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peregrine

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Everything posted by peregrine

  1. No problem! It sounds like I don't have any damage to my esophagus from acid reflux, and the morphology is overall normal. One weird thing was that I still had some food in my stomach despite not eating for 8 hours (they asked for 6 hours of fasting and I happened to do 8)... he suggested Iberogast (and told me to talk with my PCP about it) to help with that and the symptoms in general. Still waiting on the results from the biopsies for bacteria and lactose intolerance. I was skeptical of Iberogast initially (herbal mix?!), but this study is pretty convincing: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2036.2004.02275.x/abstract "Meta-analysis: phytotherapy of functional dyspepsia with the herbal drug preparation STW 5 (Iberogast)" - apparently it has a significant impact on stomach symptoms and is as effective as conventional medical treatment in some cases. Now just waiting for the results and the news from my PCP! [btw, corina, I'm actually living in Europe now - Zürich specifically]
  2. Just wanted to post a positive experience with procedural sedation and POTS in case folks are looking for case studies. I had an upper endoscopy (mouth to the bottom of the stomach) this morning with procedural sedation with propofol. The doctor used double his normal dose of saline (he usually uses 250mL but used 500mL with me), and they used a mouthguard (standard, I think). O2sat (via pulse oximetry) and blood pressure were both monitored. I remember feeling "funny" and then waking up feeling very drowsy but otherwise okay; I was also pretty talkative! For the next hour or so I was very dizzy (required my cane to walk safely), but otherwise have had no POTS symptoms triggered (dizziness like this isn't normal for me with POTS or otherwise). Jaw also feels fine, despite the H-EDS and jaw troubles. Only downside is the sore throat! But I'm taking it easy today and resting at home just in case. I didn't even feel faint from the IV, which is a real wonder as that's usually a serious trigger. I had spoken with the doctor on the phone yesterday and he seemed receptive to my concerns/suggestions; definitely a good thing to do with POTS before any procedure involving meds!
  3. Blue, just read your comment in my email. One possibility re: cutting down on meds is that the doctors are concerned about rebound headaches, which are not uncommon with chronic pain medication (you can read about them on wikipedia). This might explain their concern, rather than being concerned about you overusing opiates for Bad Reasons or something like that. (Regardless, it ***** a ton, and I am super-sorry to hear that!)
  4. Heading to my regular doctor tomorrow AM to talk about having been sick for a week and coughing up green stuff from my lungs (pneumonia? who knows). Ewwww! No fun. I'm curious if anyone here has had an increase in "sympathetic" symptoms - specifically higher heart rate and higher blood pressure - when pretty sick. Between guanfacine (similar to clonidine) and atenolol, my blood pressure has been a nice 95/60 lying down and 105-110/70 while standing up, and heart rate 55-60 while lying down, 70-80 standing. The fludrocortisone (Florinef) hasn't given me supine hypertension - it actually hasn't affected my blood pressure at all, though it does help my symptoms a lot! With this sickness, though, my average lying and sitting blood pressure has been more like 125/75, and I've even peaked to 150/95 (scary for me), and lots of tachycardia and palpitations, plus the usual issues controlling body temperature and having strong tremor. I'm still taking my meds as usual and getting plenty of fluids and rest, so I'm not sure what's going on. Is this a typical thing? How do you address it when you're sick with non-POTSy infections? My neurologist didn't seem to have much to say about it...
  5. Welp, I've been on guanfacine for about 2 months now, so figured I should answer my own post in case it's helpful to others. It took a few weeks for me to ease off the clonidine - I got some rebound hypertension during the transition, so we briefly upped my guanfacine to compensate, then took it down again. Guanfacine has generally been good - my insurance doesn't cover it, but it's pretty cheap (about the same as the copay would be for a month's supply, about $8). I even did some statistics last night (since I keep records) - here are the results that were statistically significant! Guanfacine does seem to worsen my heat tolerance and nausea somewhat compared with clonidine, and I do report more other symptoms. On the other hand, I am less fatigued, and also have fewer issues of microsleeps (nodding off in the middle of the day while not trying to nap), both things that were worsened by clonidine. I also dream more - back to my pre-clonidine dream amount - which I hadn't even realized the clonidine had decreased! There are a few good papers out there about the comparison, which were helpful: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1430114/ - "Differences in psychic performance with guanfacine and clonidine in normotensive subjects" http://www.ncbi.nlm.nih.gov/pubmed/6994771 - "Central effects of guanfacine and clonidine during wakefulness and sleep in healthy subjects"
  6. My psychiatrist today suggested I talk with my neurologist about guanfacine, a more selective alpha agonist than clonidine (an alpha-2A agonist instead of just an alpha agonist like clonidine). She says it might have fewer side effects, since it's more selective. I know that one person here has used it, but had to stop due to side effects. Does anyone here have thoughts or experience, or any insight? Thanks!
