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  1. ADMIN NOTE: Read this entire topic before attempting a switch to Prozac. Be sure to read details and cautions below . Consult a knowledgeable medical practitioner before changing medications. Also see Tips for tapering off Prozac (fluoxetine) Switching or bridging with another related drug, usually of a longer half-life, is a 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 most 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 or Celexa and its sibling escilatopram or 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. 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: 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. Difficulty tapering off the bridge drug. All of the bridge drugs can be difficult to taper themselves. About serotonin toxicity: For antidepressants, you run the risk of serotonergic toxicity if you are taking an SNRI, particularly at a high dose, with an SSRI, or too much of one antidepressant. (Never take an MAOI in combination with another antidepressant!) Serotonergic effects of an SSRI such as Prozac, Celexa, or Lexapro are ADDED when combined with an SNRI such as desvenlafaxine (Pristiq), duloxetine (Cymbalta), venlafaxine (Effexor), venlafaxine XR (Effexor XR), milnacipran (Savella), and levomilnacipran (Fetzima). This is why doctors familiar with the Prozac switch will cross-taper by adding a LOW DOSE of Prozac to an SNRI. Another concern: Escilatopram (Lexapro) is several times stronger, milligram for milligram, than the other SSRIs. If you add 10mg Lexapro to the high dose of 60mg Cymbalta, for example, you run the risk of serotonergic toxicity -- 10mg Lexapro is equal to approximately 30mg Prozac. So, like anything else, a drug switch is not guaranteed to work. When to switch or bridge 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 a new drug, or the substitution may not work to forestall withdrawal symptoms. This is the "the devil you know is better than the devil you don't know" rule. 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 Effexor and Paxil, they do the Prozac switch from the beginning.) If you are having intolerable withdrawal from another antidepressant, it may be worth risking the worst case: 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. 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 Prozac 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. Note on above: If you have tapered to a lower dose of Seroxat/Paxil, Effexor, Cipramil/Celexa, Lustral/Zoloft, etc., 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. More is not better for nervous systems sensitized by withdrawal. 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. What should the final Prozac dose be? Please 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 probably safest to err on the lower side of a Prozac dose "equivalent" -- such as 5mg -- to your original drug. Here is a graphic representation of cross-tapering: If the second antidepressant is Prozac, given Prozac's long half-life, it may take up to 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 it throughout the cross-taper, you could end up with serotonin toxicity from too much Prozac. 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 Also see this discussion about cross-tapering with Prozac: Smoothing out a transition to Prozac 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 Prozac. (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.
  2. ADMIN NOTE If you are looking for information about switching or "bridging" to Prozac to go off your antidepressant, read this ENTIRE topic: https://www.survivingantidepressants.org/topic/19373-the-prozac-switch-or-bridging-with-prozac/ Prozac was the first popular SSRI, released in 1987, and was a substantial source of profit for Eli Lilly for many years. It became available in a generic form in 2001 (Lilly's fortunes subsequently plummeted). It comes in 10mg, 20mg, and 40mg capsules, as well as a liquid (20Mg/5Ml), which is very helpful for tapering off. After a single oral 40 mg dose, peak plasma concentrations occur after 6 to 8 hours. In Australia and parts of Asia, brand-name Prozac is available in 20mg flavored dispersible tablets, instructions for which advise that they may be dissolved in water. The tablets are scored, indicating they may be split. (In the UK, similar fluoxetine dispersible tablets are called Olena.) Prozac also comes in a 90mg weekly capsule, containing coated pellets for delayed release adding 2 hours for peak plasma concentrations (very rarely prescribed). It has the longest half-life of any SSRI. After you take it for a few days, half-life is about 16 days. Fluoxetine itself has a half-life of 2-4 days, but as it is processed, your body creates an active antidepressant metabolite, norfluoxetine, which has a half-life of 7-15 days. So Prozac keeps on extending its half-life as it is metabolized. According to http://en.wikipedia.org/wiki/Fluoxetine , fluoxetine and norfluoxetine inhibit each other's metabolism, extending the half-life of the drug. Because the half-lives