I am planning on starting to withdraw from pramipexole. I have been prescribed gabapentin on a daily dose of 3 x 600mg daily to start taking as I withdraw off pramipexole. Should I start with 600mg for a few days, then add another 600mg dose say a week later, and then an additional 600mg a week after this? My neurologist has said that I will likely have to play with the dosage a little to find the level that works for me. I am just not sure where to start.
I have the same question regarding the buprenorphine/naloxone dosage. I have been prescribed 1mg of this up to twice daily as needed.
I understand that the gabapentin is unlikely to work while still taking pramipexole but need to get it built up in the system. I can use the buprenorphine during this time to control the RLS . So should I take it around the same time as the gabapentin, about 2 hours before bedtime? I can take a second dose of buprenorphine, and if I feel this is needed do I take it four hours before bed or take it much earlier in the day. The neurologist also said that I can halve or quarter the buprenorphine to start with as several of her other patients find that is enough.
I welcome thoughts, suggestions, advice on timing and amounts to get started.
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Kejimkujik
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Sounds like good advice from your doctor. Buprenophine works quite fast, that is if the come as sublingual pills. So start with quarter or half pill and add another bit after say 1-1.5h if it doesn’t work well enough. The buprenorphine may give relief from day 1.
The gabapentin most likely needs several weeks.
But - what is the aim? Build up gabapentin and rely on that mainly or alone once you have found your effective dose? And is the buprenorphine only to cover the withdrawal from pramipexole and build up of gabapentin? If so, look up replies from Sue Johnson as she comprehensively gives our common experience on this.
However, withdrawal and build up is going to take a while if you follow the slow and steady route. If the buprenorphine is very effective for you, you may be able to speed this up. In any case, if you aim to in the end rely on gabapentin alone, be aware that reducing and stopping buprenorphine will most likely also involve withdrawal - including worsened RLS. Things to think about and discuss with your doctor.
For now, I wish you a good start, smooth journey and calm nights!
PS I am on buprenorphine only, couldn’t get on with gabapentin.
You should start out with 300 mg 3 weeks before you are off pramipexole. You need to ask your doctor for a prescription for 100 mg of gabapentin since you don't want to increase that quickly and you may not need 1800 mg. Increasing slowly helps with any side effects. After you have been on gabapentin 3 weeks, as it takes that long to be effective you can increase by 100 mg every couple of days until you get to 900 mg. Then wait until you are off pramipexole and your symptoms have settled. Then continue increasing by 100 mg until you find the dose that works for you. According to the Mayo Clinic Updated Algorithm on RLS: "Most RLS patients require 1200 to 1800 mg of gabapentin."
Take it 1 to 2 hours before bedtime. Since you will be taking more than 600 mg take the extra 4 hours before bedtime as it is not as well absorbed above 600 mg. If you need more than 1200 mg, take the extra 6 hours before bedtime. If you take magnesium, even in a multivitamin, take it at least 3 hours before or after gabapentin as it interferes with the absorption of gabapentin and if you take calcium don't take it within 2 hours for the same reason.
Most of the side effects will disappear after a few weeks and the few that don't will usually lessen. Those that remain are usually worth it for the elimination of the RLS symptoms.
so another question....I really appreciate your patience and invaluable advice and the people sharing their experiences of what worked for them. My question is that everything is suggesting taking medications in the evening as that is when RLS generally kicks in. However, I experience it anytime of day. For exampleyesterday, I took incidentally just two pramipexole , 1 in mid afternoon and the second around 9pm yesterday, and the first 300mg gabapentin at 9pm. I took my iron supplement at 11pm with 500mg vit C tablet (chewable). This morning when heading out to drive I felt RLS kick in and so took a pramipexole. As i get to withdrawal time for pramipexole would it be useful to be taking any meds earlier in the day to spread them out more to reflect how RLS affects me now? or stick to taking them later in the day you have advised, and the morning and afternoon RLS will disappear as it is the augmentation of pramipexole causing this? I think my neurologist said something to the effect that I could take a tiny amount of the opioid in the morning and an equally tiny amount in the evening. Or is this all going to be a trial and error? There really is no such thing as one size fits all lol.
Yes it is the augmentation causing it so while that is happening you can take your medicine during the day especially the opioid and yes you will need to experiment. However since the gabapentin isn't helping much at this point and since it helps with sleep, I would take all of it in the evening.
