View Full Version : potential guanfacine overdose


Lambeau
04-27-13, 06:28 PM
I was newly diagnosed, then prescribed 1 mg IR guanfacine TID. I have had a lot of trouble finding a doctor that would believe me, and now have found one that I believe almost killed me. He was given my list of medications, and with that list was 1omg BID valium for spasms, and 10 mg bid flexeril for spasms, as I have had severe back problems, and 6 months ago had an L4/S1 fusion.

I know a bit about drug interactions, as I have college backround in biochemistry, cell, and molecular biology and have worked as an MA for a cardiologist. I have a pain specialist that has been testing me regularly, and I have been opiate free for almost 3 weeks now, and he is 100% willing to back me up if any psychiatrists start in on me being a drug seeker for bringing up obvious ADHD. This doctor finally believes me, and we have a 20 minute argument about guanfacine needing to be started at 1 mg at night, and titered up to 4 mg/day if needed.

There is also a huge contraindication of use of this drug with other CNS depressants, ie valium and flexeril. I also had a discussion about his idea that a CNS stimulant for treatment would be a contraindication and dangerous from valium use, which I know is not true at all. I told him if he needed to talk to my pain specialist, who has an extended history of passed drug tests, and that I had not used any illicit drugs in a great while, including alcohol.

He said he trusted me, and didn't need to talk to my doctor, but tried to put an emphasis on the hyperactivity aspect, of which mine is mostly under control compared to my youth, and the attention part is where I lack severely right now.

So I start the drug at 1 mg TID, and at first dose at 9 am, I was passed out after feeling light headed around what I think is 9:30, and woke up 2 hours later, kids unfed and unwatched, and late for PM kindergarten. I decide day 2 to continue, and pass out sitting up with my computer on my lap, mid typing. I go down to 0.5 mg on day 3, knowing that I was probably severely hypotensive and could have been close to death, and even with only taking 0.5mg once that day, I pass out (90% sure syncope) for 5 hours on my couch, shoes on, sitting up, and computer in my lap.

I am now 2 days completely off, and after doing research, as well as speaking to my father in law, who is a cardiologist, I find out that the dose was 3 times higher than should have been given at first, and that there is a contraindication of use with valium and flexeril, and no contraindication of the use of stimulants with valium as I told him I knew.

He then said he did not believe I had ADHD because of the way I reacted to the medication, although my father in law said that that was an dangerously high dose to start someone on, and that it could have caused hypotension and bradycardia to the point of death. Now I am in month 3 of trying to get help, and my impulse control as far as anger goes is flying out the window faster than lightning, and I am having to undergo a $650 psychological test to figure out what is "really going on" which is blatantly obviously ADHD and has been for years.

So now I am another month untreated. It has been masked for the last year from opiate pain therapy, which enhances dopamine. The other times in my life I have been successful and able to be around for more than an hour, I was on dopamine drugs, once a very high dose of wellbutrin, and the other was the 5 years I was a competitive power lifter, taking ephedrine at a moderately high dose as told to by my coach. During my 5 years of competing, I was taking 15 hours of classes a semester for biology, working 20 hours a week, playing music (I am an EDM DJ) 4-5 times a month, as well as co owner of a successful record label, and was producing, and getting music signed regularly.

Off the ephedra from quitting cometing to go to graduate school, and it was 9 months before I was out of the program, failing classes that were typically a cakewalk in undergraduate school.

I am at the end of my rope, and feel I could explode at any minute. I don't want to self medicate, but I feel I don't have a choice until they finally, 3 months, 4 doctors, and $800 later, I have ADHD.

I almost feel like taking legal action against this doctor. Has anyone else experienced this, as far as drug interactions and overdose, and the fact that I am getting the run around and am spending a great deal of money, as I am disabled, and can not afford this much longer.

namazu
04-27-13, 06:51 PM
So I start the drug at 1 mg TID, and at first dose at 9 am, I was passed out after feeling light headed around what I think is 9:30, and woke up 2 hours later, kids unfed and unwatched, and late for PM kindergarten. I decide day 2 to continue, and pass out sitting up with my computer on my lap, mid typing. I go down to 0.5 mg on day 3, knowing that I was probably severely hypotensive and could have been close to death, and even with only taking 0.5mg once that day, I pass out (90% sure syncope) for 5 hours on my couch, shoes on, sitting up, and computer in my lap.
Wow, that sounds awful. I'm sorry you experienced that.

