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Old 08-22-2018, 09:47 PM #1
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Default AP Switching: Aripiprozole to Quetiapine

Have any of you had experience with switching from Abilify to Seroquel?


For those with limited time, etc., please feel free to skip the background info and pick up on the paragraphs below the last set of double lines AP Switching: Aripiprozole to Quetiapine


===========================================


Briefly, our 16yr old (PDD-NOS) had been placed on Abilify for 2 and one-half years when he becoming very irritated and angry. The first time he was placed on it, it was in conjunction with Luvox. At first, things improved for quite some time, but as the Luvox began reaching close to therapeutic doses (and they did a very slow titration, can't fault them for bringing it up too fast), he began manifesting, what I would call, disinhibition - something we'd only see with SSRI's. The odd, inappropriate and totally-uncharacteristic behaviors began spilling over at school and we withdrew him from all medications.


His PsyMD had warned that the return of the anger would probably have us to return DS to the Abilify, which it did.


He was on it for 2yrs or so without any mood stabilizers and it seemed to work well, for the most part. Saw no side effects, to speak of, till the end.


It was decided to take him off the Abilify for a number of reasons, the primary one being what I suppose would be the onset of a type of impulsivity (becoming manic-like about those things he impulsively decides to do), which has become debilitating.


Trileptal was tried unsuccessfully during the period of a very slow reduction of the ariprozole over the course of the summer, before the Seroquel was started a few weeks ago.


Cross tapering Abilify (at 7.5 - 5mg; reduced from its 21+ mg level 10 weeks previously) Seroquel was started at 75mg during the final week of his taking Abilify and Trileptal, afterwhich it was eventual raised to 200mg over 2 or 3 weeks.




Cut to the chase. What DS experienced, in addition to the somnolence (one of the few pluses), out of control hunger, reduction in drive and interest was surprisingly an increase in anger. A marked increase. Levels of intensity that we'd previously not seen.


When it began spilling over in school and he began having altercations with other students, over-reacting with verbal threats, we decided to begin back-pedaling with the Seroquel. It didn't take too much of a reduction (to about 100mg) before he began experiencing difficulty sleeping, night-mania returns with a vengeance, etc.


Despite things looking dim with respects to Quetiapine, we were'nt ready to give up on it just yet. We had seen moments of epiphany in DS, something that was indeed, extremely rare with him. I'd always said that given the choice of having his teeth yanked out with a pair of pliers and no anesthesia or having a moment of quiet, thoughtful reflection, he would pick the former as being the less painful option.


Maybe, despite the PsyDoc taking a pretty conservative approach with respects to tapering, it still wasn't done slowly enough. So we began increasing, ever so slightly.


Now, within 60 - 75% of his previous max of 200mg/day, the hostility/anger/irritation (he says he will feel more 'autistic', easily irritated by small, irrelevant things) is beginning to heat up (it has never really dissipated, it is either only manageable or not manageable), the hunger for sugars and carbs is again, out of control but, this time, there is no epiphany, no reflection, he doesn't want to go to bed and when he does, I don't think he sleeps well.

======================================================


Question: What is the likelihood of the increased irritation and increased anger (experienced spontaneously throughout the day, regardless of dosing time, scheduling, where he is at) continuing or worsening as we climb towards a therapeutic dose of Seroquel. I know that some effects of this AP have been known to abate with time in some individuals.


Does anyone recognize a pattern here? I thought it notable that as the perseverance and mania-like symptoms decreased with increasing Quetiapine levels, spontaneous anger and irritation increased. Almost inversely proportional.


Or are the individual drugs within the second generation antipsychotic class so idiosyncratic, any discussion as to likelihoods of what to expect are reduced to pointless speculation?


Hope to hear from those of you who've been down this road yourselves or know someone who has.

Cheers!
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Old 08-27-2018, 02:17 AM #2
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Default Re: AP Switching: Aripiprozole to Quetiapine

I suppose a good rule of thumb is if one finds reading their own post induces headaches and agitation then...



Humane Version

Replaced 16yr old's Abilify with Seroquel because the Abilify no longer worked satisfactorily.


