Jonathan93: tapering Effexor XR, mirtazapine and sertraline

[DataGuy]

Hope you are still feeling better @Jonathan93. In a scenario like this, it may be useful to do a small updose. You don't want to expose your system to symptoms like this for too long. 

[sunnysideup69]

Hi @Jonathan93, Been reading your thread with curiosity. Fellow Venlafaxine user here  .

 

Firstly, I'm sorry you had an uptick in symptoms as you go lower on your dose. I think it's wise to stop, for now, and even consider a tiny updose, as @DataGuysuggested.

 

No pressure to respond but I was wondering whether you are still taking the extended release form of Effexor, or whether you had swapped to instant release, as you mentioned earlier. And you are bead counting, rather than weighing, right? Asking as am reading up on how to taper.

[Jonathan93]

Hello Guys, I dont feel super good, but I did stabilise.  Since phases of windows got a lot better, I am not updosing. @DataGuy But I am definitely going to do a longer hold on this Dose!  I am still doing the Extended Release  @sunnysideup69 .. but i thought about switching to immediate release alot since I'm arriving at smaller doses. You are still at Extended Release ? @sunnysideup69

I am bead counting not weighting. Each bead is 0,261 mg.

[Jonathan93]

Little update: Im feeling ok. The Depersonalization and Derealizationsymptoms are still there, but got a lot less severe. My panic attacks faded. Im still anxious and in a depressed state, but on thursday evening I had a window of like 3-4 hours where I was feeling really good and everything seemed to be gone, sadly it did not last but I enjoyed it.

[DataGuy]

That is a great to hear, @Jonathan93. Hope the windows continue to appear!

 

Yes, best to hold until you feel better, then be very cautious. If you can wait at least a month after you feel better to taper again, that is ideal. 

[Jonathan93]

Update: After my post on 1 April I had a good phase for like 6-7 days. Since then I'm really depressed. I have a lot of stomach/colon issues and no appetite.

I I have abdominal fullness and it always feels like there is to much food in me. I dont know else how to explain it on english, sorry. Any tips for this are highly welcome. If I am not better in 2 weeks, I really think about updosing to 37,5 mg again. I just really pray for better days right now, cause I need to function somehow. Since Im feeling pretty bad, most of the time since tapering on the 7th march, I did not change my dose.

[DataGuy]

Hi @Jonathan93,

 

Sorry to hear you are not feeling well. I think your priority now should be stabilization, do not worry about tapering or making progress getting off the meds. The fullness and bloating feeling is a full-blown withdrawal symptom, and a fairly common one. 

 

I would not recommend waiting two weeks, I would updose now. You don't want your body to remain in this state. There is nothing to be gained from it progress-wise. In fact, it may slow your progress. When people taper too fast, or cold turkey, there can be a nervous system sensitization or injury which occurs, wherein they become very sensitive to any sort of med and cannot even reinstate the medication they were previously taking (in addition to severe physical and psych symptoms, sensitivity to stress etc). I think wd symptoms are sort of this syndrome in miniature, whereby the more severe the symptoms, the closer you get to this state of hypersensitization/injury. If you look around the forum, you can see examples of it. A recent example I can think of is @HardTimes, who attempted to reinstate multiple times, but found it didn't really help. At that point it is no longer simply withdrawal, but an injury to the nervous system. The absence of the medication is no longer the primary problem. And that is what the slow, symptom-based taper is geared towards avoiding. The hope is to give your system the opportunity to adapt to life without the med at its own pace, whilst avoiding the injury aspect of withdrawal as much as possible. The injured state can take a very long time to heal from, so it is best to updose and hold for quite some time until you feel better. 

 

Don't get discouraged. Everyone wants to get off quickly, and everyone usually tests their limits while tapering. It's a learning experience, and you will know better next time, but you don't want to fly too close to the sun. 

 

PS: we do have a thread on this topic with a few academic articles for reference: 

 

Edited April 22, 2022 by DataGuy

[Jonathan93]

Ok thanks for the reply, so do u think 37,5 mg is ok ? Then hopefully stabilize and taper again? Or just 0,52 up  like my last dose?

[DataGuy]

What was the last dose you felt stable at? I would simply increase until you get back up to that. Maybe not all at once if you are uncomfortable with it. Remember it will take a few days to feel the full effect of the reinstatement dose. 

