Sonny: tapering Cymbalta

[Sonny]

[50, male] Hi. I'm about to embark on a taper of the dreaded Cymbalta, which I have been on for almost 4 months-- 1 month of ramp up plus 3 months at 30mg. I'm quitting because its main effects have been lethargy, apathy, and demotivation. Some anxiety and sleep relief comes with that but it's not worth the zombification. This stuff scares me and I want nothing more to do with it. Starting about 6 weeks ago, my shrink added Wellbutrin 150mg which hasn't made much difference.

 

About 6 years ago I went through this same process with a prior shrink (for the same complaint, anxiety)-- try Prozac, experience apathy/lethargy, add Wellbutrin. The Wellbutrin felt pretty amazing but ultimately was too speedy and I decided to quit everything. I agreed to Wellbutrin once again in hopes of a similar effect but this time no luck. I think the ugliness of Cymbalta just drowns everything else out.

 

Unfortunately I don't recall the exact details of my prior Prozac/Wellbutrin taper but my best guess is that it lasted between 6 months and 1 year (I was aware of this site and the importance of slowness). There were no adverse effects during the taper.

 

So my primary goal this go round is to taper Cymbalta. But I'm torn between wanting to taper safely/slowly vs reducing my overall exposure and getting back to my pre-zombie state as soon as possible. If I were to do 10% at 2 week steps I'd be looking at an 18 month taper from 30mg. This seems too long. Since I've only been on it 3-4 months, I'm hoping I can go a little faster than that. I'm thinking of trying 15% at 1.5 week steps which would take a total of 10 months. Along the way I may or may not pause to taper some piece of the Wellbutrin, depending on how it all goes. 

 

My question is whether or not my 10 month taper plan seems reasonable.

 

Thanks for any input.

 

Sonny

 

 

[getofflex]

Hello, and welcome to SA.  We are a volunteer-run community of people who have been or are getting off of psychiatric drugs.  I will give you some basic information about the dependency these drugs cause, and how to safely taper off, then suggestions at the end about your proposed taper. 

 

Here is some important information about how these drugs actually work.  This explains why we get symptoms from going off of these medications, and why it's so important to taper slowly and carefully, and be very cautious about changing our doses: 

 

How Psychiatric Drugs Remodel Your Brain

 

 

This helps you understand what withdrawal syndrome is.  You should be able to minimize or eliminate withdrawal if you taper according to our suggestions.  

 

Video on Recovery from Psych Drugs

 

Windows and Waves Pattern of Stabilization

 

 

Tapering is best done extremely slowly, and we generally taper by 10% of the current dose no more than once every 4 weeks, so that the reduction becomes exponentially smaller.

 

 Why Taper by 10% of my Dosage  

 

Tips for Tapering Cymbalta

 

Here is a link with checklists of common WD symptoms: 

 

Dr Joseph Glenmullen Withdrawal Symptom Checklists

 

 

Here are some techniques to cope with symptoms: 

 

Non Drug Ways to Cope with Withdrawal Symptoms

 

Stability is really important when we are tapering off psych meds.  Please read the link about stability:

 

Keep It Simple, Slow, and Stable

 

 

We don't suggest many supplements, but 2 that many of us find helpful are magnesium and omega-3 fish oil. Here are the links for info about those. It is suggested to add one at a time, and start with a low dose to see how it affects you. 

Magnesium

Omega 3 Fish Oil

 

You got away with doing a fast taper in the past with your prozac and Wellbutrin.  However, that may not be the case this time.  I, too, got away with fast tapers off Paxil when I was in my 30's, but I had to taper off Lexapro very slowly, and had significant withdrawal when I tried to fast taper it before I found this forum per my doctors instructions.  It took years for my nervous system to settle down from 2 fast taper attempts.  As we go on and and off and on psych drugs, our nervous systems tend to become more sensitive, and more easily destabilized by psych med changes.  What you can do, is try the 10% per month reduction, and if you have no withdrawal symptoms those first couple of reductions, then the next time, try waiting only 3 weeks instead of four.  This procedure is described in the link about why taper by 10% of my dosage.  

 

Here is a link about cold turkeys/fast tapers: 

 

Cold Turkey and Too Fast Tapers

On 10/6/2022 at 8:44 PM, Sonny said:

Since I've only been on it 3-4 months, I'm hoping I can go a little faster than that. I'm thinking of trying 15% at 1.5 week steps which would take a total of 10 months.

