1. If it is a first case, I advocate treating it with olanzapine. In the evening, start with olanzapine 10 mg, if there is no abnormal reaction, from the next day onwards, use olanzapine 20 mg every night. 1 to 2 weeks later, if the symptoms have not disappeared, increase to 25 or 30 mg. As for taking the medication once or splitting it in the morning and evening, you can choose according to the specific reaction and on your own. At the same time, you should take Benadryl (2-3 times a day, 1-2 tablets each time) to prevent side effects If you can’t sit still after taking the medication you can temporarily add 2 capsules of Takayasu, which can usually be relieved within 15 minutes, there is no need to panic. Some patients with lorazepam or other tranquilizers, can also solve the problem.
At this time, it is reasonable to increase the dose of benzhexol for 2 tablets each time, or 3 times a day, it is possible to fundamentally prevent the emergence of such side effects. (Note: The instruction manual of benzhexol is written some of its ‘side effects’; in fact, it only refers to long-term (years to a dozen years) taking, or the occasional problem when mega-dose, the daily application of benzhexol dose has no side effects at all, only the benefit of preventing antipsychotic side effects, there is no harm, can be completely assured. ) Treatment must reach complete disappearance of the original symptoms (note: not basic improvement) before moving to the consolidation period.
The so-called consolidation period is to consolidate with the original dose for at least 2 to 3 months, after which the dose can be gradually reduced; finally, it is switched to pentoxifylline for maintenance. Pentoxifylline is currently the ideal maintenance drug, inexpensive ($5 per month), no side effects, no weight gain, no impact on blood glucose or lipid metabolism, and no compulsion. It can be co-administered in advance when the therapeutic drug is reduced to a smaller dose, then it is more secure when reducing the therapeutic drug.
2, if it is a repeated application of risperidone, aripiprazole, quetiapine and other antipsychotics, still no solution to the problem of cases, I suggest to stop the original drug at once, and switch to olanzapine treatment. Hopefully, the dose will be increased to 25 or 30 mg in one step. Of course, it is also possible to add olanzapine on top of the original medication. However, I do not advocate the latter approach, leaving the drugs such as risperidone, aripiprazole and quetiapine there, which I think has little benefit and vainly increases the side effects.
3. When olanzapine is applied for treatment, there are very few side effects. However, some reactions will inevitably occur in individual cases, such as
1) Drowsiness: This is not a bad thing, you can not care, let him sleep, a few days later will adapt on their own. But be careful to move slowly when getting up to avoid dizziness.
2) Dull face and slow movement: This is a mild extraconal side effect, you can take Benadryl 2-4 times a day, 1-2 tablets each time.
3)Sitting still can not: some patients after taking the drug, there are ‘standing also bad, sitting also bad’, ‘itchy in the heart’ or ‘itchy, sore in the bones’ distracted, fidgety Situation walking around phase difference: if it is a side reaction, they will complain and ask for a solution; if it is a disease symptom, the patient does not consider ‘walking around’ to be a problem and does not ask for a solution), you can take Benadryl, 2-4 times a day, 1-2 tablets each time, or temporarily take insulin 1-2 tablets to solve the problem (see the previous).
4) Increased appetite: care should be taken to control the diet, eating as little or no carbohydrates as possible (rice can only eat half a bowl a day, steamed buns can only eat half a day, just like with diabetes). You must limit the eating of snacks and eat without snacks at home. You can also take metformin for diabetes, one tablet three times a day, which may help with less weight gain. After recovery, once the medication is reduced, it is guaranteed that you will still regain slimness.
5) A very small number of patients may experience an upward rolling of both eyes after taking the drug, called ‘motility crisis’. The way to counteract this is to increase the dose of Benadryl. You can usually take the drug 2 to 4 times a day, 1 to 2 tablets each time.
6) Some patients experience obsessive-compulsive symptoms, which need not be ignored in mild cases. If it is more serious and affects life, you can take fluoxetine 40 mg every morning.
