary

http://www.mayoclinic.org/diseases-conditions/somatic-symptom-disorder/basics/tests-diagnosis/con-20124065