linsilada: protracted withdrawal from mirtazapine

[linsilada]

Hello! I am seeking advice on behalf of my brother (44yo) who does not speak English. He is currently going through severe withdrawal since June 2024 after quitting meds cold turkey. It wasn’t until 2 months ago that we found out that his mystery symptoms were actually withdrawal from psychotropics. I will first summarise his history below:

 

Summer 2023 - self-administered alprazolam (~1/4 of 0.5mg tablets) for ~ 2months for work stress and sleep issues
~ September 2023 - cold turkey, following withdrawal
October 2023 - severe nausea and vomiting forcing him to take sick leave until Feb 2024
November 2023 - starts taking mirtazapine (1/4 of 15mg tablets), this alleviated some symptoms from the alprazolam withdrawal (e.g. anxiety) but nausea and vomiting persists until ~ April 2024
February 2024 - back to work
May 2024 - is prescribed blood pressure meds (candesartan)
End of May 2024 - sudden onset of numbness, neuropathy is his leg, this induces panic so he self-medicates with a small dose of alprazolam (~ 1/8 of the 0.5mg tablets) for ~5-6 days, this is followed by a bad reaction (I’m missing details on this)
First week of June 2024 - quits all remaining meds cold turkey, develops severe withdrawal, goes on sick leave again

 

Important to note that he does have some history with psychotropics and withdrawal in his 20s.

 

We’re on month 4 right now with only marginal improvements. Unfortunately because we didn’t know what was causing his “mystery illness” until approx. 2 months in after I started researching his symptoms, we missed the window for reinstating early on where he could benefit from this the most. Needless to say he has seen multiple doctors and none have been helpful. His new psychiatrist initially suggested that it is relapse, most recently prescribed 20mg of paroxetine - having researched this that seemed like very dangerous advice so I told him not to take it.

 

As for symptoms, he has pretty much been through them all except for psychosis. I am not sure if he has akathisia - he does have something that he describes as “inner restlessness” so that may be it? His symptoms keep changing and at the moment his most pressing issues are body aches (back and leg), insomnia, vision/eye disturbances, jaw clenching/ head and neck muscle spasms or twitches, tremor, health anxiety and fear, crying spells, something close to suicidal ideation (“If I didn’t have my family to think about I would have ended it. It’s that bad. I am suffering.”)

 

Anxiety and restlessness are the worst in the mornings, afternoons and evenings are much more manageable.

 

We were waiting and hoping his symptoms would resolve, he seemed to be getting much better in September but the past week or so has been tough (imo he is decompensating from stress because his mother in law moved in with them, I think his family support system overall is not great but that may just be my bias). I am worried that it is too much for him and I’ve been trying to figure out whether reinstating mirtazapine at a very low dose could help him stabilise but there doesn’t seem to seem to be any clear info on this. There are issues with potential kindling, not to mention that we likely won’t have access to the liquid formula of the drug in our country (Czech Republic) and grinding down 15mg pills to measure out fractions is probably not feasible.

 

I would appreciate any advice!

 

Thank you so much!  

 

 

[LotusRising]

@linsilada

 

Welcome to SA,

 

Sorry it's taken so long to respond. Our site is very busy.

 

On 10/5/2024 at 7:51 AM, linsilada said:

self-administered alprazolam (~1/4 of 0.5mg tablets) for ~ 2months for work stress and sleep issues

Did he take alprazolam daily during this time?

 

On 10/5/2024 at 7:51 AM, linsilada said:

November 2023 - starts taking mirtazapine (1/4 of 15mg tablets), this alleviated some symptoms from the alprazolam withdrawal (e.g. anxiety) but nausea and vomiting persists until ~ April 2024

What symptoms were alleviated when he started mirtazapine?

 

On 10/5/2024 at 7:51 AM, linsilada said:

His symptoms keep changing

It's common for symptoms to change as you move through The Windows and Waves Pattern of Stabilization.

