Devi: Tapering from Escitalopram, Pregablin and Quetiapine - Which one first?

[Devi]

Hello everyone,

 

I would be grateful for some advice about which one of these drugs to taper from first. I am currently tapering the Quetiapine after a crisis last year when my dose was put up.

My current medication:

Escitalopram (Lexepro) 15mg - been on this for 10 years

Quetiapine - 300mg - been on this for about 4 years

Pregabline - 150mg - been on this for 3 months (and once in 2015 for about 6 months.

 

I have been on Escitalopram for 10 years. At that time, I was also given Mertazapine 30mg which I was easily able to withdraw from quite quickly. I continued on the Escitalopram alone until 2013 when I felt brave enough to try and taper. I spent about 6 months doing this (but now realize that I was tapering much too quickly). I cleaned up my diet and self-care, took supplements and didn't experience any withdrawal symptoms. 2-3 months later, I woke up one day in extreme panic with the most intense physical sensations. A few months living with this constantly, I was suicidal and in crisis. I immediately went back on the Escitalopram.To cut a long story short, I was put on lots of different drugs again (on top of the Escitalopram) for 'treatment resistant depression' - Mertazapine, Lithium. Nothing helped, I became homeless and suicidal. After some time, I began taking Quetiapine 200mg and 150mg of Pregablin on top of the Escitalopram 15mg. In 2015 stabilised but don't believe it was because of the drugs. I came off the Pregabln using the liquid medication and didn't have any withdrawal symptoms. I was completely stable for about 4 years on this combination of drugs but hated the side effects of the Quetiapine - mainly weight gain and the disruption to my social life and it's extreme sedation. 

 

However in September 2019, completely out of the blue, with no triggers, again I woke up in extreme terror wit the same physical sensations which led me into suicidal crisis again and was hospitalised briefly. I didn't want to adjust my medication because I really didn't believe it was doing anything. If it was, how could this happen to me again? After a few months, I was so desperate, I sought out psychiatric input and my Quetiapine dose was put up to 450mg (50mg in the morning, 400mg at night). I have since stablized and have begun to reduce my Quetiapine dose. I have been reducing 25mg every week and am now on 300mg.

 

Questions:

• In the last few years, I didn't have the courage to taper down from the 200mg of Quetiapine I was on for 4 years. Should I keep going on the taper I'm on now and try to get off it completely?
• My previous withdrawal from Pregablin in 2015 was easy. Should I start with this?
• When I withdrew from the Escitalopram in 2013 and had severe symptoms 2-3 months later, the psychiatrist said that this was the underlying illness recurring. I'm not sure this is true as I had no obvious triggers, no extra stress in my life.
• The drug i would most like to be free from is the Quetiapine.

 

Thank you for any input.

[Gridley]

Welcome to SA, Devi.

 

We generally recommend tapering activating drugs, known as accelerators, first, leaving the more sedating drugs, known as brakes to be tapered later.  Otherwise, as you decrease the brake, you will experience activation from accelerator, such as sleeplessness and anxiety.  If you reduce the accelerator while taking a sedating drug, the sedating drug may help alleviate the activation of withdrawal. In your cocktail, the SSRI Escitalopram is an accelerators, while the Quetiapine and Pregabaline are brakes.  I know you want to taper the Quetiapine first due to the weight gain, but our recommendation, for the reasons above,

would be to start with the Escitalopram.  You really don't want to be battling insomnia and anxiety while tapering.  Only taper one drug at a time.  Please read:

 

Taking multiple psych drugs? Which drug to taper first?

 

I experienced the reasons for this rule when, before I discovered SA, I tapered a brake, Imipramine first instead of Escitalopram. and suffered extreme and unremitting anxiety.  It didn't abate until I stopped my Imipramine taper and started tapering Escitalopram.  

 

We recommend tapering by no more than 10% of your current dose every four weeks.

 

Why taper by 10% of my dosage?

 

This link is specifically about tapering Escitalopram, including how to get the non-standard doses you'll need for the 10% taper.

 

Tips for tapering off Lexapro (escitalopram)

 

14 hours ago, Devi said:

When I withdrew from the Escitalopram in 2013 and had severe symptoms 2-3 months later, the psychiatrist said that this was the underlying illness recurring. I'm not sure this is true as I had no obvious triggers, no extra stress in my life.

 

Very likely you were experiencing withdrawal symptoms from a too-fast taper.  It is very common for them to occur 3 months into a fast taper.  Doctors, who know nothing of withdrawal and don't even believe it exists, invariably attribute withdrawal symptoms to "return of the underlying illness."

 

We don't recommend a lot of supplements on SA, as many members report being sensitive to them due to our over-reactive nervous systems, but two supplements that we do recommend are magnesium (glycinate is a good form) and omega 3 (fish oil). Many people find these to be calming to the nervous system. 

 

Magnesium, nature's calcium channel blocker 

 

Omega-3 fatty acids (fish oil) 

 

Add in one at a time and at a low dose in case you do experience problems.

 

This is your Introduction topic, where you can ask questions and connect with other members.  We're glad you found your way here.

 

 

 

 

 

[Devi]

Thank you Gridley. I've done a lot of reading on the SA site about the rate of tapering. I can see that in 2013 I tapered too quickly off the Escitalopram. 

 

If I did withdraw from the Quetiapine first, would the Pregablin be considered sedating enough to then help me through the Escitalopram taper?

 

Is there anyone else out there on the same combination of Escitalopram (Lexepro), Quetiapine (Serequel) and Pregablin (Lyrica)? It would be helpful to learn from other people's tapering experiences.

 

I have a supportive GP. Although she knows nothing about psych med withdrawal, she did manage to get me the liquid Lyrica last time I withdrew from Pregablin in 2016.