Awesome thank you. Have not started the suboxone yet. Thought to focus on gabapentin and see how that works for me over the next three weeks. Then will start to reduce the pramipexole and see how an increase in gabapentin works. The neurologist did say that which route I take is really down to how I am on whichever meds or combination thereof and she could not tell me that. She has some on just high dose gabapentin, some who just use suboxone as they had a hard time on gabapentin, some she switched to pregabalin and that worked...
I have to say it is interesting to have someone who has basically put me in the driving seat as to how this is going to look.
I hope your doctor gave you this advice: to come off pramipexole reduce by half of a .125 tablet every 2 weeks or so. You will have increased symptoms. You may need to reduce more slowly or with a smaller amount. Wait until the increased symptoms from each reduction has settled before going to the next one. You will suffer and but the buprenorphine should help out with the symptoms especially as you near the end and it may make it possible to reduce more quickly.
You can take the buprenorphine at the same time as gabapentin.
So my tablets are .25 mg so I should reduce by a quarter tablet at a time. Probably a stupid question but do I take a quarter off the three daily tablets I am now taking or just off one and take the remaining two as whole .25 mg tablets? Am having some brain fog around this now so have to break things down into very specific details.
If I remember our conversation correctly the neurologist feels that I have RLS severely enough and the gabapentin won't work fully until off pramipexole that I be prepared to draw on the suboxone at least to get off pramipexole.
I am wondering about using pramipexole and buprenorphine at the same time? I think the standard advice when coming off pramipexole is to taper down and add opiates if needed. In my case, I stopped pramipexole completely when I started buprenorphine because it eliminated the need for it. While tapering off while using pregabalin, I needed to take an additional .125 - .5 mg of pramipexole when symptoms were bad. But I did not need any more pramipexole after starting buprenorphine. I believe both meds are sedating, and using them together can increase the sedating effect. DA withdrawal can cause depression, insomnia, etc., so tapering down makes sense. With my very fast withdrawal, I did experience depression and occasional insomnia (cannabis solves that for me). But that seems resolved now at the 2 1/2 month mark. Presumably pramipexole doesn't reduce the effectiveness of buprenorphine? If my experience (and Joolsg also I think?) is common, then maybe the primary reason for a slow pramipexole taper is DAWS, not the RLS symptoms (as those reolved immediately with buprenorphine. But the slow taper comes with the downside of more sedative side effects while on both - which is still probably better than DAWS for most people. Make sense??
You are correct that pramipexole doesn't reduce the effectiveness of buprenorphine. Both DAWS and opioids can cause insomnia. Whether the buprenorphine controls the increased RLS symptoms while coming off it depends partially on the individual and the dose of buprenorphine and whether the person can stand the side effects they have which is also individual of the buprenorphine dose necessary to control the DAWS.
Slightly off topic so apologies I was on a Buprenorphine 10mg patch for 2years and told NOT to take Gabapentin or CoCodamol.
2 years on after terrible gut problems which no-one could identify and after stopping most of my other medications apart from Metformin and suicidal I stopped the patch. I suffered no side effects other than an immediate cessation of all stomach problems
Gp’s reaction ‘oh never heard that before’ end of subject no replacement pain medication offered.
Sue, please can you advise. I still have a repeat prescription for Gabapentin 300mg 3 times a day should I start this as the pain from my various ailments is making functioning impossible.
Just off one. If you can't easily cut them you can get an inexpensive jewelry scale on Amazon ($11 in the US) that measures down to .01 gram and shave off enough to measure a quarter or ask your doctor to prescribe .125 tablets.
I'll relate my recent experience - hope it can help. I started tapering down pramipexole while starting pregabalin (75mg). Only when starting buprenorphine did the RLS stop. I didn't like the pregabalin side effect of weight gain, and given the fact that it takes a while after coming off DAs for the dopamine receptors to reset, I figured I would revisit pregabalin later. I started with suboxone sublingual strips (2 mg buprenorphine, .5mg naloxone), using 1/4 of a strip at night (so .5mg of buprenorphine). That was more than enough to keep RLS at bay. I even tried taking 1/4 strip every other night, and that worked for a week or so before needing to go back to nightly. I think the long half-life of buprenorphine (30 hours+) is what made it last 2 days for me. That long half-life makes me wonder why your neurologist would prescribe twice a day? I did find as I experimented with dosage (trying 1/5 of a strip, 1/6, 1/8) that I might need a strip in the afternoon instead of night if I wanted to take a nap. That's the great thing about the sublinguals - you can take it as needed, and they are fairly fast acting (30 minutes or a little more for me). I ultimately settled on 1/6 of a strip, and didn't have to take it any earlier after I got into that routine. A couple weeks ago I switched to the buprenorphine patch to see if that helped with constipation - the buprenorphine side effect that did not lessen for me after the first month or two. And the patch does seem to be much better in that regard.