  7. Let's see here... I'm going to count times that were not just bad presyncope, but actual about-to-black-out types of episodes (actual syncope only once, but plenty of "stay with me, come on, breath slower, stay with us here.." kind of stuff. As a 15-year-old kid I was super-afraid of needles (not the combative type, just crying and terrified). My pediatrician tried Emla cream (a really good topical anesthetic) for a blood draw. It worked - I didn't feel the needle - but I fainted in the parking lot afterwards (stepfather caught me, fortunately). I was also sick at the time - probably didn't help. [since then I have gotten much better, and just lie down for blood draws] Nearly passed out again (not quite black out) after having to get a restick for a blood draw at 22. At 25, about two months after POTS stuff started, the cardiac electrophysiologist I had an appointment with explained - in detail - how an ablation is done. I apparently got white and shakey (and kept talking about vomiting and wanting to lie on the cold, hard floor); end result, she had me lay down pronto, and was pretty impressed. At 26, about a month later (whoo fall birthdays), I got my first MRI with IV contrast, and nearly passed out again when they put the cannula in. I'd gotten some xylocaine beforehand, which meant repeat needlestick, which didn't help. Two separate times since then I have nearly passed out due to pain - once while my PT did some serious myofascial work on my abdominal wall, and a second time when I had xylocaine injected to treat an abscess in a particularly sensitive area. At 27, a year later, I got another MRI with IV contrast (whoo annual screening), and almost passed out again. So, other than the one real syncope, it's all been very, very close (I was lying down for almost all of the rest, which probably prevented a full syncopal episode). But I would say mostly due to fear (the real syncope at 15), and sometimes very close due to pain.
  8. Hi k&ajsmom - sorry to join the conversation so late! I have been taking Lamictal for the last 8 years, and it doesn't seem to have caused any POTS-type reactions before I started having POTS several years ago. As far as I know it's pretty good for that. SNRIs mostly affect your serotonin and norepinephrine levels (Wellbutrin, which is not technically an SNRI but is a non-SSRI antidepressant, affects norepinephrine and dopamine). I have noticed Cymbalta (an SNRI) affecting my POTS symptoms in a slightly worse way, but since it was what seems to have triggered my POTS in the first place, that may be specific to me. The explanation about your partner is kind of weird - what I would say (not a doctor, of course, but) is that adrenaline levels in your body are what tend to affect sweating, adrenaline rushes, high heart rate, etc. Things like SNRIs mostly affect the levels of norepinephrine in your brain, which can decrease chronic pain (as in Cymbalta) and depression, but not so much in your body most of the time, although Cymbalta can increase your blood pressure slightly; basically, it mostly does things in the brain. However, if episodes with adrenal surges are due to stuff happening in your brain (perhaps like PTSD, for example), then the SNRI can work on preventing the response to things that trigger those episodes - basically, you see something that stresses you/triggers you; you don't react as strongly because your brain neurotransmitters are more stable; ergo fewer body responses because your brain isn't going haywire. Does that make sense? Certainly for me the Cymbalta and Lamictal didn't do anything for the body in a good way! I have found that clonidine does help in that area, though - it works in the brainstem to "mute" signals that encourage production of adrenaline in the glands on top of the kidneys, so you get mostly body effects. I know clonidine is used for ADHD, but I haven't seen anything for it in PTSD; for me it does decrease my overstimulation and tendency to look behind me to make sure nobody is coming up behind me (since I space out a lot), so I wonder if anyone has looked at that in PTSD. Anyways, hope that is helpful! Feel free to pm me if you have other questions, or ask here, or whatever :^)
