chemzu1991: Sertraline and Tegretol unwanted interaction

[chemzu1991]

Hi,

I am currently in a very delicate situation and I was hoping to get some guidance. I appreciate your help and time. I am experiencing symptoms of withdrawal associated to PSSD, from an interaction between my antidepressant and Tegretol. Tegretol reduces the plasma levels of Sertraline by about 70% and about a month ago, I noticed a shift in my emotional and sexual state, as well as a returning of my anxiety. This coincides with the literature stating that Tegretol significantly reduces Sertraline, and therefore there was an interaction present. These symptoms first arrived on November 1st. On November 18th, I increased my Sertraline dose from 37.5mg to 50mg per doctor's recommendation. I have read the articles on reinstatement provided here. The next step my provider wants to try is to reduce my Tegretol from 400 to 300mg. This naturally would increase the Sertraline levels as a result. My question to you is: I have waited 6 weeks since the reinstatement of 50mg dose of sertraline. Should I take the next step my provider suggests? This would further increase my sertraline. I don't want to shock my body with too many changes as it recovers. Unfortunately, this interaction with Tegretol mimics a fast withdrawal: literature says up to a 70% reduction of plasma levels of sertraline. So from 37.5 to less than 10mg. Thanks again.

Edited December 13, 2024 by Emonda
Name to title

[chemzu1991]

Hi all,

 

Per my signature, I have been going through a difficult time. Tegretol potently reduces Zoloft levels by up to 70%. My provider failed to mention this interaction. I have been on Zoloft close to 9 years and have never touched the 37.5mg dose. As of early November, I experienced PSSD withdrawal-like symptoms (lower libido, muted orgasms, emotional blunting) out of nowhere.

 

I got afraid and per my provider's order I increased the Zoloft dose to 50mg to account for this reduction. I did this within 21 days of my symptoms showing up. My understanding is that PSSD is after discontinuing an SSRI completely. I am technically still on the medication (possibly 10-12mg of Zoloft accounting for the Tegretol effect). 

 

My logic was that since Tegretol decreased my Zoloft, increasing the dose by 12.5mg would bring back balance. I have read the articles on reinstatement, and have learned that it is best done within a month. There is an account of an individual on reddit who reduced their 10 year 50mg dose of Sertraline by half and experienced muted orgasms. They did not reinstate and have not done so for a year. I also know that PSSD sufferers strongly advise against reinstatement, as it is playing Russian roulette. 

 

I just need help brainstorming. Was increasing the Zoloft dose the right move? Is this PSSD or just a withdrawal reaction? I do not plan to make any further increases and hold this dose.

 

Thank you!

 

[Emonda]

Welcome @chemzu1991

Sorry to hear of your experience.

 

An interaction between your two medications is listed at the Drug Interaction Checker...a known issue.

 

Actually, I just saw a 3rd drug in your signature you didn't mention in your post: Seroquel. Please put all three into the Drug Interaction Checker (google it) and see what you learn.

 

So, your problems have started since you added Tegretol and Seroquel in September? They sound like the problem. I'm not sure I'd try to fix the problem by increasing Sertraline.

 

On 12/13/2024 at 4:14 PM, chemzu1991 said:

Should I take the next step my provider suggests? This would further increase my sertraline.

 

This site can only comment on slowly tapering ADs. When people are given a cocktail of drugs by the doctor, it can be problematic. It seems you are now experiencing this, unfortunately.

 

On 12/15/2024 at 4:37 AM, chemzu1991 said:

I do not plan to make any further increases and hold this dose.

 

Sounds prudent.

 

On 12/15/2024 at 4:37 AM, chemzu1991 said:

Is this PSSD or just a withdrawal reaction?

 

Sexual dysfunction is a known side effect of ADs. I experienced it with Sertraline, and it resolved once I lowered the dose / was off it. It was decades ago...so I don't recall the specifics.

 

Time and patience, whilst holding your dose, can do wonders.

 

Is your plan to taper off ADs? If so, that is something we can share some insights on.

 

Wishing you well.

 

Emonda

[chemzu1991]

Hi Emonda thank you for your response. Unfortunately, I believe that the sexual dysfunction is not a side effect of these drugs, but rather a withdrawal response from this abrupt drop in Sertraline from the Tegretol interaction. Tegretol potently reduces Sertraline levels. The reason being, that the symptoms appeared overnight and coincide with a return of my anxiety. It all happened over the span of a week in early November. 