Did you contact your doctor or pharmacist after the first time it happened to report it and see if they had suggestions?

I am now 2 days completely off, and after doing research, as well as speaking to my father in law, who is a cardiologist, I find out that the dose was 3 times higher than should have been given at first, and that there is a contraindication of use with valium and flexeril, and no contraindication of the use of stimulants with valium as I told him I knew.
Hmm.... Are you taking a different form of guanfacine (i.e., not Intuniv)?

Per the prescribing info (http://pi.shirecontent.com/?product=intuniv&country=USA&language=ENG), 1mg is the typical recommended starting dose for Intuniv, so I'm not sure what the rationale for starting at 1/3 of that dose would be -- especially since the medication doesn't come in smaller units, and the pills aren't supposed to be divided.

Valium isn't listed as a contraindication, though there's a note that doctors should be sure to consider the potential additive effects of sedatives when deciding if and how much to prescribe.

Instant-release guanfacine is a different story in terms of starting dose.

He then said he did not believe I had ADHD because of the way I reacted to the medication
Yikes.

So now I am another month untreated. It has been masked for the last year from opiate pain therapy, which enhances dopamine. The other times in my life I have been successful and able to be around for more than an hour, I was on dopamine drugs, once a very high dose of wellbutrin, and the other was the 5 years I was a competitive power lifter, taking ephedrine at a moderately high dose as told to by my coach. During my 5 years of competing, I was taking 15 hours of classes a semester for biology, working 20 hours a week, playing music (I am an EDM DJ) 4-5 times a month, as well as co owner of a successful record label, and was producing, and getting music signed regularly.
Did you mention to the doctor that you found Wellbutrin helpful? I don't know if it plays nicely with the other meds you're taking, but it is often prescribed off-label for ADHD and may be of benefit to you (given that it helped before), without the risks (real and perceived) associated with controlled substances.

I don't know if the doctor who prescribed the guanfacine is someone you're willing to see again, and if he doesn't believe you have ADHD (what did he suggest instead?), I'm not sure how useful it would be. Do you have a general practitioner you could work with, or would the pain specialist have any insight into meds that might not interact with the things he's prescribing?

Good luck. Things get tricky fast when you're managing multiple conditions and medications at once.

Lambeau
04-28-13, 04:21 PM
He wasn't giving me 1/3 the dose. I was a medical assistant for a while, and 1mg TID means 1 mg three times a day, which means he gave me 3 times the recommended dose, and was given the IR form, which has contraindication to benzodiazapines.

And I did contact my doctor, and he said I must not have ADHD because of the reaction, which was near death IMO, as the way I was passing out wasn't "oh, I'm tired, I should lay down" and was more like in the middle of something and was just out. I believe any person on the planet would have reacted this way to 3 times the starting dose, IR form, and with 2 CNS depressants already in the mix.

I told him I was on 300mg wellbutrin xl, and he prescribed it again. I already have a 90 day supply, and am on the maximum dose (can be 450, but rare) from my GP. My GP will have nothing to do with controlled substances, and I have to continue to see my pain specialist for Lyrica, Diazapam, and Flexeril every 3 months for nerve pain and severe back spasms. I have backed off and tried 1mg at night before bed, and I have woken up very groggy and with the worst cotton mouth ever. I am ending totally today, and not sure how I am going to handle this until it is taken care of. Three weeks off of opiates, which are dopamine enhancing drugs as well, has made the ADHD come back with a vengance, as it was gone while on the opiates. Even with the 300mg wellbutrin. Script amphetamines are basically act on the dopamine system as wellbutrin on steroids would, and as I am trying to control anger and the impulse control associated with it, the treatment (not drugs, but interactions) with the doctors thus far is making this very dangerous and has made me even more angry, and I am getting less attentive to anything at all as each day goes by. This would be the 4th or 5th time seeking psychiatric help for something (ADHD all along...misdiagnosed for years) and my condition has been made worse by attempting to get help. This is the first test any has given me, and usually just throw some condition name with no testing at all at me and meds that do not work, with several that have made my condition worse. For me to come to psych again is a heavy stretch. If it's another failure on their part, I'm not sure where to go from there. If I continue to go from Dr to Dr I am eventually going to be on a list of pill seekers, which I am not. I don't advocate self medicating to anyone for anything, but I may not have a choice if this fails. How do I handle this if they misdiagnose again, and I am once again spending my life looking for my wallet and my keys, with my laundry not done, forgetting the dishes, late everywhere I go, driving back home every time I leave for forgetting something, hyperfocusing on video games and music, short fused, and my wife ready to leave me at moments notice. Frustrated does not even describe me right now.