At some point, noticed unusual agitation, along with expected sedation and onset of a few EPS. Hypomania/perseverance abates.


Anger and increasing disconsolance become concerning, its decided to reestablish a new baseline at a slower pace.



Tapered down, extreme irritation, rants subsided, sedation subsides, hypomania increases to high levels. Slower taper back up with Seroquel, results: At the point sedation manifests, frustration tolerance at zero, hyper-irritation, rants now hours-long and intense.



We've decided to notify PsyMD of our intention to withdraw the Quetiapine Furmate.


Follow Up

Wife and I recalled this evening that he doesn't handle sedatives well at all - especially coming off of them. Seems like a pediatrician had told us once that he should never drink - or was it to never take tranquilizers? - based on his reaction to some sedative DS had been given.



Safe to say that future considerations should probably emphasize those medications that don't have major-tranquilizer-type sedation as a main property.
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Old 08-27-2018, 03:07 AM #3
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Heart Re: AP Switching: Aripiprozole to Quetiapine

You might consider the anti-epileptic drugs (AED).
These are also used as mood stabilizers. Drugs like: Depakote, gabapentin, Trileptal, Keppra, etc. These cut my agitation when it amps up.

The major tranquilizers may put your son at risk for Tardive Dyskinesia.

Continue to watch your son closely when attempting any med, as most of them can have some severe side-effects.

Thanks for being an interested parent! Not all parents look into treatment options and advocate for their children. So, thank you!

My Best,

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Old 08-27-2018, 03:49 AM #4
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Default Re: AP Switching: Aripiprozole to Quetiapine

Hey, I just want to say that I totally feel for you! It is so difficult to find a perfect medication or combination of meds. I am a parent, like you, who began looking for help when my son was 14. We didn't even have a diagnosis in the beginning. He became a different person; was depressed and anxious and antidepressants only made him more vocal and agitated to the point of physical violence. Enter Risperdone. Then Abilify. Another year later, Zyprexa. In the past 4 years we've had quite a few prescribers and some were better than others. I am sorry I cannot help. I wish you the best of luck!
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Old 08-27-2018, 08:24 AM #5
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Default Re: AP Switching: Aripiprozole to Quetiapine

Good day.

Thank you for the detailed post as it does help me at least to understand what is going on.

Abilify is one of those neuroleptics (antipsychotic is a very outdated term) with mood stabilizing effects, but is activating. This means that unlike the more sedating ones, it actually gives some energy.
With that effect, it is often used in treatment of depressive-type episodes because of how it is able to lift the mood.

Quetiapine is a more sedating AP and therefore stands as one of the first line treatments of acute mania (along with olanzapine and risperidone) and should thus have a calming effect on agitation or other manic symptoms.

In my own experiences. I was first placed on Abilify after suffering an acute manic episode a couple of years ago. Zyprexa was what the doctor used to bring my mood down with the unpleasant sedation effect, which is common in Zyprexa.
Abilify seemed to work. Odd enough. The only problem was the agitation it seemed to cause. it was from there that I was placed on quetiapine.

My experience with quetiapine? Definitely calming in comparison to Abilify. I had tapered up from 25 mg to 200 mg of Seroquel. Funny fact: quetiapine has a paradoxical effect in which lower dosages act more as an antihistamine, thus causing drowsiness. The mood stabilizing abilities of the drug start at higher dosages- not entirely sure, but definitely higher than 100 mg.

As someone has pointed out, anticonvulsant drugs are useful mood stabilizers:
Lamictal, Depakote, Trileptal etc.
These tend to be chosen for long term mood stabilizing because of the side effects of neuroleptics such as quetiapine and so forth.

Lithium is another one, but I wouldn't go there unless you really have to. It is a very old and very efficient drug if you are able to tolerate side effects.
I am not sure whether you have ever tried him on risperidone? It is often used for agitation and manic-like symptoms.

Hope this is somewhat helpful.
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Old 08-28-2018, 12:09 AM #6
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Default Re: AP Switching: Aripiprozole to Quetiapine

First of all, I'd like to thank each of you for your responses. This sharing of ideas, experiences and tips is exactly what I was looking for when I started searching forums.