 

I was very scared and didn't know what to do then. I decided to updose the Sertraline under doctor's guidance by 12.5mg. It seemed reasonable, bc I never intended to lower the Sertraline. It's been 5 weeks since the updose and my sexual dysfunction has gotten worse. 

 

In summary, the Tegretol dropped my Sertraline by about 70% in early November. This is almost as if I had reduced the drug myself from 37.5mg to under 10mg. The sexual dysfunction and apathy appeared overnight and coincides with this drop, as my anxiety also returned to pre-Sertraline levels.

 

I take Sertraline for anxiety and didn't plan to get off of it. The reason I wrote is because I don't know how to navigate this. Given the worsening of sexual side effects should I drop my dose by 10% or should I hold it for some time? The updose didn't work unfortunately.

 

I 100% think that this is a withdrawal reaction, bc I had never experienced muted orgasms on 9 years I've been on the drug. 

 

 

[Emonda]

Hi @chemzu1991

I saw you sent me a PM. We ask that all information be posted here so that others have the opportunity to contribute. Also, I work full-time, so my replies can be slow.

 

I experienced a similar issue when I tried to increase the speed of my current taper - I'm confident my issue was a WD symptom, given the timing. It was traumatic. I slowed the taper down, and things returned to normal over a few months.

 

I believe I understand what you have written. The addition of the two new drugs has seemingly interacted with the original drug (Sertraline) and caused the problem. If you choose to reduce one of the new drugs, it is best to only adjust one at a time, by a maximum of 10%. If you adjust two at a time and you have issues, you won't know what the cause is.

 

I don't believe anyone on this site will tell you to increase Sertraline. We can only provide info to help people slowly taper off ADs.

 

Let us know what you decide.

 

Warm wishes.

[Altostrata]

It's more likely that you are experiencing common adverse effects of sertraline and carbamazepine than a withdrawal reaction. PSSD occurs only when you are completely off the drug.

[chemzu1991]

Thank you @Emonda for your response and kindness. I apologize for my franticness. This is the only resource I have and psychiatrists don't know anything about tapering. I have been failed by the medical establishment and figuring this out on my own has been traumatizing. The past two months have been very dark. 

 

I think the decision to updose 12.5mg of sertraline was to stabilize the withdrawal. I am not completely off the drug and given SERT occupancy studies, I believe the 12.5 increase was not excessive, but modest. If at 9mg Sertraline has about 50% SERT occupancy, increasing it by 12.5mg is about a 20% increase in SERT occupancy, so this aligns with the guidelines of small updosing. 

[chemzu1991]

Thank you for replying @Altostrata. The symptoms happened abruptly overnight.  One morning I woke up with muted orgasm, low libido and apathy. I am positive that the Sertraline dropped by half or more of its current dosing during early November. Doctors don't do plasma level testing of Sertraline routinely. I am running on intuition and the scientific data suggests close to a 50% to 70% drop of my previous Sertraline dose caused by Tegretol (through enzyme induction). Tegretol increases the metabolism of Sertraline, such that overtime plasma levels drop significantly. 

 

From 37.5mg it likely dropped to under 10mg akin to a fast taper. The reason I reached out is because I was unsure whether updosing by 12.5mg was the right action. I did it within 18-21 days of when the sexual dysfunction appeared. I also don't know if I should stay on my current dose of Sertraline as with the increase the sexual dysfunction has intensified. Should I drop it by 10%?

 

Next step could be reducing my Tegretol (the troublemaker), but that would be very risky because of my severe depression. This is so messy. Let me know if you have any Qs. 

 

To summarize: Tegretol reduced my Sertraline on November 1st from 37.5 to 10mg. This is when sexual dysfunction and apathy emerged.

On November 18 I updosed by 12.5 to account for this drop. As of 12/19 sexual dysfunction has intensified (5 weeks after). I'm wondering whether to drop the Sertraline by 10% or stay on it for sometime to stabilize my CNS. 

[Emonda]

4 hours ago, chemzu1991 said:

I apologize for my franticness

 

No apology is required.

 

4 hours ago, chemzu1991 said:

This is the only resource I have and psychiatrists don't know anything about tapering. I have been failed by the medical establishment and figuring this out on my own has been traumatizing. The past two months have been very dark. 

 

I completely understand. I've been there.

 

Drug cocktails can be very unhelpful. 

 

Once stable, if you want to discuss tapering, we are here for you.

 

Emonda

[chemzu1991]

On 12/19/2024 at 5:23 PM, Emonda said:

I experienced a similar issue when I tried to increase the speed of my current taper - I'm confident my issue was a WD symptom, given the timing. It was traumatic. I slowed the taper down, and things returned to normal over a few months.