Personally, I think this is risky, and I wouldn't do that if it were me.  If you read the previous link, it can cause many months to years of painful withdrawal.  It only takes the brain 1 month to become dependent upon psych drugs.  

 

On 10/6/2022 at 8:44 PM, Sonny said:

Along the way I may or may not pause to taper some piece of the Wellbutrin, depending on how it all goes. 

 

This is fine, as long as you allow a several month stretch in between tapers to make sure your system has fully adjusted to the previous taper of Cymbalta.  Only taper one drug at a time.  

 

Good luck, and let us know how it goes.  

 

[Sonny]

Thank you for your input, getofflex.

 

I see that Cymbalta Hurts Worse recommends 5% max reductions, thus a ~3 years or so taper. So I guess that makes 18 months seem not so bad! On the other hand, I feel so drugged up all the time like I've just taken the max dose of benadryl, and my liver enzymes are now through the roof, so it's tough to be patient and continue to willingly expose myself to this. But I will heed your advice and likely settle on something longer than the 10 month plan.

 

other questions. . .

 

1- To begin the taper, I have to first switch manufacturers to a brand with micro-beads. Over at CHW, people describe going into withdrawal when making lateral brand switches which I guess makes sense if dosages are imprecise and one gets unlucky with the new brand underdosing relative to the old brand. To mitigate, they recommend holding for 3 weeks post-switch. Is this form of withdrawal something you are familiar with and are there any SA specific guidelines pertaining to it? Would it make sense to take the hold idea one step further by cross-tapering between brands, e.g. adding 25% of the new brand per week over four weeks (100/0, 75/25, 5050, 25/75, 0/100) ? Is it a documented fact that generics are allowed imprecise dosing and therefore it would also be wise to take only one brand of pill during a taper (instead of combining micro-beads and mini-tabs)?

 

2- I need to begin taking a statin for genetically high cholesterol. Are there guidelines for introducing another med during a taper, and anything in particular regarding statins?

 

thanks again for your help-

 

 

 

[Sonny]

Just want to add that I now understand that the CHW folks recommend 5% every two weeks, so it's basically the same as SA's 10% every four weeks. So I'm really looking at a 3 year recommended taper either way. Does SA have a view about the CHW 5%/2 week version? Any reason to be wary of it?

[getofflex]

On 10/10/2022 at 4:34 PM, Sonny said:

my liver enzymes are now through the roof, so it's tough to be patient and continue to willingly expose myself to this.

When this is the case, you may want to do a faster taper if the liver enzymes being off is due to the drug. 
 

On 10/10/2022 at 4:34 PM, Sonny said:

ould it make sense to take the hold idea one step further by cross-tapering between brands, e.g. adding 25% of the new brand per week over four weeks (100/0, 75/25, 5050, 25/75, 0/100)

Yes, I would suggest doing this. 
 

Statins can cause the side effects of muscle weakness and loss of memory. If it were me, I would do more research into it before I start taking it.

Edited November 29, 2022 by getofflex

[manymoretodays]

  

On 3/3/2023 at 11:29 AM, Sonny said:

Thanks MMT. Yes I'm referring to the same paper. Sorry for inverting the order of the authors' names.

 

You mention other research lit that recommends 10% hyperbolic dose reductions. Other than Altostrata's paper, I haven't seen these. Could you share links?

 

Certainly the slower the taper, the fewer withdrawal effects. But withdrawal effects may not be the only source of harm from SSRIs. Prolonged exposure could also be a risk, not only to the CNS, but other organs as well, particularly the liver. It also means more of one's life spent enduring the adverse, often debilitating effects. Also it's plausible that long term intransigence of these effects would correlate to chronic drug exposure (e.g. PSSD).

 

Horowitz and Taylor's paper is great in that it confirms the SA wisdom of hyperbolic tapering. But their recommendation of a 10% SERT drawdown (8-10 step taper) is so radically different than SA's 2% SERT drawdown (40-50 steps). That's 6 months vs. 2.5 years.

 

I think the reason for the discrepancy is that we don't know the perfect SERT drawdown rate-- 2% and 10% are both arbitrary guesses. Is that fair? Or are there more specific rationales for either recommendation? Does the SA community have experience with faster hyperbolic, Horowitz-style tapers? Is there good reason to expect that it wouldn't work?

