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  1. ADMIN NOTE: Read this entire topic before attempting a switch to fluoxetine. Be sure to read details and cautions below . Consult a knowledgeable medical practitioner before changing medications. Also see Tips for tapering off fluoxetine (Prozac) Switching or bridging with another related drug, usually of a longer half-life, is a medically recognized way to get off psychiatric drugs, particularly if you find tapering your original drug to be intolerable. Many people with failed tapers from venlafaxine (Effexor), desvenlafaxine (Pristiq), paroxetine (Paxil), and duloxetine (Cymbalta) find they need to bridge in order to go off the drug. For many doctors, a switch to Prozac to go off a different antidepressant is routine. Because of the risks of switching drugs -- see below -- we recommend attempting a very gradual direct taper from your drug, with bridging with a different drug only a last resort. There are a lot of unknowns in bridging. Fluoxetine (Prozac) has the longest half-life of any of the modern antidepressants. Because it takes more than a week for a dose to be metabolized completely, a careful taper off fluoxetine is easier for many people -- see information about Tapering off Prozac. And, at least fluoxetine comes in a liquid. (Do not assume fluoxetine is "self-tapering"! We have many people here with Prozac withdrawal syndrome. While going off fluoxetine usually has less risk, one might still develop withdrawal symptoms going off fluoxetine. No bridging strategy is risk-free.) Citalopram (Celexa )and its sibling escilatopram (Lexapro) have half-lives of about 35 hours, a relatively long half-life among SSRIs, and are other candidates for a bridging strategy. They also come in a liquid form. You must find a knowledgeable doctor to help you to with a bridging strategy. The cross-taper method discussed below is probably the safest way to make a change in drugs. You might wish to print this post out to discuss it with your doctor. For most people the switch goes smoothly but for some it doesn't. The drawbacks of switching to another drug to get off the first drug, described below, apply to ALL bridging strategies for ALL drugs, including benzodiazepines (where people often want to bridge with diazepam per the Ashton method). Risks of bridging A bridging strategy has the following drawbacks for a minority of those who try it: Dropping the first antidepressant in the switch may cause withdrawal symptoms even though you're taking a bridge drug. Adverse reaction to the bridge drug, such as Prozac. Serotonin toxicity or adverse effects of a drug combination. If withdrawal symptoms are already underway, switching to a bridge drug may not help. A cross-taper requires a number of careful steps. Difficulty tapering off the bridge drug. All of the bridge drugs can be difficult to taper themselves. So, like anything else, a drug switch is not guaranteed to work. When to switch or bridge "The devil you know is better than the devil you don't know". A direct taper from the drug to which your nervous system is accustomed carries less risk than a switch to a new drug. You may have a bad reaction to the substitute drug, or the substitution may not work to forestall withdrawal symptoms. The risk of a switch is justified if you find a taper from the original drug is simply too difficult. Usually people will do a switch when they find reducing the original antidepressant by even a small amount -- 10% or even 5% -- causes intolerable withdrawal symptoms. (I have heard doctors say they don't even try tapering off paroxetine (Paxil) or venlafaxine (Effexor ), they switch to Prozac at the beginning of the tapering process.) If you are having intolerable withdrawal or adverse effects from an antidepressant, it may be worth risking the worst case, which is that a switch to a bridge drug doesn't help and you have withdrawal syndrome anyway. If you're thinking of switching simply as a matter of convenience, you need to weigh the risks against the amount of convenience you would gain. Generally, switching for convenience is a bad idea. CAUTION: A switch to a bridge drug is not guaranteed to work. It's safer to slow down a taper than count on a switch. A switch really should be used only when a taper becomes unbearable or there are other serious adverse effects from the medication. You must work with a doctor who is familiar with bridging, in case you develop severe symptoms. Overview of cross-tapering method For drug switches, many doctors prefer cross-tapering, where a low dose of one drug is added and gradually increased while the first drug is reduced. For a period, both drugs are taken at the same time. Here is a graphic representation of cross-tapering: If you are making a switch to Prozac, the second antidepressant is fluoxetine (Prozac). Given fluoxetine's long half-life, it may take a couple of weeks to reach full effect. The effect of the amount you add at each stage of the cross-taper will build throughout the process. As it is possible to overshoot Prozac dosage, it's best to be very conservative about increasing fluoxetine throughout the cross-taper, you could end up with serotonin toxicity from too much fluoxetine (see below). Also see this discussion about cross-tapering with Prozac: Serotonin toxicity and serotonin syndrome You run the risk of serotonin toxicity if you are taking too much serotonergic. Most antidepressants (and some other drugs, such as triptans and MDMA) are serotonergics. Serotonergic effects of antidepressants are added when you take more than one of them, particularly if you add an SSRI (such as Prozac, Celexa, or Lexapro) to an SNRI (such as desvenlafaxine (Pristiq), duloxetine (Cymbalta), venlafaxine (Effexor), venlafaxine XR (Effexor XR), milnacipran (Savella), and levomilnacipran (Fetzima)). (Other types of antidepressants should not be combined with tricyclics or MAOIs.) Symptoms of too much serotonergic can be: Nervousness, anxiety, akathisia, sleeplessness, fast heartbeat. Symptoms of serotonin toxicity can be these plus disorientation, sweating, and others. Serotonin syndrome is even more serious. See Serotonin Syndrome or Serotonin Toxicity Reduction of the drug dose should resolve serotonin toxicity. Note that if you cross-taper, you will be taking 2 drugs at once for part of the time. Because of the potential of serotonin toxicity by overdosing SSRIs as well as in combination with SNRIs, it's safest to err on the lower side of a Prozac dose "equivalent" -- such as 5mg -- to your original drug. This is why doctors familiar with the Prozac switch will cross-taper by adding an initial LOW DOSE of Prozac to an SNRI. Start low, the effect of fluoxetine will increase over several weeks. Another concern: Escilatopram (Lexapro) is several times stronger, milligram for milligram, than the other SSRIs. If you add 10mg escilatopram to the high dose of 60mg duloxetine (Cymbalta), for example, you run the risk of serotonergic toxicity -- 10mg escilatopram is equal to approximately 20mg-30mg duloxetine. How much fluoxetine (Prozac) to substitute for my drug? Since fluoxetine's half-life is so much longer than those of other antdepressants, its effect is a little different. It's not a stronger antidepressant, but the effect of each dose lasts much longer. This may be the reason a lower dose of fluoxetine often seems to adequately substitute for other antidepressants. For an idea of equivalent doses of your medication to fluoxetine (Prozac) read this post (January 7, 2018) in this topic. It compares fluoxetine 40mg/day (a fairly high dose of Prozac) to other antidepressants. Source of that data: https://www.ncbi.nlm.nih.gov/pubmed/25911132 If you have tapered to a lower dose of an antidepressant, an even lower dose of Prozac may be more tolerable. If you are about half-way down, you might want to try 10mg Prozac. If you have decreased further, you may wish to try 5mg Prozac. If you have substituted fluoxetine for your drug and after two weeks, you feel you have withdrawal symptoms, you may wish to gradually the fluoxetine dosage. After each change in fluoxetine, wait at least 2 weeks to see the effect before deciding on another increase. More is not better for nervous systems sensitized by withdrawal. EXAMPLES OF THE PROZAC SWITCH Below is information I've gathered from doctors about how to do the Prozac switch. You will see there is no standard protocol. Healy 2009 method for the Prozac switch From Healy 2009 Halting SSRIs withdrawal guidelines: Phelps-Kelly 2010 method for Prozac switch From Clinicians share information about slow tapering (2010) Jim Phelps, one of the authors of the above, posted in 2005 in some detail about the so-called "Prozac bridging" strategy. He said it is described in Joseph Glenmullen's book, Prozac Backlash, maybe in the chapter titled of "Held Hostage." The technique Dr. Phelps described in this post skips doses and finishes with alternating dosages, which we do not recommend for people who are sensitive to withdrawal symptoms. Given that fluoxetine liquid is available, this is completely unnecessary. Foster 2012 method for Prozac switch Dr. Mark Foster, a GP whose mission is to get people safely off psychiatric drugs includes this in a presentation he gives to doctors. http://www.gobhi.org/spring_conference_powerpoints/safewithdrawal_of_psychotropics%5Bautosaved%5D.ppt. His method involves overlapping Prozac with the other antidepressant -- cross-tapering. Prey 2012 method for Prozac switch Another knowledgeable doctor (whom I trust) explained his technique to me (this is the technique I personally would prefer if I had to do it, it seems much gentler) For a "normal" dose of Effexor (150mg per day or more) or Paxil (20mg) or Cymbalta (20mg), he would switch to 10mg Prozac with a week of overlap. In other words, take both medications for a week and then drop the Effexor. Lower doses of Effexor or other antidepressant require lower doses of Prozac as a "bridge." The lower dose of Prozac reduces the risk of excessive serotonergic stimulation (serotonin toxicity) from the combination of the two antidepressants during the overlap period. Do not stay on the combination of the first antidepressant and Prozac for more than 2 weeks, or you run the risk of your nervous system accommodating to the combination and having difficulty tapering off both antidepressants. Later, taper off Prozac. He acknowledged Prozac can have its withdrawal problems, but given Prozac's long half-life, gradual tapering should be easier than tapering off Effexor. Smoothing out a transition to fluoxetine Even with a cross-taper, your system might feel a jolt after you finally drop the initial antidepressant, particularly if it is an SNRI, such as Effexor, Pristiq, or Cymbalta, or other drug that is not an SSRI like fluoxetine. (Other SSRIs include Paxil, Zoloft, Luvox, Celexa, Lexapro). If you go through a rough patch after the transition, patients find they can take a tiny chip of the original drug (or a bead or two, if it's a capsule containing beads) for a week or two to smooth out the transition. Eventually, you'd take a chip as needed only when you feel a wave of withdrawal from the original drug, and then finally leave the original drug entirely behind. (A gelatin capsule might make a tablet fragment easier to get down, but it is not necessary if you can wash it down with a good swallow of water. The gelatin capsule quickly dissolves in your stomach.) Here's an example. There is no shame in doing this. Whatever works, works.
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