are so long, the full effect of Prozac on the brain may not be felt for several weeks. fluoxetine (1-6 days) ---> norfluoxetine (up to 16 days) ---> other metabolites Prozac is mainly metabolized by the liver enzymes identified by cytochrome P450 CYP2D6 and CYP2C9/2C19, and inhibits its own metabolism via cyp 2D6 and cyp 2c19, which means lower doses get metabolized faster. (Prozac and its metabolites are also mild to moderate inhibitors of CYP1A2, CYP2B6, CYP2C9, and CYP3A4.) Is Prozac "self-tapering"? Because of its very long half-life, Prozac has the reputation of being "self-tapering," meaning it requires only a short taper. However, some people do suffer withdrawal from Prozac, just as severe as other SSRIs. Because of the long half-life, withdrawal symptoms simply take longer to appear. We suggest starting out with a slow taper of 10% per month for a couple of months; if no withdrawal symptoms appear, rate of taper may be increased -- but slow down if withdrawal symptoms arise. Reduce by 10% per month to start The 10% rule holds for Prozac, just like other psychiatric drugs: Reduce by 10% per month, calculated on the last dosage. (The amount of the reduction gets progressively smaller.) See Why taper by 10% of my dosage? Using fluoxetine liquid to taper This is by far the easiest way to taper by very small amounts. It comes in a concentation of 20mg fluoxetine in 5mL of liquid, meaning there is 4mg of fluoxetine in 1mL. If you are taking 10mg Prozac now, the liquid equivalent would 2.5mL. If you want to take 9mg of Prozac, you would take 2.25mL of the liquid. Always check the concentration of the liquid you get as it can vary among manufacturers, and adjust your calculations accordingly. If your fluoxetine liquid contains 20mg fluoxetine in 5mL of liquid: 1 mL= 4mg 0.5mL = 2mg 0.25mL = 1mg 0.2ml = 0.8mg You will need an oral syringe to measure out your dose of the liquid. To use the oral syringe, you need a special cap to put on the bottle of liquid Prozac. The cap should have a hole in it, the tip of the oral syringe fits into this. Read this about oral syringes. If your pharmacist doesn't have a cap, ask for a smaller medicine bottle with this type of cap. Pour some of your liquid Prozac into it and draw your dosage from the smaller bottle. Here's an illustration of how to draw the medication from the bottle http://survivingantidepressants.org/index.php?/topic/235-tapering-techniques/page__view__findpost__p__2284 Also see http://survivingantidepressants.org/index.php?/topic/235-tapering-techniques/page__view__findpost__p__21391 See more detail about how to measure and taper Prozac-brand liquid here http://survivingantidepressants.org/index.php?/topic/759-tips-for-tapering-off-prozac-fluoxetine/page__view__findpost__p__41090 Making your own Prozac liquid Prozac is one of the few psychiatric medications with a long history of do-it-yourself dilution in water or juice. Mixed in cranberry juice, it's been called "Cranzac." My own personal preference would be to dilute it with water, to avoid any degradation that might be caused by sugar or acid in the juice. Also, it will be easier to see how well the Prozac is dissolved in water. (There may be particles swirling around, that's the filler in the Prozac capsule that doesn't dissolve.) Your Prozac solution may be a little bitter -- just swallow it quickly. You might want to chase it with a little fruit juice. There are instructions for DIY Prozac solution here: http://depression.about.com/cs/sideeffects/ht/cranzac.htm (A psychiatrist posts about it here.) For very gradual tapering, for example, you can dissolve a 10mg capsule or orally dispersible tablet in 10mL of water to make a solution with 1mg Prozac in 1mg of water. To take 1mg Prozac, use an oral syringe to take out 1mL. Refrigerated, it's supposed to be stable for 14 days. From a pharmaceutical technician manual Using a liquid can be a very precise way to taper. Using a combination of tablets or capsules and liquid Rather than switch directly to an all-liquid dose, you may wish to take part of your dose in liquid and part in lower-dose tablets or capsules, gradually converting to all liquid as you get to lower dosages. This can be very convenient and reduce any problems switching from one form of the drug to another. For example, if you are taking more than 10mg Prozac per day, you could get your prescription filled in 10mg capsules and take part of your daily dosage in a 10mg capsule and the rest in liquid. If your doctor prescribes liquid and tablets or capsules at the same time, most likely, he or she will have to indicate "divided doses" in the prescriptions to get the drugs covered by insurance. Dividing contents of capsules into empty gelatin capsules One way of tapering is to split up the powder in a capsule into smaller dosages. Go to a health food store and get empty gelatin capsules, the biggest they've got. When you open up a Prozac capsule, you can carefully pour a fraction of the powder into empty gelatin capsules. You won't have 5mg per capsule exactly, because it's difficult to eyeball the amounts. If you want to be more precise, carefully pour the powder onto a piece of black paper and divide it into quarters with a knife, then scoop each 1/4 into an empty gelatin capsule. See more about this technique at http://survivingantidepressants.org/index.php?