Quote:
Originally Posted by Wild Coyote View Post
You might consider the anti-epileptic drugs (AED).
These are also used as mood stabilizers. Drugs like: Depakote, gabapentin, Trileptal, Keppra, etc. These cut my agitation when it amps up.

Yes, we had some experience with Trileptal and gabapentin is something we are going to inquire of when we see our son's PsyMD tomorrow. I know you've had experience with it.


Quote:
Originally Posted by Wild Coyote View Post


The major tranquilizers may put your son at risk for Tardive Dyskinesia.

Continue to watch your son closely when attempting any med, as most of them can have some severe side-effects.


I think you are spot-on here. He was experiencing tremors, muscle stiffness - all involuntary motor movements - as well as 'irresistible urges' to rotate his forearms rapidly and the like. AFAIK, it hadn't reached the point of facial/tongue movements although there was one incident he described, when he was at 200mg (comparatively small, I know) where muscles around the esophageal area cramped/wouldn't let go - which freaked him pretty badly.


We'd noticed that DS warnt down in the basement doing weight lifting and gym routines at all hours, whenever the impulse struck - we took it as a sign some of the hypomania was abating - turned out, it was arm/leg weakness and muscle spasms that were putting the clamps on. Not good.




Quote:
Originally Posted by Wild Coyote View Post
Thanks for being an interested parent! Not all parents look into treatment options and advocate for their children. So, thank you!

My Best,

WC

We are out there, to be sure. Probably a lot more than any of us would guess. Like so many extras from a Walking Dead episode, just milling about, looking for a light to go to.


Quote:
Originally Posted by EllieGreene View Post
Hey, I just want to say that I totally feel for you! It is so difficult to find a perfect medication or combination of meds. I am a parent, like you, who began looking for help when my son was 14. We didn't even have a diagnosis in the beginning. He became a different person; was depressed and anxious and antidepressants only made him more vocal and agitated to the point of physical violence. Enter Risperdone. Then Abilify. Another year later, Zyprexa. In the past 4 years we've had quite a few prescribers and some were better than others. I am sorry I cannot help. I wish you the best of luck!

Thanks Ellie!



Quote:
It is so difficult to find a perfect medication or combination of meds.
Uh-huh. Uh-huh. Yes. And within this single sentence is a world of hurt, struggle - hope.



Just realized as I was reading your statement, for most people (who aren't inflicted, don't struggle with) reading that, it would have as much emotional weight as if they'd read "It's so difficult to find the right allergy med that works but doesn't put me to sleep." They've no idea what's involved, the complexity of how these meds interact with each other, with the human condition and the enormous and very personal consequences those interactions have on not just how we feel and how we function - but who we are, what we might become as a result of taking them.


Ja, I say "we". Of course, you know.


Quote:
...and antidepressants only made him more vocal and agitated to the point of physical violence. ...
Antidepressants - Our son's reaction to the Seroquel seems very close to your's experience with SSRIs. He'd tried them several times throughout the course of things and it was always the same - this very odd sort of dis-inhibition would pop out of no - where. In some ways, it was more disturbing than the increasing aggression and anger - which you could see him trying to fight it; even though he'd be red-faced and mad as a March Hare, it was still our son in there, somewhere.


But with this ...disinhibition - whatever it was, it was like "that's not him. That's not part of his personality, life-experiences, that's someone else"

Even though the incident in question wouldna be noticed by anyone else or thought of as much out of line.



Ah - I've gone on and on and on ... hadn't meant to do that. When its sittin down here for three minutes and then having to handle something else for twenty, its a l-o-o-o-o-o-o-ng meander.


Quote:
I am sorry I cannot help.
AP Switching: Aripiprozole to Quetiapine I think its fair to say otherwise AP Switching: Aripiprozole to Quetiapine


Quote:
Originally Posted by TicTacGo View Post
Good day.

Thank you for the detailed post as it does help me at least to understand what is going on.

Abilify is one of those neuroleptics (antipsychotic is a very outdated term) with mood stabilizing effects, but is activating. This means that unlike the more sedating ones, it actually gives some energy.
With that effect, it is often used in treatment of depressive-type episodes because of how it is able to lift the mood.