4. The advantages of olanzapine are.
1)The efficacy is significantly better than risperidone, quetiapine, ziprasidone, or aripiprazole, which can be said to be not a class;
2) Extraconal side effects are significantly less than risperidone or ziprasidone; although sedation is not possible, it can be resolved smoothly after splitting the dose, or temporarily taking the drug;
3) It is the only antipsychotic drug that has no effect on cardiac function (unlike ziprasidone, which causes abnormal cardiac function);
4) Although it may induce compulsion, it is less likely than clozapine or risperidone;
5) weight gain may be greater, but this can be addressed by diet control; also metformin (a drug for diabetes), one tablet with each meal, may help.
6) There are already national products, 10 mg for $20 per tablet; regardless of efficacy or side effects, and imported goods, the exact same.
5, if olanzapine alone, still not as desired. Then you can combine those antipsychotics that are not exactly the same pharmacological mechanism on the basis of olanzapine 20-30 mg: I suggest combining amisulpride (must be 1200 mg per day, 2 times a day on the first day, 1 tablet each time (i.e. 200 mg), the second and third days, 2 times a day, 2 tablets each time, from the fourth day onwards, 2 times a day, 3 tablets each time; that is, 1200 mg; do not just take 400 or 800 mg, which will certainly not solve the problem; (note)); or start with a combination of therapeutic doses of pentoxifylline, 5 to 20 mg (i.e., 1/4 to 1 tablet) per day.
The efficacy is better with amisulpride, but pentoxifylline is cheaper; you can choose which one to use first according to your economic condition. (Note: Amisulpride is difficult to cross the blood-brain barrier, so a large dose must be taken before a portion of the drug ‘slips’ in and plays a therapeutic role. A smaller dose will not be therapeutic. (The statement “400 mg can treat negative symptoms” in the drug’s instructions is wrong.) In some cases, after olanzapine and amisulpride have not solved the problem, pentoxifylline can be added at 5 to 20 mg per day. Often there is a significant improvement as well.
If symptoms remain despite the combination of the three drugs, consider adding haloperidol, starting with 3 tablets (2 mg each) twice a day and adding 2 tablets a day, all the way up to 20 tablets (i.e. 40 mg) or even 25 tablets (i.e. 50 mg) a day. You can also try adding sulpiride, from 2 tablets (100 mg each) twice a day for 1 week to 10-12 tablets a day; but the effect is hard to say. If you want to add aripiprazole, you can also try it, but the facts tell us that it does not help.
Of course, it is possible to add clozapine, starting with 2 tablets (25 mg each) twice a day and gradually increasing to 20 tablets a day within 2-3 weeks; however, clozapine has a number of side effects, especially the possibility of producing leukopenia (below 4.0) in 0.1% of cases, and blood tests must be performed every 1-2 weeks as a precaution. I personally do not advocate adding clozapine after olanzapine. Clozapine has many unpredictable and incomprehensible paroxysmal side effects that are difficult to deal with, and the possibility of “addiction” makes it difficult to stop using it.
If necessary, there is another drug that can be added, which is the original Japanese Peropirox, 4 mg per tablet, which can be increased to 12 tablets per day (i.e. 48 mg) in 3 or 4 days. One patient who was combining multiple medications and did not see any results, added peropirox and it actually solved the problem. There were no significant side effects with this drug.
Special attention should be paid to: regardless of the combination of drugs, each drug must be used in its full therapeutic dose, otherwise it is unlikely to work. Never “use a little of this, then add a little of that”! That kind of stupid medication method will not solve the problem. (Each antipsychotic has its own blood concentration, and it is impossible to add the blood concentration of olanzapine to that of amisulpride, so if only a little bit of each drug is used, it will not work as a ‘cooperative’.
Just as internal medicine doctors treat bacterial infections, if penicillin alone does not work, they can use streptomycin. But they will never cut the penicillin dose in half and the streptomycin dose in half; they must use the full dose of both antimicrobials! (It seems that only those so-called psychiatric quacks who do not understand pharmacology will use just a little bit of this and add a little bit of that, and the result is bound to be harmful to the patient!)
In short, there may be several ways to combine medications, and what should be noted.
1) If the disease is relatively mild, just 25 mg of olanzapine will completely solve the problem. It has been shown that only very few cases require a therapeutic dose of less than 20 mg, so I suggest that 25 mg or more must be applied.