  9. Like Rama, how much it helps can be hard to tell since every specialist has a different opinion and approach. For me, it was useful to look at my symptoms and look for patterns - for example, I don't pool visibly unless I've been in a hot shower, but I do sweat a lot and startle easily. During my TTT, I did pool visibly. My blood pressure is more often high than low. I get lightheaded and spacey, and overstimulated, but have never actually fainted due to POTS. If you look at my labs (e.g. the autoimmune ones), they are negative, and there was no sudden start or linked illness or accident. My standing/lying norepi has never been tested. Based on 24-hour urine sodium, my blood volume (this is a proxy and not an absolute like you would get with a radiological test) is pretty normal, and I retain salt just fine. I have joint hypermobility syndrome, which is (depending on who you ask) a form of EDS. I don't get any of the MCAS symptoms. My QSART was positive, so I probably have some mild neuropathy, and my toes are numb. The end result of thinking about things that way was that it helped guide treatment. For example, because of the limited pooling and okay blood volume and salt retention and normal to high blood pressure, we have never tried midodrine or Florinef, but I do wear compression stockings and take salt because those are generally helpful as volume expanders (my neurologist described it that way to the medical student he had with him one day, who was trying to figure out why I was on betas and clonidine but also eating salt!). Because there doesn't seem to be any autoimmune component to my POTS, we haven't thought much about IVIG or similar treatments. Betas have been helpful. After a while of badgering my neurologist, he agreed to try clonidine, which has made many of the sympathetic-type symptoms (sweating, startling, being overwhelmed, resulting fatigue) much better, so my SNS was probably a bit overactive. The combination of joint hypermobility syndrome and numb toes also suggests some more minor role of pooling, so I probably have some combination of secondary (JHS/neuropathy) and primary (hyper-ish) POTS. Pyridostigmine hasn't helped, so my parasympathetic nervous system is probably okay. So I guess I would say - types of POTS can be a useful way to think about it, but I find it's more helpful to look at your symptoms and see where they fit in terms of what parts of the body are affected, what treatments they respond to, etc. I find that figuring out what treatments I respond to is more helpful than looking at test results, mostly because in the end it's all about what works! Being a bit too rigid about classification can also keep you from trying something that might work, but isn't typical for a given type. *shrug*
  10. I don't drive, and probably never will again at this point (I have a license, have never owned a car, but used Zipcar to get cat litter, etc - an hourly car rental). I mentioned to my psychiatrist (when we thought it was a med side effect) that it didn't seem safe, and she agreed; I did drive briefly last summer with my partner coaching me, but in the last six months I have been much too spacey to drive. I like what hilbiligrl says above - "I always feel like I'm "stuck" in some type of "pre faint mode" but for long periods of time" - certainly no fun! My neurologist has never said I can't drive, but when I mentioned that I didn't feel safe, he said "okay." I think he trusts my judgment. I'm reluctant to give up my driver's license if I don't absolutely have to. My dad suggested I get a motorcycle or scooter so that when I am too spacey I will at least only injure myself. Wow, thanks, Dad, I really appreciate the help. These days I am uncertain about bicycling (an okay way to get around Seattle) - I can't ride an upright bike for unrelated medical reasons, and I don't want to spend the money on a recumbant bike until I know it's safe. Back when I did bicycle (upright bike) it was a good way to get groceries home. One can certainly order heavy things like cat litter from Amazon, though it's a little more expensive. I've considered, if biking works, getting an electric assist bike to navigate steep uphills to save my heart and lightheadedness! It's annoying having to think about public transit, etc when figuring out where to move to next year. Does the place have good public transit? Does it operate later at night, on Sundays, etc? Can it get me to an airport, hospital, etc? Is the place walkable so I can walk to buy groceries since I can't drive? Etc. Very glad Seattle meets all of those criteria, and I can take buses nearly literally door to door from home to work if I absolutely have to. In some ways I'm glad I found out the driving thing before moving out of the city or buying a house... I always wanted to live in the country but now I think it's just not an option.
