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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Hi Dr. Since Sunday every time I eat something I

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Dr. Ashok Kumar

Psychiatrist

Practicing since :2000

Answered : 3003 Questions

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Posted on Fri, 21 Dec 2018 in General Health
Question: Hi Dr.

Since Sunday every time I eat something I get immediately bloated, nauseous, have diarrhea, and get very tired/slow thinking. This only happens after I take my morning meds (lamictal 100mg, Nardil 15 mgs, and sometimes Modafinil).

This morning combo has traditionally given me a boost, but now I am feeling sick. The GI symptoms only happen immediately after I eat, which makes me think it is a nervous system issues rather than a stomach bug.

The only recent changes have been addition of Prazosin 1mg at night time to my gabapentin 100 mgs. Also I stopped drinking alcohol and started taking disulfiram, but the symptoms started before I stopped drinking. I may have mentioned before that since prazosin has such a short half life (3-4) hours I'm worried that there is a rebound effect and my body is sensitive to the peripheral return of adrenaline/NE to my system...I take nardil too which has an effect on gaba, norepinephrine, etc.

Later in the day I only have the GI symptoms, not the lethargy and brain fog, so I am tempted to think my morning meds are reacting with the lingering effects of gabapentin and prazosin. You told me prazosin has these side effects but I don't see how 1mg at 11pm would effect me at noon the next day. Is one of my other meds slowing the metabolism of prazosin?

They include: Lamictal 150 mgs, gabapentin 100 mgs, Nardil 45mgs, klonopin .125-.25 mgs, and Isentriss/descovy for HIV infection (controlled, no viral load). I generally take 50 mgs modafinil or 2.5 mg ritalin bid for wakefullness and motivation, but the symptoms occurred today without taking either.

Thanks
doctor
Answered by Dr. Ashok Kumar 24 hours later
Brief Answer:
Consultation

Detailed Answer:
Hello,
Thanks for posting again at healthcaremagic.

I have reviewed the symptoms experienced by you after use of medications/food intake and ongoing medications. It is true that Prazosin can be cause for the Gastrointestinal symptoms but I do not think this holds true in your case. Fortunately there is no medication which slows the metabolism of prazosin.

The possibility for this problem is probably lies with your diet as you need to observe many precautions in regard to diet when using Nardil. I am sure that you must be following many of those instructions but I think there is need to review your diet options for further exploration of problem.

The second thing which I like to state is that probably use of Proton pump inhibitor such as Prilosec can be tried as therapeutic measure for this bloating and other symptoms. There is not much scientific background for this suggestion but there is no harm in trying it.

I hope this helps you.
Feel free to write back to me if you have more questions.
Thanks and regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ashok Kumar 40 minutes later
thank you! the GI symptoms seem to be passing...perhaps it was just a stomach bug, however the cognitive problems/lethargy are continuing in the morning...Is there a chance that there is still enough gabapentin in my system so that the morning dosage of nardil and lamictal are adding to the cognitive issues? I'm thinking primarily of GABA and glutaminergic activities that they both seem to have.

I'm probably going to switch up my sleep meds--adding trazodone (small dose) or bringing klonopin back in--because I am not sleeping well currently. I am going to ask a separate question about trazodone.
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Follow up: Dr. Ashok Kumar 1 hour later
ACTUALLY it's easier for me to write the question here because you have all my med info in front of you...

trazodone has proven to be good for sleep however I tend to get very edgy and irritable the following day. I'm guessing it is the Mccp metabolite. Also I am a slow metabolizer of trazodone according to me gene testing...is there a way to offset the MCCP metabolite? thanks
doctor
Answered by Dr. Ashok Kumar 13 hours later
Brief Answer:
Follow up

Detailed Answer:
Hello,
Thanks for reverting back to me.

First of all there is little possibility that Gabapentin plays any role in cognitive impairment on the following days of medication. The half life of gabapentin is just 5-7 hours and so there is good possibility that free form of gabapentin is metabolised to the 75% extent on the following day.

Now regarding the another part of question the ill effect of trazodone can be controlled in the following manner.
1. Using least possible dose of trazodone- say 25 mg or 50 mg.
2. With use of modafinil- This is a medicine which increases alertness and at the same time induces the CYP 3A4, enzyme involved in the metabolism of trazodone.

I hope this helps you.
Feel free to write back to me if you have more questions.
Thanks and regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ashok Kumar 8 hours later
but the MCPP is metabolized by 2d6...will that not create more avail MCPP, which acts as a releaser of the monoamines (which I suspect is causing the agitation)? thanks
doctor
Answered by Dr. Ashok Kumar 12 hours later
Brief Answer:
Follow up

Detailed Answer:
Hello,
Thanks for follow up.

It is true that MCPP is metabolised by CYP2d6 but with enhancement of 3A4 the trazodone will get early clearance and so the MCPP will be available early for metabolism, say late night or before the morning sets in.

We are not touching 2d6 as little is available for 2d6 enhancement among psychiatric medications. In case Modafinil does not help than the first suggestion "Using least possible dose of trazodone- say 25 mg or 50 mg" is remains option to offset the effect of MCPP.

I hope this clarifies.
Thanks and regards.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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