 

Here is the topic on this subject if you want to read more: 

 

[Jonathan93]

It was 33, 35 so just 0,52 mg more.. I am still not sure because I had a window of like a week for 7 days. I have to think a night about it before I make this decision. 

[DataGuy]

Sounds good @Jonathan93. It's ultimately your decision, and you have all the information you need. Hope either way it works out well. 

[Jonathan93]

Thank you for the advice! I will stick with my decision for now. Im still not sure if this microdose-tapering was a good idea, like tapering 0,261 mg every week. It seemed to mess up with my brain. Rn Im doing, a bit better. Bloating and fullness improved, but is not fully recovered. I visited my family on the weekend with improved my state a bit. Especially the family dog is a great distraction. 

 

Tomorrow, I have my quarterly meeting with my psychiatrist. Im thinking about switching my sertralin (zoloft) to Fluoxetine (Procaz) because it has a much longer half life. Ive read alot about the subject of tapering effexor xr and it seems like bridging is an option to consider.

[DataGuy]

Hi @Jonathan93,

 

Glad you have had a bit of improvement. I think microdosing is ok, you just need to find the pace that you can tolerate. The whole idea behind the slow taper is to taper based on symptoms, rather than some arbitrary rate that someone decides is best. This way you can keep your symptoms from getting out of control and stay as functional as possible throughout the taper. It is possible to render yourself disabled for years by tapering too quickly.

 

How did the meeting with the psychiatrist go? Sertraline and Fluoxetine are similar, but I don't think I'd recommend switching. The half-lives are not all that different, and the time it takes to switch and adjust to the new drug may simply slow you down, or even cause problems itself, for potentially zero benefit. 

 

 

[Jonathan93]

Update: @DataGuy I got Fluoxetine by my pharmacy, but Ive not been taken it yet. Staying with sertaline for now. My state improved a lot on the 25th April, this window lasted for like 15 to 16 days which is a good sign. Right now Im in a low/depressed mood again since last friday. Hope it does not stay that long.  I did not change my dose and Im not planning to in the next few weeks.

 

Are you sure that the half lifes are not that different? Ive read that sertraline has about 24 hours and Fluoxetine can have half life up to 7 days? Is this not an advantage I should use? Im just interested, because I want to get rid of the Effexor so bad.

[DataGuy]

I should clarify: the half-lives are different, but they should not be the main cause of problems in wd. Sertraline around 24 hours, fluoxetine around 1-3 days. Both have active metabolites which exert their own pharmacological effects. Fluoxetine's metabolite (norfluoxetine) has an even longer half-life and both fluoxetine and norfluoxetine and inhibit their own metabolism, so they will be building up in your system for quite a long time before they reach a steady state. Sertraline's active metabolite is less pharmacologically active but also has a longer half-life than Sertraline. It is the inhibition of their own metabolism and the long half-life of norfluoxetine which would substantially extend the pharmacological activity of fluoxetine. And yes it would be active much longer than Sertraline and its metabolite. But the question is, is that desirable? Usually drugs that have half-lives that are longer than a day are not a big problem in wd. Doctors usually cite fluoxetine as "better" for wd because they have historically recommended very rapid tapers to patients, such as halving the drug twice over a period of a few weeks and then stopping. So in that context, they see fluoxetine and its metabolite as significantly extending the period in which you still have pharmacologically active drug in your system. If you are tapering over a period of years, the impact of this will be negligible, unless you believe the reduction in sertraline in your blood over the course of a day is causing problems (it's possible). You could test this by splitting your dose and taking Sertraline twice per day instead of once. Here is a topic on the subject with some instructions. Do you feel reliably worse at certain times of day vs others? 

 

I think it would be very useful, before you consider switching, to make a list of pros and cons.

 

Some pros I can think of to not switching:

1) no wasted time crossing over from one drug to the other

2) no unexpected worsening or sensitization of your nervous system from the shock of adjusting to another drug

3) Avoiding the risk of switching for an unknown benefit (which might be zero, or even a net negative). Switching is done under the assumption that the half-life of sertraline is the problem, but it could be a number of other things causing issues.

4) May be difficult to find an equivalent dose without taking too much or too little Fluoxetine

5) Status quo or 'watchful waiting' is often better in medicine than new drugs / treatments, since most have very limited benefit + their own unique problems. Taking action to 'manage' things without good evidence of benefit is often a recipe for running into additional problems. 