  11. Hmm - it depends. Walking is my usual form of exercise, and I do feel worse during (mostly the horrid spaciness and some lightheadedness) which is better when I stop and sit down afterwards. For "real" aerobic exercise (recumbant bike, stress test, hills while walking), definitely worse during (more spacey, more lightheaded, more completely out of it), but I do have to sit and cool off in stages so I don't fall over when I get up from the bike. Though, during the stress test, I had a non-recumbant bike, and they said "keep pedaling to cool off, then sit there! That will keep you from passing out" and I was thinking "no, get me off this bike, I am about to pass out and sitting here with my legs hanging down is worse!" Sadly they had no place to lie down after the stress test (seriously, I was kind of surprised and peeved). For anaerobic stuff, or stuff with controlled breathing (like lifting a heavy item, or pulling against resistance, or spirometry), definitely worse at the end/after - like doing a Valsalva maneuver. I almost collapsed after the spirometry was over, much to the chagrin of the pulmonologist (I told him that it would be rough, he said "it's ok, everyone feels winded and lightheaded" and sure enough, they didn't get that I meant it would be more severe for me).
  12. I only itch when I'm visibly pooling blood - e.g. after a shower. But the itching then is super-fierce, and the only thing that removes it is sitting down and raising my legs. I do have probable SFN (based on QSART, not biopsy), but I tend to have more numbness in my feet rather than itching.
  13. Are you referring to Julian Stewart's 2012 paper ("Mechanisms of Sympathetic Regulation in Orthostatic Intolerance")? I found that paper quite useful, particularly the data on how TTT responses are different in folks with POTS and folks with NMH/NCS that isn't an end consequence of POTS. His theory on cerebral blood flow being largely independent of the sympathetic nervous system does help explain why, despite treatment with clonidine, my spaciness has not improved, while pretty much everything else - including classical SNS effects like sweating and overheating, and also fatigue that I ascribe to SNS overactivity - have mostly stopped happening to me, quite dramatically. Granted, I don't *know* that spaciness is due to cerebral blood flow issues (some parts of it, like always looking over my shoulder, becoming overstimulated, or starting more with sudden input, have also calmed somewhat with the clonidine - that hypervigilance-type behavior does go hand in hand with the SNS), but it does fit nicely into my personal mental model of how my POTS works. To clarify, also, clonidine has helped somewhat with my seated/lying down cognitive impairment - I can now read papers for work! - but not with standing cognitive impairment; I still get flustered when I'm standing up. I'm wondering if perhaps it's helping indirectly via removing fatigue and distraction (if SNS overactivity is reduced, perhaps I am able to pay more attention to things/concentrate better when my brain already has enough blood due to sitting, whereas in the past I had enough blood, but had too much SNS activity and so couldn't focus), if it isn't having direct effects on cerebral blood flow? Who knows; no easy way to measure it without TCD, which seems to be not in general use anywhere, and certainly not for personal experiments like this! I do get cognitive impairment with clonidine at other times when seated/lying down, but it does correlate nicely with clonidine-induced low blood pressure - it makes good sense that one would have cognitive impairment when overall blood pressure is low. Would you be willing to explain more about the parasympathetic innervation of pia matter idea? I haven't heard anything about it and am curious!
  14. I don't know about the specific value of change in HR, but it doesn't surprise me. Like you said, swallowing increases HR. Drinking through a straw you're tensing a lot of the muscles in your neck and upper chest to create suction, and I could easily see that increasing HR for a short period. Our bodies also have small HR changes with breathing - your HR goes up when you inhale, down when you exhale (respiratory sinus arrhythmia - the name sounds terrible but that's how the body normally works). Does it happen without a straw if you are able to drink without one?
  15. "That's a diagnosis called Münchausen syndrome and I don't have it." [i'm not sure you would be comfortable saying this to your friend, but what he describes is an actual psychiatric diagnosis that most folks with POTS don't have.]
