166 replies to this topic

[greyeyed123]

Well, her confusion and balance issues seem to be worse on the extra oxycodone. (Especially 1 to 3 hours after taking it, then improves right before the next dose...then worsens again 1-3 hours later, etc.)  I'm thinking of going back to her normal dose. She's only been on the higher dose for 6-7 days.  Should I worry about withdrawals and taper over a few days?  We only have a few of the 5/325's left, so I'll have to switch to the 7.5/325's pretty soon, but I'll only give her 3 a day instead of 4, which will only be a little more than her old dose.

[fishinghat]

She has only been on the higher dose for 6 to 7 days so I would be tempted to just switch her back to her regular dose BUT it might be safer to reduce her dose half way back to her original dose for at least 3 days to see if there is any withdrawal symptoms. This is just my thoughts so it is really up to you.

[greyeyed123]

For her midnight dose, she did have more shakes and confusion, but went right back to sleep without issue.  This morning she fell going to the bathroom (minor fall, next to bed, landed on her butt, didn't hit her head), but it was a 1/2 hour before her morning medications so most of her Parkinson's meds had worn off.  She was having minor hallucinations both times--thought she saw a cat at midnight, and thought someone was in the house this morning.  She had these kind of hallucinations on dilaudid previously (except more often and more severe) and I was concerned this might happen on the higher dose of oxycodone. She had a few others the last few days, and also started hanging off the right side of her chair (confused and "out of it") in the same way she did when on hydrocodone and was sneaking an extra half (she was in charge of her meds back then). 

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Right now I'm just going to keep on keepin' on with 4 of the 5/325's a day.  If there are any huge problems, the extra halves are available. I am kinda concerned when the the 5/325's run out and I have to give her 3 of the 7.5/325's per day. The doctor said that would be about the same, but would that fluctuate in her blood so she might have the same side effects?  Or would it mostly be the same as taking 4 of the 5/325's?

[fishinghat]

Her daily dose of oxy  would be 975 mg (3 x 7.5/325) com pared to 1300 mg (4 x 5/325). A significant change. At 33.3% higher dose. The increased effect of the acetaminophen would help offset the change in hydrocodone but not that much. The hydrocodone is the major player. Remember that the half-life of oxy is around 5 hours (varies a lot). So going to 4 times a day not only is a 33% increase but the blood levels overlap more leading to more oxy in the system reaching a peak in about 1 week. At 3 times a day there is only 33% of the oxy left in the system when another pill is taken 8 hours later. At 4 times a day there is still 50% of the oxy left in the system when you take the next pill 6 hours later. Just some things to think about.

[greyeyed123]

She's not on the hydrocodone anymore, just the oxycodone.  We do have regular OTC extra strength tylenol if needed.  We haven't used that in a very long time, but we were told she could take one or two of those a day if she needed to even before this change.

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In terms of her balance, agitation, and confusion, she seems BETTER the longer it has been since she's taken a dose. And the fluctuations in her pain don't seem to correspond much with the pain medication (I swear sometimes it seems to make it worse).  She always says it "takes the edge off" a little bit, but I'm not sure if her perceptions of that is accurate as she sometimes gives conflicting descriptions of how she feels (and her perceptions/memories of the outside world are often confused or inaccurate, so I often take what she says about how she feels internally with a grain of salt and try to judge from how she's acting).

[fishinghat]

My apologies. I was thinking she was on hydrocodone. The same principles apply to the oxycodone though.

 

My heart goes out to you. It must be so difficult managing this situation when you can not rely on her input. You are doing a very good job though. You could keep track of her loss of balance events. Note the time and how long after the last dose. You would need to do this over a couple 3 weeks to get reliable info. From that you may get an idea on how the medication is affecting her. Unluckily her Parkinson symptoms would naturally ebb and flow and that would make establishing a pattern more difficult.  Watching her for symptoms is not real practical as you can not always follow her around day and night. I wish there was a better way to tell. Sorry I can't help much.

[greyeyed123]

It's 10:30 and she's already much better than she was in the last 5 mornings. She was wobbly at first and I followed her around just in case, but her confusion seems to have resolved, and she's not agitated at all.  Hoping the rest of the day goes as well.  The pain doctor scheduled her next appointment for a month instead of 2 just in case this didn't work, so we go back on the 28th. I'm hoping once we have to switch to 3 of the 7.5/325's a day that she does as well.  We'll only need to make it a week or two before the appointment and have them switch her back to the 5/325's.

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Part of her falling is from lack of exercise (and insisting on wearing slippers that keep her off balance, although I have convinced her to wear shoes most of the time). I found some Parkinson's exercise videos on youtube that might be helpful.  She took physical therapy about 3 years ago and it helped quite a bit, but since then dad went for physical therapy for his back pain and his paranoia (from PTSD) kicked in and now all physical therapy is a scam to get your money, etc., and I can't mention it without a 2 hour diatribe. She doesn't really want to go anyway, but he doesn't make it any easier. Maybe I can work with her at home to get some improvement. 