2) If the condition only improves with olanzapine alone, but it is not completely resolved; then you must use either amisulpride 1200 mg per day (currently more expensive, about $100 per day), or pentoxifylline 15 to 20 mg per day (cheaper, $1 per day).
3) If it doesn’t work after using two drugs, you can only combine three: olanzapine 25 mg + amisulpride 1200 mg + pentoxifylline 20 mg.
4) If it doesn’t work again, combine four drugs: olanzapine 25 mg + amisulpride 1200 mg + pentoxifylline 20 mg + haloperidol 40-50 mg.
5) If the problem is still not solved, try adding peropirox 48-60 mg again.
6)While taking the above drugs, you must take Benadryl at the same time, 2 to 3 times a day, 1 to 2 tablets each time; there are only benefits and no disadvantages.
7) If the problem is not solved by taking the medication like (5), but there are no side effects and the QTc of ECG does not exceed 480, you can consider increasing the following doses appropriately: Olanzapine 30 mg, Amisulpride 1400 mg, Peropirox 60 mg. However, a higher dose does not necessarily increase the efficacy, but increases the side effects in vain.
8) In patients who are already on olanzapine, adding clozapine or risperidone may not be meaningful, that is, it will not increase the efficacy much.
9) Patients who are already on four or five drugs do not need to add aripiprazole, which has proven to be ineffective.
10) Each time you change the type of drug or the dose, you have to observe for 4 to 6 weeks to determine whether it is effective or not. If a change in condition occurs just after a change in drug or dose, it is a fluctuation of the disease itself and not directly related to the drug.
11) Sodium valproate is not a “cure-all” drug that can adjust mood, and it has no therapeutic effect on schizophrenia, so it should not be taken.
6. If the treatment has been effective, after the symptoms have completely disappeared, it is necessary to consolidate for at least 2 to 3 months before gradually trying to reduce the medication (the longer the consolidation time, the better).
1) Generally, you should first reduce olanzapine by 2.5 mg every 2 weeks for the first 2 times, and if the disease is still maintained as normal, reduce it by 5 mg each time from the 3rd time until it is finished.
2) Then, reduce amisulpride by 200 mg every 2 weeks until it is finished.
3) If haloperidol is also used in combination, then reduce haloperidol, either by 1 tablet every 2 or 3 days until it is reduced. This is also the case with peropirox.
3) The last remaining pentoxifylline: if it is applied 15 or 20 mg per day, then after continuing to take it for two months, you can reduce it to 10 mg; then 1-2 months, reduce it to 5 mg per day. For another 1-2 months, reduce to 20 mg per week (i.e., about 2.5 mg per day) for maintenance.
4) The dose of fluoxetine used to treat obsessive-compulsive symptoms depends on how the obsessive-compulsive symptoms are. If there are no more obsessive-compulsive symptoms, you can try to reduce 20 mg every 2 months after the final change to pentoxifylline alone for maintenance.
5) As for benzhexol (Antan), it should depend on the presence or absence of extra-cone side effects. Generally speaking, it is possible to try to stop Benzedrine after 1 month of maintenance with pentoxifylline alone at 20 mg per week. By the way: Benzedrine itself only has some side effects of dilated pupils and dry mouth, there is no harm to the body, no need to be concerned, can be taken without worry; dose size, should be determined according to the need, the general dose is 2 to 3 times a day, 1 to 2 tablets each time.
7, pentoxifylline maintenance medication method, you can choose in the following three: 1) 1/7 tablets of 20 mg per day; 2) 1/4 tablets (i.e. 5 mg) each Monday, Wednesday, Friday and Sunday; 3) 1/2 tablets (i.e. 10 mg) each time twice a week. The total weekly amount must be at least 15 mg in any case. Do not risk further reduction.
In addition, the tablets must be ground into a powder so that they will not be held in the patient’s mouth (since pentafluridol is not water-soluble) and spit out at an opportunity. After switching to pentafluridol, there are still many original drugs such as olanzapine in the body, and their effects on brain tissue will not disappear at once, so other problems with sleep are bound to arise, and it will take a long time to adapt. In particular, pentafluridol does not have the same effect as sleeping pills, so sleep may be poor. At this time, it is best not to eat olanzapine or quetiapine, not to take sleeping pills; otherwise, the body itself will rely on these drugs with sleeping effects, but postpone their own adjustment.