  16. Growing up we had a family in town where the father was a stay-at-home dad and the mother worked a job with a pharmaceutical company. As a younger child it did seem a little odd to me, but kind of cool - someone doing it differently, how neat! I don't recall anyone ever making fun of the kids, and I babysat for them from time to time when the parents were out. In our own household my partner (male) stays home, sometimes doing consulting work but mostly just staying home; I work flexible hours at graduate school. In our case we don't have kids, so he is the stay at home type for no externally obvious reason (there's some depression in his case, but that's not everyone else's business). Being a stay-at-home dad for whatever reason is something to be proud of! Having grown up with a parent who was chronically ill (in my case, cancer, mom, for 10 years from ages 5-15) - I never got teased for having a mom with cancer, and some of my peers were envious of having a parent at home who could keep you company and make food. In some ways, if you can be open with the school guidance counselor or similar, that can actually help - if your daughter is stressed or upset about you being sick (goodness, let's hope not, but just in case) then the school will be aware and can help support her by meeting with the counselor or helping her with classes if you are having a rough time. However - it's not anyone's business outside the family if you don't want to tell them! I certainly was pretty flexible - in fact, although I miss my mom every day, in some ways having a chronically ill mom made me independent and mature earlier than most kids. Kids are flexible and can adapt to different situations; it helped me a ton that my mom was very open with me about her prognosis, what treatment effects she was having, what I could and couldn't do to help, when she needed me to be quiet so she could rest, etc - because I knew she would tell me if things were becoming worse (and she did, both times), I wasn't scared every day about the future. Your decision, obviously. In terms of dysautonomia/names, for people who are liable to treat dysautonomia as not serious and who don't need more info (e.g. for "this is why I can't stand up at this volunteer event" or "please, I need a seat on the bus"), I just say I have "a heart condition" and stop there. That gets the serious part across, while also getting across that you're not (1) having vapors (especially worrisome for a guy given social expectations) or (2) on death's door. Maybe you can share that with people if necessary so you can stop feeling awkward about being a stay at home dad? You shouldn't need to justify that decision, but if it helps to have a reason, maybe think about trying it.
  17. Hunh - if they said diet only then they probably do mean Type 2. Type 1 is sort of genetic, but the risk of getting it if your mother or father has it is still only around 10%; folks I know who have it don't have it in their families. Like other autoimmune disorders, it sometimes happens to people with no obvious family history.
  18. I'm finding that since upping my dose of clonidine from 0.1mg twice daily to 0.15mg twice daily, my legs get numb (pins and needles, the way limbs often fall asleep) very quickly (within minutes) when I sit crosslegged or with my legs stretched out in front of me (lower than the heart at all times when I sit, to be clear). As with the last time I increased my dose, I am having the usual 2 weeks of nasty hypotension (I normally range 110/70 to 140/90 and I am down at 80/45 consistently now; I haven't passed out but am very, very tired). Could these be linked? Does hypotension cause this? It's theoretically not a side effect of the clonidine directly, but could this be an indirect result? Not painful, just annoying. I do probably have small fiber neuropathy, but this is happening so fast (within minutes) that I doubt it's due to that, and I haven't had this kind of issue before. Edit - I haven't been wearing my stockings the last two days since I've been at home not standing all day (I don't tend to wear them when I am at home sitting down all day), but haven't had this happen in the past on no-stocking days; I don't know if wearing them would improve this or not. No obvious pooling, and if I were pooling I would almost certainly be able to tell.
  19. Good to know! I have been lucky in that dramamine and goldfish help with my nausea, but I appreciate the heads up... ugh, that sounds terrible. (more and more these days I find I want to know how a medication works so I can figure out if my body will react poorly to it based on prior experience - e.g. I tend to avoid things that cause norepinephrine reuptake inhibition in the brain, since they tend to cause unfortunate side effects with my particular brain and body chemistry)
  20. I met someone once who was diagnosed Type 1 at 45... that was odd. My good friend from college got Type 1 at 18. It does happen late in some cases. Diabetes can actually cause small fiber neuropathy in the legs, which can lead to increased blood pooling, which can then lead to POTS or POTS-like symptoms. When I had too little sweating in my QSART test, I got my A1c tested to rule out diabetes; it's a pretty common test for differential diagnosis. If it helps, I did have absurdly frequent urination (3 times in 20 minutes once!) while on a trip with the good friend from college; I was drinking more water than usual (4L a day instead of 2L) and it turned out I just wasn't taking enough salt in, so I just increased my salt and things resolved once I got home. You can probably wait to get a blood sugar meter until you get the A1c results back; if nothing else if you do develop diabetes then insurance should cover some of the cost! These days Type 1 is pretty controllable for some folks (less so for others, it depends on a lot of factors). For example, my younger advisor in grad school is in his late 30s and is Type 1, and the only way I know is that I saw his pump when we first met; he's a super productive person and can do things I could never do (not enough sleep, too much work, young daughter). My good friend is a merchant mariner who spends most of her life working on a cargo ship. (there are totally folks with Type 1 who have tons of issues, but I thought I'd mention a few examples who are doing well)