/topic/235-tapering-techniques/page__p__3033#entry3033 If you are very sensitive to variations in dosage, this method will not be precise enough for you to control your taper. Divide up capsule contents with an electronic scale If you want to be even more precise, weigh the powder in a capsule with an electronic scale, divide it up, and put it into empty gelatin capsules. The powder is very fluffy, though -- make sure it doesn't blow off the scale. See Using a digital scale to measure doses Have a compounding pharmacy make up capsules of smaller dosages A compounding pharmacy will accurately weigh the doses and put them into capsules for you. See http://survivingantidepressants.org/index.php?/topic/235-tapering-techniques/page__p__3001#entry3001
  3. Hi all! I am a 28 year old clinical social worker who is currently withdrawing from Lexapro. I work as a medical social worker and spent most of my days helping patients with acute psychiatric and medical issues navigate their daily lives and the health system. As a seemingly experienced practictioner and someone who has battled with mental illness for the better part of 15 years, I thought I was "doing everything right". I went yearssss refusing to go on an SSRI or any medication, leading to my eventually hospitalization in which I still refused any and all medication. Many of us anxious-heavy folks grasp onto "control" to the extent that we would rather suffer immensely than even flirt with the idea of putting foreign chemicals in our bodies. So i suffered, for years. Daily panic attacks, crippling depression, suicidal ideation, agoraphobia. I was eating well, exercising, meditating, going to therapy and nothing was budging. In desperation, I went to my PCP and tried Celexa. Almost immediately I wanted to rip my skin off, I ended up in the ER. Then I tried Zoloft. Same response, skin crawling, vibrating, exhausting anxiety. Back to the ER I went. Retrospectively, I see I was started on doses far too high and should have been given a benzo to assist in the transition, but hindsight is 20/20 and at the time I was an early 20s basket case looking to just get through each hour of the day. These responses prompted me to change providers and go to a psych, as my immediate thought was "I'm bipolar! SSRI's are activating me!!!" as I have a thick family history of bipolarity. By some miracle, I sought out a psych NP with extensive trauma and PTSD experience, was diagnosed with complex PTSD, panic disorder with agoraphobia, and SLOWLY started Lexapro. My psych NP had even consulted with a panic specialist in Boston regarding the slow titration and after about a month, I worked up to 10mg and felt AMAZING. Not euphoric, not happy, but an absents of racing thoughts for the first time in years, SILENCE in my brain, calm in my body. Lexapro saved my life and I am forever grateful for that. So life resumed, I went back to school, got a masters degree, bought a home, got married, and generally did so feeling well. My agoraphobia remained a lingering symptom but I was and am fully aware of the cognitive components so I trudged on with therapy and CBT based treatment. After a few years, the racing thoughts and physical manifestations came back, I bumped up to 20mg and symptoms abated again. Once again, relative stability. But now this past year. My panic reemerged with a vengence. I was meditating, doing CBT, eating well, exercising, getting acupuncture, doing it all "right", even started some EMDR, explored other trauma processing options, the whole she-bang, but still my system was going crazy. My current psychiatrist is also my acupuncturist and is also very cautious to make sweeping med changes. We first got me back into a good acupuncture routine to help with hormones (i also have PCOS). He helped shape my diet, encouraged lifestyle changes, I did it all and still anxiety, panic, vomit. My parasympathetic nervous system was on vacation. So several weeks ago we finally decided to ween off the Lexapro and try Prozax. It was a cross taper that took a month (what I thought was a generous amount of time) but now here I am! Sick as a dog, feeling dissociated, extremely fatigued, nauseous, clouding and generally like ****. I take Alprazolam as a PRN in .5MG and have needed to utilize it daily. I am on Prozac 20mg now and haven't been on Lexapro in 2 weeks. I continue to have the aforementioned symptoms with also the joy of the brain zaps, the sweats, nightmares, and shakiness. As someone in the field, both personally and professionally, I assumed a good cross taper would minimize these symptoms, and that they would dissipate within weeks, yet here I stand a hot-mess. I am grateful to be here sharing my story and look forward to learning more about you all and your own journeys. With solidarity and love
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