[fishinghat]

There should be plenty of good videos on the internet that should help. I have used them in my occasional need for PT. I have a good physical therapist. He will look over what I select and tell me which ones are good and which ones are bad that way I can do my pt at home.

[greyeyed123]

I'm switching her to the oxycodone 7.5/325's tonight as I'm out of the 5/325's now.  The pharmacist says I can cut these (7.5's) in half even though they are not scored.  I've looked all over the net and only found one or two message boards that seem to say the same thing, but it's not entirely clear.  She's had a couple more falls this week and I'm concerned giving her a whole pill (of the 7.5's) may cause her falls to worsen in the first few hours after she takes it. Even if I only give her one pill every 8 hours, that's a lot of hours with more instability and fall risk. I was thinking of cutting them in half and spreading 5 halves out throughout the day in hopes of A) not increasing her present dose at all (actually this would reduce her a bit more than one mg), and minimizing her confusion, dizziness, and instability...without, hopefully, causing her worse withdrawals or side effects.

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Thanks in advance for any input you can offer or find on the net.

[fishinghat]

I agree. By using half doses you can adjust her overall intake in a more controlled way. It allows you more flexibility.

[greyeyed123]

Seems to have worked. Five hours seems to be work the best. She did have a few minutes of withdrawals today, but I think it was interdose lorazepam withdrawal.  No falls today.  I also only gave her 2 norflex yesterday (100mg er).  She usually takes 3 a day, but I still think she does better with only 2 a day.  I mentioned this to her neurologist previously and he said he didn't think it would matter that much (she ALWAYS insists on taking 3 as she believe it helps, but I think she gets confused and when her latest Parkinson's dose kicks in, she thinks it's the muscle relaxer making her feel better).  But later the neurologist said he didn't know what norflex was (I only said "muscle relaxers" when I asked him about 3 a day).  She had been on tizanadine (muscle relaxer), but was fainting several times a day, so we stopped that, switched to norflex (aka orphenadrine), increased her salt intake, and stopped metoprolol also. That resolved her fainting at the time, but now she's falling more (if not completely fainting; sometimes it's a partial faint, sometimes she just freezes up and falls, sometimes she loses her balance;  I know some is orthostatic hypotension associated with Parkinson's, so that's why the extra salt helped previously).

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I think I can leave her bedtime muscle relaxer out without her noticing (last night, she had only taken one by the time bedtime rolled around, so I just gave her the second one and put the third one back).  At this point I'm thinking she's just over-medicated, as well as needing some physical therapy.  She ended up on 3 of the norflex a day when we started tapering the lorazepam over a year ago, and she was having cramps (probably from the tapering). She will never say no to extra meds, and since there was no noticeable adverse effect today (actually she seemed better), I think I'll continue a few days and see if her falling stops.

[fishinghat]

Man, what a complicate nightmare. One of my professors once said that in biology everything is interrelated. You can't change one thing without effecting another. Your situation is an excellent example of that.

[greyeyed123]

Do you know if Norflex (aka orphenadrine) has withdrawal symptoms, and where I might find what they specifically are?  (I've searched all over, but the information seems spotty or incomplete.) Mom has been having a lot of fainting, so I reduced her down to 2 of the 100 mg ER tabs from 3 a day. She seemed better for a couple of days, and then fainted several times in one day. I went to zero for one day, and no fainting. The next day she DEMANDED at least one, so I gave her one about 2pm. The next day, the fainting began again. I told her she isn't getting any more of them, which upset her, but the fainting is getting ridiculous. It's been about 3 days with none. The fainting almost completely resolved. Yesterday she was much better, but today she is worse...although not worse all day (a couple of hours in the morning were normal, and a couple in the afternoon), fainting twice. For a couple of the last few days I increased her salt (the fainting has happened before, with low blood pressure, so her neurologist said to increase the salt--I think I mentioned that above). But over the last two days she's had a couple very high blood pressure readings--although I'm not always sure if my readings are always correct.

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She seems much more sensitive to interdose lorazepam withdrawal now, even though I've had that on pause for at least a week. Yesterday I adjusted her parkinson's meds to every 3 hours and 15 minutes instead of every 3 hours 30 minutes to see how she did. She did much better yesterday (walking around much more often without her walker and without fainting), yet today she seemed to only have "islands" of good hours and the rest was bad, although mostly her blood pressure seemed higher (during all the days of fainting it was very low). 

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I'm suspecting some lingering withdrawal from the orphenadrine is causing her to feel bad and raise her blood pressure, but I don't really know. I was giving her more salt for a few days, but for the last two I've stopped that as her blood pressure was high on several occasions (accompanied by more complaints of pain, feeling awful, and generally looking the way she does in mild lorazepam withdrawal--no screaming, just anxious and shaking and wondering if she has an infection or could be having a heart attack, etc., then 30-60 minutes after her next dose of lorazepam she is better, although not great; sometimes 30-60 minutes after her next dose of oxycodone she is better too, but not always...so I don't know).

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Thanks for any input you have.

[fishinghat]

Be back soon with some info.

[fishinghat]

It took a little digging but this is all I could find.