Quetiapine is a more sedating AP and therefore stands as one of the first line treatments of acute mania (along with olanzapine and risperidone) and should thus have a calming effect on agitation or other manic symptoms.

In my own experiences. I was first placed on Abilify after suffering an acute manic episode a couple of years ago. Zyprexa was what the doctor used to bring my mood down with the unpleasant sedation effect, which is common in Zyprexa.
Abilify seemed to work. Odd enough. The only problem was the agitation it seemed to cause. it was from there that I was placed on quetiapine.

My experience with quetiapine? Definitely calming in comparison to Abilify. I had tapered up from 25 mg to 200 mg of Seroquel. Funny fact: quetiapine has a paradoxical effect in which lower dosages act more as an antihistamine, thus causing drowsiness. The mood stabilizing abilities of the drug start at higher dosages- not entirely sure, but definitely higher than 100 mg.

As someone has pointed out, anticonvulsant drugs are useful mood stabilizers:
Lamictal, Depakote, Trileptal etc.
These tend to be chosen for long term mood stabilizing because of the side effects of neuroleptics such as quetiapine and so forth.

Lithium is another one, but I wouldn't go there unless you really have to. It is a very old and very efficient drug if you are able to tolerate side effects.
I am not sure whether you have ever tried him on risperidone? It is often used for agitation and manic-like symptoms.

Hope this is somewhat helpful.

TicTacDo - !!! I've many questions for you (hope you don't mind AP Switching: Aripiprozole to Quetiapine) as I had previously wondered about some of the points you've brought up and want to run our one time experience with Risperdone by you.


Realize I am indeed gonna need to fire up the trusty OO editor for that - I think I've been timed-out/kicked off here for some time.


Tomorrow, DS has his first meeting with his PsyMD since things have taken their course. I'll try and put my head around it afterwards.


Thanks again to all of you!


Cheers
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Old 08-28-2018, 02:35 PM #7
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Default Re: AP Switching: Aripiprozole to Quetiapine

Of course I do not mind! I'll help where I can!
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Old 08-28-2018, 02:52 PM #8
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Default Re: AP Switching: Aripiprozole to Quetiapine

He's not still on Luvox, right? Combining Luvox and Seroquel isn't recommended.

Also remember that a person with autism can be mega sensitive to medication. What is a normal dose for a "normal" person can be a grave overdose for an autistic individual, also "us" autistic people have more out of the norm reactions to meds. Can take a while finding something that works. What is his worst problem that needs to be addressed?
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Old 08-28-2018, 03:00 PM #9
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Default Re: AP Switching: Aripiprozole to Quetiapine

Quote:
Originally Posted by -jimi- View Post
He's not still on Luvox, right? Combining Luvox and Seroquel isn't recommended.

Also remember that a person with autism can be mega sensitive to medication. What is a normal dose for a "normal" person can be a grave overdose for an autistic individual, also "us" autistic people have more out of the norm reactions to meds. Can take a while finding something that works. What is his worst problem that needs to be addressed?
Seroquel in particular? I have read that it can interact with antidepressants and antipsychotics.

He is hopefully not on Luvox and Seroquel.
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Old 08-28-2018, 04:27 PM #10
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Default Re: AP Switching: Aripiprozole to Quetiapine

No, not in particular. But Luvox (which I am on), interacts with "everything". With opiates, opioids, Lithium, Tegretol, several neuroleptics but Seroquel is one of the worst offenders, benzos and with caffeine. There are more interactions but can't really remember. Some interactions should be completely avoided while some can be managed with adjusting dosages (like when I got on Luvox I lowered my Xanax to 75 %). I read up several things about Seroquel like in many cases Luvox will "only" make Seroquel twice as strong, but if you have particular genetics it can be as much as 20 times!! I think that might have happened to me when they gave me Seroquel. Because I was completely wiped out from extremely small dosages. The first dosage I tried which would be normal for sleep for another person, was probably a major overdose for me, because I was wiped out for like a week.

Not all docs check for interactions.
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