 

Pros for switching:

1. Could be having a specific problem with Sertraline that is removed when switching 

2. Half-life may indeed be a significant problem for you

.....

I cannot think of too many pros to switching, but maybe you can add some more.

 

I think 1. is pretty unlikely because if you were having a specific adverse reaction to Sertraline, you would feel better when reducing it, not worse.

 

Sorry, had started to write this reply yesterday, but fell asleep after work. I'm glad you had a nice window, @Jonathan93. Will be interested to hear what you think and what your full reasoning is behind switching. Hope things continue to improve : )

[Jonathan93]

Hello @DataGuy

 

At first thank you for helping and listening the pros and cons!

 

I want to clarify, I did not start on Fluoxetine! Im still sticking on Sertraline and Im probably stick to it longer (will taper after coming off effexor)... its just an option so far... 

 

I consider this option because Im tired of beeing on 3 meds at the same time, tapering Effexor is such a pain and struggle and Ive just the feeling that Fluoxetine will serve me better in the long run for tapering Effexor.

 

Im tapering Effexor now for almost 2 fricking years and Im literally just so mad that it is so hard to get off this medication. Especially the last 32 mg will be so annoying. My hope by switching sertraline with Fluoxetine is getting off Effexor will be easier.

Sorry for being on rant, this tapering drains my energy 😪

 

 

 

 

[DataGuy]

I think you are doing the right thing tapering effexor first, @Jonathan93. It is usually the most difficult to come off of those three, and it's important to get off it in a good position so that you don't need to spend too much time recovering before tapering the other ones. I can relate to your frustrations though. I remember tapering clonazepam and being frustrated it was taking months. Near the conclusion I rushed through the last part of the taper, reasoning I would heal when I was off, but this did not end well at all. 

 

I think the best advice is to embrace the functionality you have and just accept that tapering is going to be your normal for the next little while. It doesn't mean you can't make good progress in life and enjoy things. There will definitely be periods of frustration and elevated symptoms, but hopefully we can minimize those with the knowledge and experience you have gained. 

 

I know it is infuriating. It is hard to avoid feeling that. Perhaps that is a good thing to write about and come to terms with in a journal. It may help to clarify your feelings and cultivate acceptance of the situation. Yes, tapering will take a long time...what does that mean for you? Why does it make you angry? Is the anger justifiable? (I think so). Is it useful? I wonder if Wim Hof has some answers on this front : ). I think the really good news for you is that you are still young. You are figuring this out much earlier than most people, so you'll have a long time to enjoy being drug-free after this is all over. 

 

Hope you are having a better day today, Jonathan 🙏

[Altostrata]

@Jonathan93 you are taking an unusual cocktail of 3 antidepressants. Please put ALL your drugs in the Drug Interactions Checker https://www.drugs.com/drug_interactions.php

and copy and paste the results or a link to them in this topic.

 

What times o'clock do you take your drugs, with their dosages? Are your symptoms better or worse at any times of day?

 

Please add the date you started mirtazapine to your signature.

[DataGuy]

Hi @Altostrata,

 

Here are the results of Jonathan's interaction checker: 

 

[Altostrata]

Thanks, @DataGuy That old profile does not include mirtazapine.

[Jonathan93]

Update: I had really good 3 and a half weeks and honestly I needed a break from tapering...last taper was 3 months ago.

Im ready to taper again! I started microtapering today just one bead, so 0,261 mg to feel how my body reacts, everything good so far.

[DataGuy]

That is excellent news @Jonathan93! I think continuing to take it slow is important. Keep your system in good shape and let it build up some resilience. Once you have been feeling good for a longer period you could try and move things along more quickly if you still want to. But I think stable for longer = better. It is a bit of an experiment, so important to learn as you go. 

[Jonathan93]

Update: Im happy to announce that I still did not had any setbacks while Microtapering. Still feeling really good rn.

[Altostrata]

What dosages are you taking now, @Jonathan93?

[DataGuy]

On 7/28/2022 at 9:09 PM, Altostrata said:

What dosages are you taking now, @Jonathan93?

Yes, would be great if you could update your signature next time you swing by @Jonathan93. Congrats on doing so well!

 

[Jonathan93]

@Altostrata@DataGuy You should see my dosage in my Signature. Right now Mirtazapin 15 mg Sertralin 25 mg and Effexor XR 31,52 mg.