 

 

 

Hey Sonny,

I quoted your last response over here, so we don't clutter up the articles section too much, and to have a look see at your specifics as well.  Egads, Cymbalta is tough enough to taper given the forms that it comes in, and then you've got Wellbutrin too, and increased liver enzymes I presume.  Due to no other cause identifiable than the drugs you've been prescribed?

 

What I had referred I think I should have been clearer on. It was in regard to another more recent paper done by Horowitz involving antipsychotics(AP's) and D2 receptors.  The full text is still available in the PDF at this link:

Horowitz, 2021: A Method for Tapering Antipsychotic Treatment That May Minimize the Risk of Relapse

pg. 1123 and in the second column, it's clearer.  And I know different receptor occupancy than serotonin alone, but I find it helpful.

 

Now for you, you have a more pressing case of wanting to get off any medications that may influence your liver, those enzymes, and with hopes of normalizing liver status someday once off possible offending agents.

So you may need to design your taper around receptor occupancy.

Why taper? SERT transporter occupancy studies show the importance of gradual change in plasma concentration

and shoot, I don't want to download the whole article but here is direct link where you may be able to do so:

https://www.academia.edu/15180544/A_dose-finding_study_of_duloxetine_based_on_serotonin_transporter_occupancy

you'll find your curve there and maybe even a complicated math formula to use, that may help with your further planning of a Cymbalta taper based on SERT occupancy at various doses.

 

People respond differently.  They have different histories and ages and support systems or that inherent ability to support oneself........ all sorts of factors come into play besides......not simple math, complicated mathematical equations.......and so.........

I'm really more of a humanities type.  Oh I do my best to understand the concepts, and better now than ever.......yet still.

 

So we don't have a one size fits all.  I think it's explained here, pretty clear why we do it how we do.  With some, I might someday be comfortable saying at the higher doses.........to perhaps, or that I might consider tapers of 10% of the previous dose at 2 week intervals......up to a certain point and dose, and receptor occupancy.......and then........just look at some of those curves.........back down at the lower doses when changes are more significant in the time frame.

We don't have a measurement of baseline pre-drug receptor functioning.  And we don't have a measurement for when that normalizes after drug changes or gets closer to factory settings.

 

We'd love to see you put together your own taper timing, and love to see you be successful too, without too much in the way of WD and symptoms.

You can be your case of one and contribute to the greater understanding.

You sound smart and math inclined.  See what you come up with.

 

Get your liver functions checked every 3 to 6 months please too.  Insist.

 

I really do wish you well.

That Love, peace, healing, and growth become all yours again,

mmt

 

Oh, and for good measure......here are your current drug interactions too, compliments of Drugs.com

https://www.drugs.com/interactions-check.php?drug_list=949-2273,440-2469&types[]=major&types[]=minor&types[]=moderate&types[]=food&types[]=therapeutic_duplication&professional=1

 

And why the Cymbalta taper prior to Wellbutrin XL?  How did you decide on that?

Tips for tapering off Wellbutrin(buproprion)

 

and might be helpful too:  Taking multiple psych drugs?  Which one to taper first?

 

What liver problems are you referring to as well?

Not that I have all the answers.......I do not, but happy to help when I can.  I'm scarcer being around, but still so inclined, as it helps further my healing and rebuild of sorts.......

Edited March 6, 2023 by manymoretodays
additional links for Sonny's library here

[Sonny]

Thanks for your reply, MMT.

 

Re my liver tests: My ALT is high since I began Cymbalta. Other enzymes are normal. My PCP is not worried about it because it's only ALT, not mulitple enzymes. He also doubts the connection with Cymbalta. I did an abdominal ultrasound and it was normal. I will do another hepatic panel soon.

 

Cymbalta makes me lazy, sleepy, apathetic, etc. while Wellbutrin doesn't seem to do much of anything, so I'm motivated to taper Cymbalta asap. Wellbutrin can wait.

 

Thank you for the references. I'm pretty comfortable by now with the duloxetine dose/SERT curve (I think), bead counting, etc. Currently I'm 16 weeks into my Cymbalta taper, at 11.2mg, down from 30mg. 58% SERT occupancy, down from 75%. Dose reductions in the 9-13.5% range, SERT occupancy reductions in the 2-3.5% range. Two week intervals.