 

@Emonda@Altostrata Since I updosed by 12.5mg 5 weeks ago after the symptoms showed up, my sexual dysfunction has worsened. Should I hold this new dose for a little bit longer or should I start lowering this immediately? For context: There was an unintentional lowering on November 1st (drug interaction) and an intentional updose on November 18th. 

 

The reason I went up the dose, was because of the abrupt lowering and emergence of sexual dysfunction. I did it fairly quickly within 18 days of symptom emergence. Since it happened overnight, I don't think it is linked to the drug itself, but to the rapid lowering of Sertraline (some form of withdrawal reaction). @Altostrata see post above where I explain this in full detail.

[Emonda]

Hi chemzu1991,

I note Alto is following your thread. No need to tag her.

 

If the problem started after you added drugs 'B' and 'C', they sound like the problem. I believe Alto suggested the same thing: It's more likely that you are experiencing common adverse effects of sertraline and carbamazepine.

 

If I experienced your scenario, I'd be focusing on slowly removing those new drugs, one at a time.

[chemzu1991]

My situation is akin to a rapid taper. Say for instance (remove drugs B and C from the equation). Let's say I tapered from 50 to 12.5mg of Sertraline. The quick taper then caused withdrawal symptoms (sexual dysfunction in my case). To remediate this I quickly raised my dose by 12.5mg 18 days later. Now, the sexual dysfunction has worsened. What should I do? Hold the new dose or remove it right away?

 

Unfortunately I can't remove Tegretol and Seroquel right away, because of depression and severe insomnia being treated.

 

I apologize for the confusion. This is a very unusual situation and the best way I can describe it is (above). 

[LostInCanada]

Unfortunately this site is here for the purpose of getting off ADs. It sounds like you feel you need them to deal with depression and insomnia. We cannot recommend tweaks in your medication. This is something you must do with your health care team.

All we can do is recommend slowly tapering off one drug at a time. There is no quick fix to the problems caused by these drugs once dosages have been rapidly changed and more drugs have been added. The recommendation is taper slowly, no more than 10% per 4 weeks, starting a taper with your most problematic drug. If this is not the course you wish to follow, please follow up with your doctor to work through their mistakes. 

[chemzu1991]

@LostInCanada thanks for your response. I am looking for advice regarding a potential withdrawal reaction caused by my Sertraline being lowered to subtherapeutic levels. 

 

I haven't experienced this degree of anhedonia and sexual dysfunction while on Sertraline, the 9 years I've been on the drug. Everything turned around last month. 

 

The tegretol is a mood stabilizer that helps with depression, but it is known to interact with many medications. I joined this website because it is literally created around antidepressant withdrawal, and that IS what I believe I am experiencing. Anhedonia is listed as one of the withdrawal symptoms on main page of this website. 

 

Many people here report that they experience withdrawal symptoms because of fast tapering. 

[chemzu1991]

Hi,

 

Has anyone experienced anhedonia, muted orgasms, genital numbness while tapering and not completely off of their antidepressants?

 

Is PSSD considered a withdrawal reaction?

 

I have been trying to find guidance everywhere. There is only one other documented case of an individual who got PSSD-like symptoms when tapering Zoloft from 50 to 25mg. These symptoms did not resolve for him for a year. He stayed on his last dose out of fear of worsening.

 

Thanks.

 

 

[chemzu1991]

Quick general question for everyone:

 

How long after a dose increase do I have to wait before I decide to reduce the overall dose by 10%?

 

My updose of 12.5mg of sertraline has only yielded negative effects after 6 weeks: worsening anhedonia and sexual dysfunction. 

 

 

[Emonda]

What did you decide?

 

On 12/27/2024 at 1:12 PM, chemzu1991 said:

How long after a dose increase do I have to wait before I decide to reduce the overall dose by 10%?

 

How long? Stability is important. You made the change back in November, I believe, so to make a reduction now does not sound rushed.

 

If you want to make reductions, I'd be guided by the maximum of 10% per month.

 

Why taper by 10% of my dosage? The reductions should get smaller and smaller each month, for example: 10mg, 9mg, 8.1mg, 7.3mg etc. This process involves a degree of trial and error, as there is no way of predicting how an individual will respond. Importantly, if you develop unpleasant side effects from tapering, halt the taper, give yourself time to settle, and once stable, taper more slowly and by smaller amounts moving forward. The experience of others suggests that the lower you go in dose, the slower you need to go with tapering.

 

Hope this helps.