The problem of abnormal menstruation in female patients is not solved immediately after maintenance with pentoxifylline alone, but usually takes half to one year. Therefore, it is important to be patient and wait for the drug that has accumulated in the body for months or years to be excreted before it returns to normal. Never apply progesterone to create an ‘artificial cycle’ as this will delay the recovery date even more! (See related article for details)
After switching to pentoxifylline alone, the reduced self-control caused by the original olanzapine medication will not improve immediately, it may take six months or more, so be patient! Reboxetine is still required if necessary (see 9).
8. While applying the above drugs, it is recommended to check the ECG once a month in order to ensure that there are no accidents. The advantage of olanzapine is that it does not have any adverse effects on the heart, but it is best to review the ECG several times as well. If the ECG report says ‘sinus tachycardia’, it means that the heart beats faster when the ECG is done, so don’t worry about it. If it says ‘sinus arrhythmia’, it means that the heartbeat will be faster or slower with breathing; this is normal and has nothing to do with it.
What should be noted is: Are there more ‘premature beats’? Is there any ‘st depression’ (a significant depression of >5mm)? Is there any ‘QTc prolongation’ (normal value is ‘below 470 or 480’)? It is better to compare with the ECG before taking the medication, if QTc exceeds the normal limit (>480) or increases more than 60 at once, then the medication should be reduced. As for liver function, it can be rechecked monthly or every 2 or 3 months. If elevated transaminases are found, there is no need to be nervous(note), even if you don’t take the so-called ‘liver-protective drugs’ (in fact, there are no ‘liver-protective drugs’ in the world), they will often return to normal on their own within a few weeks to a month. Amisulpride has no problem affecting transaminases because it is not metabolized in the liver.
From the point of view of the human liver, any drug is a “poison” and the liver is the body’s “detoxification plant”, which will degrade and destroy it. Therefore, if you take any drug (except for things that don’t enter the liver, such as amisulpride), the liver has to work to eliminate it, which actually adds to its burden.
There are some drugs to which the liver has a certain sensitivity, such as olanzapine. If a person is allergic to olanzapine, the permeability of the cell membrane of the liver cells will change, and transaminases will leak out, and the concentration of transaminases in the blood will increase. In fact, this is not “liver damage”, but a temporary allergy that will return to normal after a few weeks. There is no need for additional medication. Because any drug will increase the burden on the liver, so in addition to the drugs that must be used to treat the disease, should not be added indiscriminately what ‘liver protection drugs’, but to increase the burden on it, but not what protective effect.
9, now with the antipsychotic drugs will more or less block the NE neurotransmitter receptors, so they will reduce self-control, the result is: attention is not easy to focus, memory is worse, patients feel that the brain can not open; some patients will be “sticky” in the parents side, seemingly childish. Take Reboxetine, can increase the number of NE neurotransmitters, may be able to play some improvement effect; but these receptors are still blocked after all, NE neurotransmitters increased, may not be able to this completely solve the problem.
Let’s say that the mailbox is blocked, even if the letter carrier is added, it may not be possible to restore the flow of information. Moreover, the effect of this receptor blockade will not disappear immediately after the discontinuation of olanzapine, and may last for several months. Pentoxifylline also has this effect, only to a lesser extent. These problems can also occur if you use a therapeutic dose of 10 mg per day. It is always necessary to wait until the dose is as small as 15 or 20 mg per week, and to wait for a considerable period of time before full recovery. This process, often, varies from person to person. Some patients have ADHD as a child, the original is poor self-control, then again to recover, it is impossible to recover to others as good control.
10. As for the problem of high prolactin. All antipsychotics will block DA, the human pituitary gland will be mistaken for pregnant, they secrete a lot of lactogen. This is the consequence of taking medication. It is not a disease and there is no need to be overly stressed. Please do not go to such tests to avoid misunderstanding.
11. As for the problem of memory. Memory has two steps: remembering, and memory preservation.