namazu
04-29-13, 01:04 AM
Ah, sorry, I missed the part about it being IR and TID. That makes a big difference. (I'm surprised no one at the pharmacy caught the high starting dose and potential for interaction, either -- they're usually trained to spot that kind of thing and double-check.)

I really don't have any great advice, but I can sympathize, having had doctors in the past who weren't well-versed in treating ADHD or in managing polypharmacy, and having experienced the ugly side of misdiagnosis and ill-fated prescriptions.

Hopefully as you get further out from the opiate use, and as the Wellbutrin starts to kick in, things won't feel quite as miserable.

Have you been in touch with your state's Department of Rehabilitation? Given your complex history, they may be able to arrange a full evaluation at a reduced rate, if it is warranted to explore or document processing problems and impairments. Then you may have a stronger case for pursuing that line of treatment. Perhaps the Department of Rehabilitation could hook you up with someone qualified to assess ADHD in the context of a history of addiction/self-medication and other complicating conditions. (Probably that's wishful thinking...)

If not, it's at least an unexplored avenue. No guarantees, but it may be worth a shot.

Meanwhile, look into recommendations for cutting down on computer games...if it's a game system, could you sell it to raise some money for evaluation and treatment, and at the same time, remove that distraction? If it's web-based, look into blocking or limiting your time on those sites.

Since you're out of work at the moment, you're probably also seriously lacking structure in your day. Setting up some kind of routine (with help from your wife, your doctor, your kids -- whomever) could be useful both as a memory prompt and as a general getting-out-of-a-rut strategy. I know full well that this is easier said than done, and it's something I struggle with greatly myself, but it is beneficial if you can find some help to get it going and stick with it.

Best of luck, and take care.

InvitroCanibal
06-18-13, 02:02 AM
Your Doc sounds terrible. Metabolism plays a huge part in all medications and it's invidiualized for many people and ethnic groups. Then there is weight, gender and even more such as family history. So how you respond to a med does not indicate your diagnosis one way or the other. I have noticed actually that most the ADHD people i've known had low blood pressure and were semi hypotensive in fact. An unusual thing it seems.

Did he take blood pressure readings first thing, before prescribing these meds?

Always evaluate the doctor in the first session as much as they evaluate you. Ask them questions, see what answers they give and watch to make sure they sound confident and make sense. Make sure your questions were fully answered.

Also keep in mind how much time he spent the first session, whether it felt rushed and also how many questions he asked you before coming to any diagnosis and what kind of questions. A good doctor asks a lot of questions and doesn't just score a multiple choice test that patients answer.

As far as paying hundreds for a diagnosis, that varies from place to place. If you are a student there are resources you can use that are sometimes provided by the college. Often health insurance is provided at every college for students as well. You should be able to find definitive testing through any college actually, but it probably wont be provided by them specifically, rather they can give you people to contact that specialize in the diagnosis. And believe me, you want a specialist because a specialist will know a good psychiatrist as well as an adhd coach if they are not either of those already. ADHD specialist put standard docs to shame honestly.

When I say specialist I mean either a psychologist or psychiatrist who has studied adhd for a long time and can make a respectable diagnosis. Many pediatricians are good but they have more trouble with adult adhd and understanding how it transitions.