 

In your signature, you mention he took alprazolam for about 5 days; was there any improvement in symptoms during this time?

 

How long has he been completely medication-free?

 

Have you read through the topic on Reinstating and Stabilizing?

[linsilada]

Hi @LotusRising! Thank you so much for approving my post and for your reply. I’ve checked with my brother wrt your questions and here’s what he had to say:

 

12 hours ago, LotusRising said:

Did he take alprazolam daily during this time?

 

Summer 2023: He did take alprazolam daily, at night, for a period of approx. 1 - 2 months (he’s not sure about the time frame exactly).

 

Quote

What symptoms were alleviated when he started mirtazapine?

 

It helped with anxiety, fear, and issues with thermoregulation (he was overly sensitive to heated spaces or even strong sunshine). There might have been other symptoms but his memory is hazy and he did not attribute it to the medication at the time because he did not know it could cause withdrawal.  The mirtazapine did not help with nausea and vomitting - this still continued for several months.

 

Quote

In your signature, you mention he took alprazolam for about 5 days; was there any improvement in symptoms during this time?

 

After taking alprazolam he felt a bit clamer and perhaps more tired, but he also started sweating a lot and had more issues with thermoregulation. The alprazolam did not resolve the paresthesia, and his leg still felt cold. Moreover, he had a terrifying stiffness attack (freeze reaction?) on the 5th day (couldn't move without extreme difficulty) and later vomitted as well. This attack was what prompted him to stop all meds.

 

Quote

How long has he been completely medication-free?

 

Since 5 June 2024.

 

Quote

Have you read through the topic on Reinstating and Stabilizing?

 

Thank you for linking this! I did have a look at it earlier and I've also read through some other threads on volumetric dose measurement since my original post. I think dissolving the tablets in water would be the way to go if he were to reinstate, stabilize, and later taper. Really the main question we have right now is whether it is likely to be safe for him to go back on mirtazapine or not, and at what dosage. And whether reinstatement is the best way to help him.

 

He's definitely overly sensitive to any kinds of herbal supplements and vitamins (he had tried magnesium before but it did not agree with him) so that is not an option I'm afraid. He tried acupuncture this week and got a panic attack and vomitted at the acupuncturists's so sadly that was another traumatic experience for him.

 

[LotusRising]

@linsilada

 

8 hours ago, linsilada said:

And whether reinstatement is the best way to help him.

I can't say for sure if reinstatement will be successful. Since he is outside the 3 month timeframe where reinstatement reliably works, it might work and it might not. If you decide that reinstatement is an option, we would recommend a much smaller reinstatement dose than the last dose. 

 

I think it would be important to weight out the risks/benefits; was he better, or worse after taking mirtazapine the first time? Is it worth the risk to try reinstating?

 

8 hours ago, linsilada said:

After taking alprazolam he felt a bit clamer and perhaps more tired, but he also started sweating a lot and had more issues with thermoregulation. The alprazolam did not resolve the paresthesia, and his leg still felt cold. Moreover, he had a terrifying stiffness attack (freeze reaction?) on the 5th day (couldn't move without extreme difficulty) and later vomitted as well. This attack was what prompted him to stop all meds.

I wonder if his system is too sensitized from previous use and CT of alprazolam; this could be partially contributing to his current symptoms.

 

Is he doing any nervous system regulation/vagus nerve exercises?

 

 

[Guest]

Hello, @linsilada.

 

On 10/5/2024 at 4:51 PM, linsilada said:

November 2023 - starts taking mirtazapine (1/4 of 15mg tablets), this alleviated some symptoms from the alprazolam withdrawal (e.g. anxiety) but nausea and vomiting persists until ~ April 2024

What did your brother do to make the nausea go away? Or did it pass by itself? Was this nausea constant or did it go away at times? Also, regarding this topic, I have a question, do you write that he vomited during an acupuncture session, does he have a tendency to nervous vomiting? Was there such a thing during the exciting moments before, before taking psychotropic drugs? Sorry for such questions, I have a problem with nausea, so it is important for me to know if there are other people with such a problem from withdrawal syndrome or if I have psychogenic nausea such as from nerves or depression as the psychiatrist says and this is not related to withdrawal syndrome..

