[lindaf]

Hi..I was previously on ativan for years, it stopped working for my anxiety, but my family Dr. wouldn't increase it to a full .5 mil and put me on lexapro and xanax. The xanax wasn't working well, so they put me on klonepin. That wasn't working and I have finally gone to see a psychiatrist who actually thinks anxiety is a medical problem, and we are trying to go back to the prozac and ativan. I have been on it since Friday and this morning I had an anxiety attack, and a .5 mg ativan didn't help, so he told me i can take as many as 4 a day while i'm getting used to it. I am not sure if the klonepin wasn't working, maybe it was and was in my system all the time. Should I ask him if I could continue the klonepin and take a 1/2 of a .5 ativan when I'm feeling especially anxious? Has anyone ever heard of anyone being on both? Thank you in advance for your help!

[kimmydawn]

I can't say what your doctor might say if you ask. I would certainly discuss any changes with him that you're thinking about first, though.

When I had panic, xanax was the only thing that helped me. I tried ativan and I told the doctor that I could've taken 10 at one time and it wouldn't have helped I don't think. He said that's because it's in slow and out slow. It doesn't have the "impact" to help with anxiety as xanax does. He said it was more for "generalized anxiety". I have no clue, but that's what he said. I do know in my experience, it proved true.

What strength of xanax were you taking? Maybe it wasn't as strong as you need until you get the panic under control.

I feel for you...so much. I used to have daily and crippling panic. After a period of medication to gain some control, then biofeedback therapy, the attacks ended completely. I went off the meds. That was eight years ago and I might have one panic attack a year. I know it's so difficult right now, but know there's hope that it can get better. I'm proof.

Biofeedback was awesome for my panic. Can you check into that in your area?

Good luck and welcome to PC!

KD

[CamW]

Linda - When starting on an SSRI like Prozac™ (fluoxetine) it is very common to experience an increase in anxiety and panic attacks. The increase in anxiety/panic attacks is normal and they should begin to lessen in number and severity over the first couple weeks as your body adjusts to the Prozac™.

As for the benzodiazepines, Klonepin™ (clonazepam; CDN is Rivotril™) Xanax™ (alprazolam) and Ativan™ (lorazepam) have a very similar mechanism of action as a result of their binding to the same receptors. In humans benzodiazepines exhibit 4 distinct effects: anxiolytic (or anti-anxiety; anticonvulsant; sedative-hypnotic (or sleep inducing); and muscle relaxant effects. Anxioytic effects are mediated through binding to receptors in the limbic and cortical areas of the brain. Anticonvulsant and sedative-hypnotic effects are mediated by binding to receptors in the brainstem, while muscle relaxant effects are due to their binding to receptors in the spinal cord. Benzodiazepines bind to all of these receptors and when they bind to receptors that we do not want them to we call the resulting actions "side effects".

The receptors that benzodiazepines bind to are called (not surprisingly) benzodiazepine receptors, of which there are two varieties or "sub-types" named BZ-1 and BZ-2. BZ-1 receptor sub-types are most abundant in the cerebellum, which, in part is involved in sleep mechanisms and mediate the sedative-hypnotic and anxiolytic effects of benzodiazepines. BZ-2 receptors sub-types are most commonly found in the hippocampus and basal ganglia which, in part, are involved in memory, motor (movement), sensory, and cognitive (thinking/reasoning/intellectual activity) functions. Thus BZ-2 receptor sub-types are responsible for the muscle relaxation, ataxia (loss of coordination), and cognitive impairments caused by benzodiazepines.

Benzodiazepines work by facilitating the neurotransmitter GABA (gamma-aminobutyric acid), whose primary role is to serve as an inhibitory regulator for other neurotransmitters, such as serotonin, norepinephrine, and dopamine (among others). GABA has a net inhibitory effect on neuron (nerve cell) firing, slowing the signaling from one neuron to the next. Hyperactive neuron firing in limbic and cortical areas of the brain result in anxiety. GABA acting on these overacting neurons slows the firing thus alleviating the anxiety.

Benzodiazepines alter the shape of the "GABA-receptor complex" so that GABA either binds more tightly or more easily to it's receptor. This enhances GABA's effects and leads to a slowing of the overactive neurons that are causing the anxiety and panic attacks.

I know that this is much more than you have asked for, but it does give the rationale behind the following answer to the question of whether you should take Klonepin™ with Ativan™.