[Gridley]

11 minutes ago, Devi said:

If I did withdraw from the Quetiapine first, would the Pregablin be considered sedating enough to then help me through the Escitalopram taper?

 

My guess is no.   Pregabalin has a short half-life, only 6 hours.  So, if you decreased the Quetiapine, at some point you'd likely start experiencing some interdose anxiety or insomnia or both, which would likely then tempt you to start tinkering with the Pregabalin dosage,  taking it more often, with unknown results in terms of relieving your symptoms--plus, if you did this, you'd be increasing one drug while trying to get off another.  The quetiapine is your firewall to prevent those anxiety/insomnia symptoms while you taper.

 

I say this with some certainty because that's exactly what happened to me.  I, like you, was on two brakes (Ativan and Imipramine) and one accelerator, Imipramine.  I wanted off the Imipramine because it was no longer serving any purpose, having been prescribed off-label for colitis, which I no longer had.  Once I tapered down to a pretty low dose of Imipramine,

the anxiety kicked in hard and my other brake, Ativan, just wasn't strong enough to stop it.  It took, in addition to updosing the Imipramine and halting that taper while starting the Escitalopram taper, doubling my Ativan dosage to bring the anxiety under control. So now I have a double dose of Ativan to taper.

 

Our drugs are different, except for the Escitalopram, and everybody's experience is different, but I want to offer this as a cautionary tale about tapering counter to the activating-first rule.  

 

Regarding others' experiences, I would Google SurvivingAntidepressants.org Escitalopram Lyrica Pregabalin Quetiapine Seroquel to see what you get.  

 

It's great you have a supportive GP.  That's a big help.

 

 

[Shep]

On 2/29/2020 at 7:38 PM, Devi said:

Escitalopram (Lexepro) 15mg - been on this for 10 years

Quetiapine - 300mg - been on this for about 4 years

Pregabline - 150mg - been on this for 3 months (and once in 2015 for about 6 months.

 

 

On 2/29/2020 at 7:38 PM, Devi said:

After a few months, I was so desperate, I sought out psychiatric input and my Quetiapine dose was put up to 450mg (50mg in the morning, 400mg at night). I have since stablized and have begun to reduce my Quetiapine dose. I have been reducing 25mg every week and am now on 300mg.

 

Devi, welcome to SA from me, too.

 

Do you find the 50 mg of quetiapine more sedating than the larger dose? The reason I'm asking is because at 150 mg and less, quetiapine acts on histamine receptors more so than on dopamine. So some people find it more sedating at lower doses. In fact, it's used off label as a sleep aid at 100 mg doses or less. Some people are only prescribed 25 mg and find it's quite sedating at that dose. 

 

Do you find the pregabalin sedating? Do you take it at the same time as the quetiapine? 

 

As you let us know more about how these drugs affect you, we can help guide you in setting up a plan to taper off. 

 

Gridley has given you a wealth of information in links and advice, so please take your time and read over this information. If you find that the lower dose of quetiapine is sedating, you may want to taper down to around 100 mg to take at night for sleep and then focus on coming off the antidepressant. As Gridley wisely noted, we do preference sleep when it comes to the order of tapering off these drugs, so anything you can do to preserve your sleep is important. 

 

It will help if you could do a drug and symptoms journal for a couple of days. Please also include:

 

• supplements
• the number of hours you sleep each night

 

We'll go through this step by step and help you set up a plan for tapering off this cocktail. Please see the below for how to format your journal and then post it daily here in your Introduction thread: 

 

On 9/27/2016 at 2:49 PM, Altostrata said:

In the course of discussion in your Introductions forum topic, you may be asked to keep notes on paper of your daily symptom pattern, including when you take your drugs, their dosages, and any symptoms. We ask this because there may be something we can do to reduce the symptoms.

 

What we need to see for every single day over several days is what symptoms you get before and after you take your drugs. If you're not taking any drugs and have withdrawal symptoms, we still need to see your symptom pattern throughout the day:

 

The time of day, dosage, and severity of symptoms are essential information. Include

 

- Time and dosage for all drugs taken throughout the day, psychiatric and non-psychiatric.

- Following each dose, note any symptoms. If you are having a reaction to the drug, it may take hours for a symptom to show up -- that's why we ask you to keep notes all day long.

- If you're not taking any drugs, your symptoms throughout the day.

- Your sleep pattern. Since so many drugs disturb sleep, if you find you're waking in the middle of the night, it could be from a drug you took earlier in the evening. If you're not taking any drugs, there may be ways you can improve your sleep.

And so forth. A diary, in chronological order, looking something like this:
 

Example:

DATE:

 

6 a.m. Woke with anxiety
8 a.m. Took 2.5mg Lexapro
10 a.m. Stomach is upset
10:30 a.m. Ate breakfast
11:35 a.m. Got a headache, lasted one hour
12:35 p.m. Ate lunch
4 p.m. Feel a bit better
5 p.m. Took 2.5mg Lexapro
6 p.m. Ate dinner
9:20 p.m. Headache
10:00 p.m. Took 50mg Seroquel
10:20 p.m. Feeling dizzy
10:30 p.m. Fell asleep
2:30 a.m. Woke, took 3mg Ambien (NOT "took 1/2 tablet Ambien")
2:45 a.m. Fell asleep
4:30 a.m. Woke but got back to sleep

 

 

[Shep]

Devi, I also want to point out some drug interactions with your cocktail. Please see this report:

 

Drug Interaction Checker - quetiapine, escitalopram, and pregabalin

 

There is a MAJOR interaction between quetiapine and escitalopram and MODERATE interactions between quetiapine and pregabalin and between escitalopram and pregabalin.

 

So some of your symptoms may be drug interactions. As you let us know more about how you're taking them, we can guide you in deciding if you need to space them out to prevent these interactions.