[linsilada]

Hi @LotusRising

 

I hope you’re doing well! So sorry for the late response, things have been a bit too busy for me for the past few weeks.

 

We are still debating on whether it’s worth reinstating or not. It’s difficult to make a decision on this as I think he definitely is sensitised from the alprazolam like you said and I’m also not entirely sure if the main cause of his protracted wd is the mirtazapine or the alprazolam. He does say that what he’s experiencing currently (post-mirtazapine) is very different and way more severe than what he experienced after the alprazolam CT last year. But at the same time his current symptoms lean heavily into the neuromuscular category (myalgia, myoclonus, tremor, neuralgia, cramps, stiffness) and I may be wrong in this but I think these are usually more associated with benzodiazepines? I’m a bit worried that if the main cause really is the alprazolam, going back on mirtazapine won’t help and will mask his wd symptoms at best or, at worst, further destabilise his CNS.

 

That said, I feel like we need to do something. What he’s going through is too severe with very little improvement and we’re nearly 5 months in. His symptoms most days are a 9 on a scale of 1 (best) to 10 (worst), and while it does dip a bit during the windows it still feels like it’s all too much. He is tough so he is powering through it but it feels endless. I’m worried that the longer we wait to reinstate the less hope we have that it’ll help him get better. And at the same time I don’t see any other solutions.

 

I don’t really know what kinds of exercises to recommend anymore. Initially he was trying breathing exercises, body scan meditation, sensory grounding for anxiety, and while all of these maybe helped a little bit the effects were always short lived. He’d say he’d do the breathing and it’d work for 10mins but 20mins later he’d feel even worse. So these days he doesn’t do much apart from going on walks frequently, which helps with the inner akathisia (or rather the akathisia forces him to go out and move). I don’t think he can do yoga or anything like that right now because of the body pains, he’s already struggling on the walks when the leg stiffness kicks in.

[linsilada]

Hi @BlackKabarga

 

I'm afraid I don't have much information on this. My brother's memory is not that great so piecing past events together has been quite difficult for us. But I don't think he did anything at all to make the nausea go away, it likely improved on its own. He was vomitting daily for many months during the alprazolam wd. And he does indeed have a tencency to vomit when stressed; even now during his current mirtazapine wd he still gets nauseous and vomits every now and then. I'm so sorry I can't be of more help!

[Guest]

@linsilada

 

Thanks for the answer.

[linsilada]

Update: Unsuccessful Reinstatement

 

With the symptoms getting worse over the past month, we decided to try reinstatement last night before bed. We chose a very very low dose of 0.1mg of mirtazapine to make sure any potential adverse reactions are minimized. We prepared a 30ml suspension of the 15mg tablet and used a 1ml syringe to measure out 0.2ml to get 0.1mg of the drug. We did consult the reinstatement with his psychiatrist prior and he said to try it and see if it works (not that he understands PWS, he still thinks it's rebound or relapse and recommended he takes double the dose he was taking originally).

 

Unfortunately the reinstatement did not go well. He developed paraesthesia in his upper limbs in the night (he did experience this before, early into withdrawal) and severe akathisia with motor symptoms (repetitive hand movements) for the first time ever. The akathisia really scared me because up to this point he had only had inner akathisia (inner restlessness) so I am definitely attributing this to the reinstatement of the drug.

 

I'm not sure what the solution is at this point. I don't think it's safe for him to continue using the drug, let alone increasing the dose. Suffice to say we won't be trying it again.

 

He can't have meds, and he doesn't tolerate herbs and supplements like magnesium and fish oil, so it looks like the only thing we have left is suffering through it and trying things like breathing exercises.

 

As always, any advice would be helpful.

 

Thank you for reading.