 

I started at 9% dose reductions and have slowly nudged it upwards. My last 3 reductions have been around 12-13%. No withdrawal symptoms other than some manageable irritability/moodiness which is difficult to attribute to the taper. My side effects have only slightly improved-- basically as you'd expect with a drop from 75% occupancy to 58%. Maybe I'll push the next drop to 15%, Idk.

 

I'm pretty well scared of Cymbalta withdrawal (and subsequent injury) and don't want to poke the beast. But at the same time losing patience with these zombie ass side effects and liver stuff. So I guess all I can do is try to strike some kind of reasonable balance between recommendations from Cymbalta Hurts Worse who wants 5% drops every 4 weeks (that's like a 5 year taper or something), SA who says 10% every 3/4 weeks (a couple of years or so), Horowitz who says 25% (i.e. 10% SERT drop) every 2-4 weeks (6-8 months taper), and my shrink and PCP who both maintain that they've brought dozens of patients off Cymbalta either cold turkey or with a two week taper and never had a single complaint. Clearly I'm not going along with the shrink/PCP plan but their experience does influence the calculus a little .

 

 

[manymoretodays]

Ah oh.......on this below.  We've run across this before.  Horowitz being misquoted. 

 

15 hours ago, Sonny said:

Horowitz who says 25% (i.e. 10% SERT drop) every 2-4 weeks (6-8 months taper),

 

I assure you that a 25% taper from each previous dose of Cymbalta, or any other SSRI or SSNRI, is not going to be directly the same as a 10% SERT drop, with each taper.

 

Can you quote, and then share where you likely misread as gospel, some exploratory academic paper?

 

That's just wrong to assume, and pretty clearly wasn't what Horowitz intended, when contributing to any of these academic papers.

 

For example, back to the antipsychotic tapering academic article:

 

from pg 1123, 2nd column, this article  on tapering antipsychotics

(an academic paper, and clearly only a suggestion, also note the HOLD period of 3-6 months mentioned, and then that smaller reductions,such as 10% of the most recent dose may be more tolerable in the aim of producing more "evenly spread" perturbation to the equilibrium)

 

This suggests that many patients may tol-
erate dose reductions of 25%–50% of the most recent dose
(corresponding approximately to 5–10 percentage point
decrements of D2 occupancy) every 3–6 months. Smaller
reductions (such as 10% of the most recent dose) made
every month may be more tolerable in the aim of produ-
cing more “evenly spread” perturbation to the equilibrium

 

 

And I don't think Horowitz is saying for anyone to go down by 25% on their own, at 2 week intervals!  Plus, the antipsychotic article is around antipsychotics and D2 receptors.  Totally different.

 

I have yet to find anywhere that Horowitz is saying for anyone to taper by 25% of the last dosage every 2 weeks. 

I came up with you have now tapered by 63% of your total dosage, in 16 weeks time.  Generally, with a 10% taper done ever 4 weeks, one can expect to be at 1/2 of their starting dose in about 6 months time. 
 

Just be careful Sonny.  Why don't you sit with 10 mg Cymbalta for 3 to 6 months, once you get there.  And then do a 10% or less, off each previous dose after that? 

 

I just don't want to see you get into too much difficulty.  The difficulties that can set in can take years to resolve.  Don't risk it.

 

Best.  L, P, H, and G,

mmt

Edited March 7, 2023 by manymoretodays

[Sonny]

Hi MMT.

 

I appreciate the discussion, and your concern that I might be going too fast.

 

Regarding Horowitz: In the 2019 Lancet paper with Taylor concerning SSRIs, they shy away from recommending specific drop percentages or holding times. Instead, they place their emphasis on hyperbolic tapering in general. They do, however, sprinkle in examples of hyperbolic taper parameters which might be taken as suggestions. In table 2, they display a would-be Citalopram taper with 10% SERT occupancy reductions. From 80% SERT occupancy downward, these dosage reductions are in the 30-50% range, and the total taper is only 10 steps. They do not comment as much on holding periods. The only explicit statement they make that I see is on page 3 where they say: "a consensus suggests waiting 1–4 weeks between dose reductions, to allow withdrawal symptoms to resolve".

 

In the case of Duloxetine, a 10% SERT occupancy taper yields dose reductions in the 35-47% range (not counting the penultimate step which is 76%). So, I was sloppy in saying 25%, it's actually worse than that. Here's what a 10% SERT occupancy reduced Duloxetine taper looks like, starting at 30mg ...