Hopefully that helps good luck to you

SquarePeg
06-18-13, 03:27 AM
Not sure I understand what´s going on here but I thought Guanfacine was a non stimulant drug. I have copied some info I have on Guanfacine and Clonidine from a lecture re adhd

Clonidine and Guanfacine were first introduced as anti-hypertensive agents in the 1970s. They were partial agonists of Norepinephrine, and so what they do is they decrease the tonic and phasic activity of the locus ceruleus. They make it a little less erratic. There's also evidence that these agents increase the efficiency of neurotransmission in the prefrontal cortex, as I will elaborate momentarily. The Alpha 2 adrenergic agonists are very helpful for patients who are highly aroused, impulsive, emotionally charged up, irritable, explosive. They also play a role in reducing anxiety, defiance and agression and they're useful for controlling tics. So it turns out that Clonidine and Guanfacine have been around for decades but they've been sort of orphan medications until recently, because they were not really subjected to extensive testing until the extended release preparations were introduced in the last few years. What is the mechanism of action of the Alpha 2A Agonists? They work primarily at the norepinephrine neuron. Clonidine works at Alpha 2A, 2B and 2C receptors, whereas Guanfacine works exclusively at the Alpha 2A receptor. And this is where its beneficial effects are seen. What happens is that the medications stimulate the Alpha 2A receptors, which increases cyclic AMP production, which closes the nearby HCN channels, and increases then, the dendritic cell excitability. And it strengthens the connectivity of the microcircuits of the dorsal lateral prefrontal cortex. So in working memory and distractibility in monkeys and in humans, is improved. Distractibility is reduced. And the profusion during working memory tasks in these areas is enhanced in monkeys, when you give them either Guanfacine or Clonidine. The right amount of norepinephrine stimulation then causes the Alpha 2A receptors to inhibit cyclic AMP and therefore the neurons communicate more effectively. In this slide here, you can see this is a taken from a cross section of the den, the prefrontal cortex, dendritic spines. Under optimal neurotransmission Guanfacine or norepinephrine work at reducing cyclic AMP, and therefore the, the there's less of a, of a decline in the, in the signal. Whereas without alpha 2A stimulation, cyclic AMP allows the signal to be diverted away. And that's suboptimal transmission. So, when there's inadequate stimulation then the, the ion channels are, are open, and that weakens the neuronal input and so this is where the indirect effect, if you will, of the adrenergic receptors plays a role in, in neurotransmission in the prefrontal cortex. Presumably, then, that will increase both concentration and task completion and efficiency. Side effects, though, of the Alpha 2A Adrenergic agonists are important to consider. There's sedation and fatigue, and dizziness and these could be rate limiting problems. If you have to dose these medications very gradually in order to avoid the problems of sedation, fatigue and dizziness. There can also be side effects such as dry mouth, indigestion and nausea. Occasionally it slows the heart rate down and lowers the blood pressure, because after all, that's what these medications were designed for. There can also be nightmares and insomnia. Anxiety can be seen, depression. Rarely hallucinations. And if you suddenly stop these medications, the blood pressure can go up and become hypertension. So again, these medications can be very effective, but the side effects need to be managed very, very closely. And again, this is another important feature of these agents, that they improve neurotransmission throughout the day, and can also have beneficial effects on things like aggression and tics. Let me summarize, then, that when we look at medications for ADHD, first and foremost, stimulants and non-stimulants are effective in reducing the symptoms of ADHD. That the choice needs to be based on efficacy and tolerability. There's a high variability in the optimal dosage. So we need to really, dose these as, as optimally as possible. It's important by the way, that problems that might emerge, like sleep difficulties and appetite and irritability, need to be measured before treatment is started, so that we can assess accurately the, the impact of potential side effects. And we recommend now that medications be given 7 days a week.

So it seems dosing should be started very low and increased slowly to guard against the sedating effects and dizziness.

namazu
06-18-13, 03:48 AM
Not sure I understand what´s going on here but I thought Guanfacine was a non stimulant drug.
You're correct about guanfacine; like clonidine, it's an alpha-2a-agonist that's also used to treat high blood pressure.

So it seems dosing should be started very low and increased slowly to guard against the sedating effects and dizziness.
Yes, this is the typical way to do it. Weaning off of it, if needed, is also supposed to be done slowly to avoid the problem of "rebound hypertension" -- blood pressure spikes.

It sounds like the OP's doctor prescribed an unusually high starting dose and (perhaps not surprisingly) it didn't go well.