With the buprenorphine, I was able to taper pramipexole in half (to .125mg) for a week, then stop completely. I realize I am very lucky and probably an outlier in the ability to come off it so quickly.
So....my advice to you would be to experiment with your dosage for a couple weeks as you try to find the minimal dose that works for you. I think it took my body a month or so to adjust to it such that I could establish a regular pattern/dosage. Maybe start with half of the 1mg and see what happens. Given the long half-life, I don't think it matters much what time of day you take it. But 2 hours before bedtime is probably a good starting point. If you have any RLS symptoms after an hour or so, maybe take a little more. If .5mg works for you without needing any extra, then try to experiment with slightly reducing that. Side effects are minimized with smaller doses.
I've tried starting pregabalin again, but strangely that seemed to aggravate my RLS symptoms. So I'm only taking buprenorphine. I might give pregabalin (or gabapentin) another try in a few more months after my dopamine receptors have had more time to recover. But I'm in a great spot now.
Sue's advice about the gabapentin dosage makes sense. It seems silly to start off taking such large doses when you won't really know what effect it is having until the DA is out of your system.
Thank you this is really invaluable as an example of how to taylor ones meds to keep it to the minimum. My neurologist has prescribed the max dosage on the advice to start low. She explained some of her patients take less than a 1/4 suboxone. She wants to be sure I have the meds I need to succeed in getting off pramipexole. My RLS kicks in throughout the day. The drive to the neurologist is about 2+hours and I had to take a pramipexole two hours before we set off as sometimes it makes it worse before it makes it better and it for sure would have had a field day with me if I took nothing. I will note down the levels you tried and when as it gives me an idea of how that can work and thank you for sharing your experience.
Hi Kejimkujik. I am happy for you that you are getting off the pramipexole. Good riddance.
It takes about 30 minutes for my buprenorphine 2mg sublingual tablet to kick in. I usually take it a couple of hours before bedtime and that seems to work well for me. You will have to see what works best for you.
hello, I would say that sounds like quite a high dose of buprenorphine - so definitely start really low to see how you react to it. I take 0.8mg of buprenorphine in two 0.4 doses. When I upped it to 1.2 it was too much for me. I take it with pregabalin ( currently 150 mg ) which I think is basically the same as gabepentine. I was initially on roprinirole which is similar to prami.
It’s great that your neurologist has prescribed you all the medication that you will need however they are both extremely strong drugs so definitely progress slowly. Good luck.
I had to play around with the gabapentin dosage but have ended up withGabapentin at 6pm, 8pm & 11.15pm
I take the buprenorphine 2mg at 10pm but I see you divide your dose
I did find I needed my dosage of both in the evenings and as near to bedtime as possible but you need to work out what suits you best & depending on when you go to sleep.
In my case 11.30pm.
I found them quite forgiving in that if I am going out or travelling I adapt to suit.
I also take gabapentin (600mg as Horizant and 800mg as plain gabapentin). Plus I take 5mg of oxycodone.
I take the Horizant at 7pm and the gabapentin at 10pm which is 2h before bedtime for me. This combination for me at least provides excellent relief I would say 90% of the time. Sometimes my RLS flares up and I suspect it has something to do with what I ate which inhibits the gabapentin absorption
I have found that gabapentin and oxycodone are synergistic and I think gabapentin and buprenorphine are probably a great combination too. I 100% agree with Sue Johnson’s advice because I too had to taper up with the gabapentin. Please be patient during your tapering up. I think if you taper up too fast with any of these drugs you risk getting over medicated and the side effects are not good
Sounds like you have a knowledgeable neurologist and I am optimistic for your ultimate outcome. Switching RLS medications is NOT fun and there’s an adjustment period I have found. But there’s light at the end of the tunnel I assure you !
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