  21. Sister has chronic fatigue that has mostly improved (hers was a very definitive case of chronic mono which finally disappeared after multiple years), but denied any ANS issues after I asked her a few times on my and my ANS neurologist's thought. We don't know about mom, since she died when I was 15, but I don't recall anything; she was often on the couch but she had cancer for 10 years, and it was definitely a result of chemo, not ANS issues. Mom and sister have/had much milder versions of my joint hypermobility. If I have kids I sure hope they avoid this if possible! I was pleased when the medical student who attended my neurology appointment a week ago asked about this! (in general I was pleased - a medical student, not even a fellow/resident, learning about POTS! and he had good questions, but also asked about my life outside of POTS, which was great. he was very curious why I am on a beta blocker and clonidine but eat salt (neurologist: "general volume expander, seems to help but doesn't hurt") and similar questions - great education)
  22. One thing I would really emphasize is to get things set up with the university's disability services program (under whatever name it goes by at the relevant university). They can help with housing (as you mention above), but can also work on medically necessary absences (e.g. too faint to go to class), having a notetaker who will attend class with him to take notes for him, moving exams to the afternoon and sitting them separately from other students in a quiet place with snacks/water, trying to schedule classes (or at least study/recitation/lab sections) in the afternoons, helping with any mandatory PE requirements, shuttle services to get across campus (e.g. from dorm or parking lot to class building and between buildings, many schools have this and not just for students in wheelchairs), etc. They will need info from your son's specialist, and then you can meet with them to talk about accommodations. The other main reason I'd suggest this is that having the official stuff in place is good legal protection in case discrimination, instructors not allowing accommodations, medical leave, etc become a problem - better to have everything set up up-front and less stressful for everyone. Good luck! I didn't have dysautonomia in undergrad (developed it in grad school) but if I were in undergrad these days I would be taking advantage of a lot of the things I listed above!
  23. Hunh - do you have links for those? Would love to read them! I always appreciate the info. Personally, caffeine has no effect (I apparently get no effect from stimulants below methylphenidate (Ritalin) in potency, which is interesting given my very strong response to sedatives) - my ANS neurologist suggested trying it just in case, but no effect. I did take low-dose diltiazem (a calcium channel blocker) for about 2.5 months when things started, but I didn't notice anything other than worsening non-tachy POTS symptoms and decreased tachycardia.
  24. I say "I'm sorry" for medical emergencies - I picked it up from my mom, actually, who did it even when delirious from high fevers after chemo. I've been trying to work on it, especially in situations at doctor's offices/in the ER - I feel like saying "sorry for being a bother" and then I realize that, well, the staff are there for exactly this reason and if it weren't me it would be someone else. But I still apologize anyways! What my partner and I do instead is say "I regret the situation." "I'm sorry" implies (at least for us) that there is something you did/were responsible for - consciously or unconsciously - that was wrong that you can fix. Having POTS and not being able to do things doesn't fall under that category - you can't fix it, you aren't responsible for it in the sense that you can't make it better just by wanting it to be better. "I regret the situation" (or similar words) steps back and says "This is hard on both of us, I acknowledge that it is hard for you as my caregiver and I wish it weren't the way it is right now" but acknowledges that it's not something you can control *and* that you understand that it is hard on the other person. "I'm sorry I burned your toast/broke the teapot/made you late/didn't update you on my plans" versus "I regret that my health problems mean we couldn't go out last night." It does seem to help for us.
  25. Clonidine and I are major friends for exactly those reasons - it makes my BP somewhat more steady (it was high again when I hit my head and was in the ER, but that's hardly surprising - I *want* my body to react to that kind of stressor, just not everything else!), definitely decreases adrenaline surges/pounding heartbeat/sweat (I can wear long sleeves again!). After taking it for a few days I suddenly realized how much less fatigue I had (despite being sleepier - hilarious) and how much less I was reacting to everything outside my body (pre-clonidine I would start and have an adrenaline hit from something like a bird flying nearby, now I don't). It does make me more fatigued (I get sleep attacks kind of like narcolepsy) and I have some tremor with it, but for me it's definitely a win. I found a beta blocker helped with my lightheadedness and standing tolerance and tachycardia, but not with the adrenaline issues, which the clonidine has been great for.
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