Orphenadrine

https://dailymed.nlm...9d-26c9ec034a32

Drug Insert

The mode of therapeutic action has not been clearly identified, but may be related to its analgesic properties. Orphenadrine citrate does not directly relax tense skeletal muscles in man. Orphenadrine citrate also possesses anti-cholinergic actions.

Warnings

Some patients may experience transient episodes of light-headedness, dizziness or syncope. Orphenadrine citrate may impair the ability of the patient to engage in potentially hazardous activities such as operating machinery or driving a motor vehicle; ambulatory patients should therefore be cautioned accordingly

Note - There are numerous documents that fainting (sycope) is a common side effect of Orphenadrine.
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https://www.ncbi.nlm...pubmed/19694744

Br J Clin Pharmacol. 2009 Aug;68(2):238-42. doi: 10.1111/j.1365-2125.2009.03446.x.

The use of antipsychotic and anticholinergic antiparkinson drugs in Norway after the withdrawal of orphenadrine.

Abstract
AIMS:
Extrapyramidal side-effects induced by antipsychotic drugs are treated with dose reduction or substitution with another antipsychotic drug or by the addition of anticholinergic antiparkinson agents. The withdrawal of orphenadrine from the Norwegian market provided a possibility to investigate to what degree these alternative measures were taken in clinical practice.

METHODS:
Data were drawn from the Norwegian Prescription Database on the sales of antipsychotics and one of the two anticholinergic antiparkinson agents marketed in 2004, orphenadrine and biperiden, to a total of 39 758 outpatients. The patients were reinvestigated in 2007. The consequences of the withdrawal of orphenadrine from the Norwegian market in 2005 regarding dosing, switching and cessation of antipsychotics and use of anticholinergics were assessed for orphenadrine users compared with biperiden users.

RESULTS:
Of the patients originally using orphenadrine, 28.4% stopped using the drug without reducing the antipsychotic dose or replacing orphenadrine with another anticholinergic agent. The corresponding number for biperiden users was 19.3%. Only 11.8% of patients switched to another antipsychotic drug, but they used significantly lower antipsychotic doses than those who stayed on the same drug.

CONCLUSION:
The use of anticholinergic antiparkinson agents could be seen as superfluous for at least one-third of patients
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Postoperative orphenadrine withdrawal.
Note - I have requested this article and will let you know when/if it comes in.
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http://www.crazyboar...lComment_684888

I was on orphenadrine for a long time and was able to come off of it fairly fast, with no withdrawal effects and I had no side effects with the med when taking it.
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https://www.ehealthm...rawal-syndrome/

581 people reported to have side effects when taking Orphenadrine citrate.
Among them, 6 people (1.03%) have Drug withdrawal syndrome
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https://www.scienced...416058939003476

All five newborns were healthy and did not show withdrawal symptoms after birth.
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Withdrawal. A suspected withdrawal syndrome was reported
in a 56-year-old woman who showed slow neurological postoperative
recovery after her orphenadrine treatment had been
stopped abruptly;1 her status improved when the drug was restarted.
1. Esler MD, et al. Postoperative orphenadrine withdrawal. Br J
Anaesth 2000; 85: 497.
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http://www.rxmedscan...rphenadrine.php

Sometimes the sudden withdrawal of high Norflex doses after prolonged use it, may cause depression, irritability, loss or increase of appetite, sometimes.
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http://www.healthcar...enadrine/235568

What are the withdrawal symptoms of Orphenadrine?
Answered by Dr. Ronald Schubert 38 minutes later
Brief Answer:
Resumption of prior Parkinson's symptoms

Detailed Answer:
Thank you for contacting HCM with your health care concerns

You are currently on Orphanedrine which is an anticholinesterase use for Parkinson's disease to control tremor and muscle pain/spasms. If you suddenly stop the medication your Parkinson's or muscle spasms may get worse. Otherwise there are no significant withdrawals like after taking opiates. So if you are thinking of stopping just be aware of an increase in your prior pain or Parkinson's symptoms
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http://mm.wirral.nhs...idanceJan16.pdf

· If the plan is to discontinue the orphenadrine, the discontinuation should be slow and gradual, over 1-2 weeks. High doses of medication should be withdrawn even more gradually over a period of weeks. Possible withdrawal symptoms may include:

 feeling sick and being sick
 flu-like symptoms
 stomach cramps
 runny nose
 watery eyes
 Hypersalivation (too much saliva, which may cause you to dribble)
 indigestion
 sweating
 vivid dreams
 insomnia
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https://www.medicine.../medicine/10732
Avoid abrupt discontinuation of treatment.
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[greyeyed123]

That's largely all I found also.  (It seems to be a very old medication that is rarely used anymore.  She had been fainting previously on tizanadine, so her doctor switched her to these several months ago.)  Unless she gets worse, my plan is to keep the lorazepam at the same level for a couple of weeks and not give her any more orphenadrine.  The fainting is what I'm most worried about at this point. I already tried reducing to one a day and the fainting started again, so I guess I'm stuck.

[fishinghat]

Sorry I couldn't help more but not much out there on the subject.

 

Good luck.