SERT %  ...  dose mg  ...  dose drop

75%               30mg             n/a

65%               16mg             47%   

55%               9.6mg            40%

45%               6.2mg            45% 35%

35%               3.8mg            39%

25%               2.2mg            42%

15%                1.25mg          43%

5%                  0.3mg           76%

0                     0mg

 

 

Let me know if you think this is incorrect.

 

I have to confess that I haven't yet thoroughly read Horowitz's Antipsychotics paper (since I am not taking APs) but I will try to do so.

 

Also, to answer your question, I wouldn't want to sit with my current dose of Cymbalta for 3-6 months because I suspect that exposure is itself harmful (to both brain and other organs), i.e. my goal is to reduce exposure, not maintain it. Of course I understand where you're coming from-- that a too fast taper is undoubtedly harmful, and I may be pushing the envelope a bit.

 

Thanks again for your help, MMT.

Edited March 9, 2023 by manymoretodays
corrected 45% to 35%

[Sonny]

I see one mistake in the Duloxetine table: at the 6.2mg step, the dose reduction should be 35% instead of 45%.

[manymoretodays]

On 3/7/2023 at 7:36 PM, Sonny said:

In the case of Duloxetine, a 10% SERT occupancy taper yields dose reductions in the 35-47% range (not counting the penultimate step which is 76%). So, I was sloppy in saying 25%, it's actually worse than that. Here's what a 10% SERT occupancy reduced Duloxetine taper looks like, starting at 30mg ...

SERT %  ...  dose mg  ...  dose drop

75%               30mg             n/a

65%               16mg             47%   

55%               9.6mg            40%

45%               6.2mg            45% 35%

35%               3.8mg            39%

25%               2.2mg            42%

15%                1.25mg          43%

5%                  0.3mg           76%

0                     0mg

 

You're asking me? 

I'm no math scholar and can't do the formulas they give. 

To check.

I'm so sorry, wish I could, but I cannot.

 

Did you calculate with the duloxetine formula?

I'm impressed with that if so.

So do tell. 

Give the formula, and where found, if you have full access to an article that I don't. 

If you can include the curve too, the graph, I'd love it.

 

If it is all correctly calculated(meaning I don't know).......I still wouldn't ever recommend going that fast.  

Dose or time frames between tapers.  I can't recall what you were doing........2 weeks?  I'm fixed with 4 weeks at least between total 10% dosage drops.......I see that now.........not necessarily a bad thing as far as safety goes.

 

Irritability IS a WD symptom, and so.........don't slight it.  If there is agitation with the irritability, you know the visceral feel to it all.........count it as WD, and don't proceed further until you feel more like your better self.

 

And how is it going today.  Overall.

 

Best, and L, P, H, and G,

mmt

 

Edited March 9, 2023 by manymoretodays

[Sonny]

Hi MMT

 

I calculated using the Duloxetine dose response graph in Sorensen et al 2022. I eyeballed X and Y points on the curve as closely as I could. It's not hyper exact but close enough I think.

 

I'm currently at about 58% SERT occupancy, down from 75%. So roughly 1/5 of the way through the taper in 17 weeks. The full taper looks like about 1.5 years at this rate. Considering that I started tapering after just 4 months of "treatment", this feels like an absurdly long taper (4 or 5x longer than the treatment phase). That's why I wonder if I could go faster and find it interesting that Horowitz is suggesting that the whole taper could be wrapped up in like 6 months.

 

Regarding the irritability, that came on at about the 4th day after the last drop, lasted for 2 or 3 days, then went away. No agitation. Feel fine now other than the side effects from the presumed excess seratonin.

 

 

[Sonny]

Update:
Still tapering Duloxetine, Wellbutrin holds steady at 150xl.

 

It's been 14 months. Now at 2.3mg, down from 30mg. SERT occupancy at 25%, down from 75%. So I've basically made it 2/3 of the way. Another 7 or so months to go. I've been doing 10-15% drops every 2-4 weeks, usually about 2.5 weeks at each step.

 

The beads thing is kind of a hassle now that I'm down to 7 beads. I'm looking through a magnifying lamp to try to separate big beads from little beads to try to get more than just 7 steps out of the remaining.

 

Anyway, no issues thus far. Seems like the first 3-4 days of each new drop made me sleep worse and feel a little depressed but I can't say for sure there's causation.