[Altostrata]

Please let us know how you're doing.

[Jonathan93]

@Altostrata@DataGuy Thanks for asking! Well the last two months went pretty good. I could live a pretty normal life and I had mostly a positive  experience of life. The last 1-2 weeks I felt a bit depressed, but not like something I could not manage. My tapering still continues, but really really slowly as you may can see in my signature. My psychotherapy is still going on and it helps me a lot.. my therapist wants me to get off the drugs and so do I. In her opinion Im to slow in my tapering, but I have to listen to myself in this regard!

From 40 mg to 30 mg took in my opinion extremely long, maybe to slow in some peoples opinion. But I am in college and college can be pretty tough. Im young and I dont want to risk intense suffering as long as possible. Its still a long road... but I will hopefully get there eventually. (Goal --> zero Antidepressants) 

[DataGuy]

Thanks for the update, @Jonathan93. I'm glad you are doing so well. There is no need to listen to anyone who thinks you are going too slow. The reality is there is not great evidence as to how fast people need to taper, so the taper should simply be symptom-based and aimed at keeping yourself functional. Everyone has a different optimum speed of tapering. You're really doing an exemplary job and I hope you achieve your goal with minimal suffering. The most important thing is you are enjoying life : ). Many people have a difficult time doing that while tapering. 

[Jonathan93]

Im feeling okayish, slightly depressed but managable. Rn at 31 mg Effexor. I took a look at Chessiechats Tapering off Pristiq (Desvenlafaxine) and this was kind of motivating for me because someone else did it to zero even if it took 6 years. It will probably take as much time for me... Problem is I have two other Antidepressants to taper.. this is so demoralizing.. well I thought about stopping the effexor tapering (for now) because it will take sooo long. So at least I can taper another medication... maybe like Sertraline or Mirtazapine.

 

My idea was that at least I would taper Mirtazapine to 7,5 mg or something like this, so it does not stay at 15 mg for the next three to four years..

 

Please let me know your thoughts about this.

[Jonathan93]

Surge in anxiety today.. feeling Depersonalisation and Derealization slightly.

[Jonathan93]

I still feel anxious especially in the morning. Slight DP and DR. I wanted to taper today, but I canceled. I will wait out till symptoms disappear. 31 mg Effexor XR still to go.

[Jonathan93]

Depression is really crushing right now. I feel tired, concentration problems, anxious and just hopeless. No appetite. 

[DataGuy]

Sorry to hear, @Jonathan93. You have cut quite a bit in the last couple months though. I think you are probably right that it is time to pause for a bit. 

 

On 9/6/2022 at 9:10 AM, Jonathan93 said:

Im feeling okayish, slightly depressed but managable. Rn at 31 mg Effexor. I took a look at Chessiechats Tapering off Pristiq (Desvenlafaxine) and this was kind of motivating for me because someone else did it to zero even if it took 6 years. It will probably take as much time for me... Problem is I have two other Antidepressants to taper.. this is so demoralizing.. well I thought about stopping the effexor tapering (for now) because it will take sooo long. So at least I can taper another medication... maybe like Sertraline or Mirtazapine.

 

My idea was that at least I would taper Mirtazapine to 7,5 mg or something like this, so it does not stay at 15 mg for the next three to four years..

 

Please let me know your thoughts about this.

 

This is a difficult decision. The reason to taper the effexor first is that it is the more activating drug vs sertraline and mirtazapine, but tbh there is not a lot of solid evidence for this formula, it just seems to work in general for the average user. But if you feel you are stuck on the effexor and could make better progress tapering one of the others, you are welcome to give it a try. Effexor is notoriously difficult to taper (being an SNRI). In theory it is also better to taper the more difficult AD first, but that is just theory. The important thing if trying to taper another drug is to 1) make sure you are stable first and 2) go slow, which you of course know by now : )

[Altostrata]

Agree with @DataGuy

[Jonathan93]

Thanks for your thoughts about this! Right now im in this deep depressed state.. I have no appetite and eating is a struggle. Just feel totally bloated. I feel agitated. It is a bit better in the evening.No clue if its withdrawal right now honestly... because September is often a season where my mental health takes a plunge.

I have to get university work done and its a struggle honestly. I have to wait this out. 🤕