All benzodiazepines act at the "GABA-receptor complex" in exactly the same way. Although there is some debate among researchers, there appears to be no major differences in the intrinsic activities of currently available benzodiazepines. Clinical differences (eg. potency, half-life, etc.) are usually explained by pharmacokinetic differences (absorption, distribution, metabolism, and excretion) and the use of dosages that are not equipotent.

Therefore, I would suggest that you should only use either Ativan™ or Klonepin™, but not both. Since the Ativan™ has a faster onset of action (especially the sublingual - under the tongue - form which quickly absorbs directly into the bloodstream through the thin and very vascular membrane under the tongue). The sublingual version begins working within 5 minutes, as opposed to the 20 to 45 minutes onset of action when a tablet is swallowed. Time to relief is a very important factor in treating panic disorder.

On the other hand, Klonepin™ has a longer half-life (the time it takes for 1/2 the drug to be excreted from the body) thus it doesn't need to be taken as often. Klonepin's™ half-life (including active metabolites) is 10 - 80 hours, while Ativan's™ half-life is 10 - 20 hours.

I prefer the Ativan SL™ over Klonepin™ for panic disorder and prefer Klonepin™ over Ativan™ for long term, daily use in anxiety because of Klonepin's™ longer half-life which gives a more consistent blood level, without the peaks and valleys in blood level of the shorter acting Ativan™. Also, you would have to take Ativan™ three or four times daily, as opposed to the once or twice daily dosing of the Klonepin™.

Discuss this with your doctor and see what his/her views are. Your doctor knows your medical history. Also, make sure that you are comfortable with his conclusions. Write down your concerns and take them in with you; it is too hard to remember all your questions in the short time that you are allotted for your appointment. Make sure that your concerns are addressed; the doctor may be the expert on diagnosis and treatment, but you know your body more intimately than he does. It is important that you both come to a concordance that is satisfactory to the both of you.

I hope that this is of some help to you. - Cam

[kimmydawn]

Wow, Cam, thank you!

I quit seeing that p'doc, btw.

That's very interesting for me to know. Again, thank you.

The ativan was useless for me back in the day, but it might've been too small a dose for my panic then. I couldn't take valium at all because it caused a peculiar anxiety for me because it made me feel "buzzed" and I felt I couldn't breathe well for about 20 minutes. I can't stand that feeling with the need for hypervigilence. Klonopin doesn't cause the slowed/altered breathing, works immediately and I can carry on without too much sedation (I'm prescribed the smallest dose and take a half a tab).

Anyhow, I rarely have panic anymore but when I feel my body "ramping up", I have klonopin available and it's done the trick every time...prior to the panic then when in full panic-mode as well. It also works WONDERFULLY on the nights that I can't sleep.

Thank you again!

KD

Cam!!!! i didn't understand 1/10th of what you said, but you're right.. ...Prozac works exactly that way......love, pat.........p.s. i'm past the anxiety stage with it now, for the most part, and things are going well........i take .05 xanax maybe once a day and it seems to be holding pretty well........

[lindaf]

Thank you all so much for your help....as far as the bio-feedback goes, I have tried that, support groups etc.. I have had panic/anxiety disorder for approximately 13 years now and have tried everything. The only thing that I have found to work and let me live my life with some semblance of normalcy is medication. I ...Again...thank you so much for the info!!! Linda

[okiedokie]

Hi Linda,
I'd like to recommend you talk to your doctor about using Neurontin. It is very effective for anxiety/panic, is nonaddicting with minimal side effects. Actually, no side effects for me. Treating anxiety with this drug is actually an off-label use but it's very effective.

Good luck to you. I'd love to hear from you if you opt to go this route.
Best,
Okie

[Brookester]

Linda, In my 15 years of experience with meds, the klonopin is the med that took time to build in the system while the ativan was more fast acting. Xanax is typically used for panic and anxiety but it takes time to find out what level is best. Keep an open line of communication with your psychiatrist and tell him/her how you are feeling and what these meds are or are not doing for you. Your psychiatrist's decision/advice that you up the Ativan until you get through this anxious period sounds like a wise decision since you are having panic breakthrough. I would just stick with the Ativan instead of incorporating the klonopin, too, so you will know what drug is doing what. Trust that your doctor knows what he is doing. I have a friend who is on both Ativan and klonopin, but he has such major agoraphobia he cannot leave his house. Good Luck, Linda.