Why taper by 10% of my dosage?

[KarenB]

The OP lists several reserach sources which people can follow up.  One of these is an NHS link.   

 

Drug companies have placed people in the position of needing to taper while providing extremely little information on how to safely do so.  For this reason people have had to learn how and where they can, sharing and creating knowledge bases.  Those who have done this work are now quite relieved to have science begin to realise there is a crisis, and start to conduct appropriate research.  That the two groups are starting to work together is also quite telling.  There was recently an overwhelming response to a large research survey.   

 

This grass-roots quality is also what allows SurvivingAntidepressants to use folk-references and word-pictures to illustrate processes alongside the usual thorough explanations.  Whatever we can do to help people understand the rationale, we will do.  The fate of  Humpty Dumpty is a great picture, as is Rhi's metaphor of a trellis and garden.  What we provide is not strictly Lancet; it is more than that.  People do not need a medical degree when they arrive here desparate for information.   

 

Recently I took Alto's work (and in particular this thread's OP) to my local doctor.  It was well-received, and I am now working with the doctors to implement suitable changes in the clinic, and also in other clinics in our region.  Doctors who are less biased and less afraid are able to see that there is a crisis, and they tend to be pleased with the harm-reduction approach.

 

Members are welcome to be skeptical, however we do not wish to repeatedly explain things we have already provided sources for, and which we have seen in action thousands of times.  People are welcome to wait for science to offer irrefutable evidence if they prefer; in the mean time we'll get on with helping people as best we can. 

 

 

[bubble]

Also we are all volunteers here badly struggling with withdrawal and consequences of it and doing our best to support others in similar situation.

 

So we don't have time nor energy to persuade anyone of anything. We are not in the business of proving any points or convincing anyone. Our suffering is very real and we don't need any proof of it.

 

Problems you are talking about with your wife are different. She suffers with severe health anxiety so attacking us with your 'healthy scepticism' is a very misplaced attempt to solve your problem. She needs some good talk therapy to address the root cause of her issues. As you wrote yourself she has a tendency to worry about health irrespective of whether she reads something or not.

 

There is no point in logically arguing with her and proving with any amount of evidence that her anxiety is unfounded. It's not a matter of reason but some deeply seated fear and insecurity which has to  be unpacked and dealt with. All you need is a good therapist to work with her. Tapering is not her main problem.

[nz11]

15 hours ago, bubble said:

Also we are all volunteers here badly struggling with withdrawal and consequences of it and doing our best to support others in similar situation.

 

So we don't have time nor energy to persuade anyone of anything. We are not in the business of proving any points or convincing anyone. Our suffering is very real and we don't need any proof of it.

Great stuff Bubble

This was an excellent reply to someone who i felt had just walked into a war zone and wanted to start an argument and/or demanded proof about why we have to keep our heads down and take cover.

[Terry]

On 8/5/2011 at 3:43 PM, Altostrata said:

In a nutshell, the 10% taper method recommends a 10% dosage reduction every 4 weeks, with the 10% calculated on the last dosage. The amount of decrease is proportionate to the last dosage (not the original prescription) and keeps getting smaller.
 
(Those finding that this method too slow can always speed up by making 10% reductions more often. However, if you get withdrawal symptoms, your nervous system is telling you that you are tapering too fast.)

The 10% per month reduction method is recommended by

• Peter Breggin in Your Drug May Be Your Problem

I just looked at the tapering recommendation by Dr. Breggin.  He advocates 10% reductions based on the initial dose rather than on the last dose.  This would make the tapering time significantly less.  Your thoughts?

[ChessieCat]

1 hour ago, Terry said:

I just looked at the tapering recommendation by Dr. Breggin.  He advocates 10% reductions based on the initial dose rather than on the last dose.  This would make the tapering time significantly less.  Your thoughts?

 

I'd say no, and the reason is provided in this topic:  Why taper paper: dose-occupancy curves

 

The 10% every 4 weeks of previous dose ends up being a similar curve to the dose occupancy curves.

 

Alto's comment further down the 1st page of this topic Peter Breggin in Your Drug May Be Your Problem is quoted below:

 

On 11/10/2016 at 8:11 AM, Altostrata said:

You will have to ask Dr. Breggin why his taper is calculated on the original dose. It may be he didn't consider the implications of this: he never helped many people taper.

 

If you do it this way, your decreases become an ever-large proportion of your current dose. If you start at 20mg, at 4mg, a 2mg (10% of 20mg) reduction is 50% of the dosage to which your nervous system has (hopefully) adapted.

 

You might start out slow, but you speed up as you go along. We have many people here who have tried this and developed withdrawal symptoms.

 

Periodic dosage reduction of 10% calculated on the current dose is a much gentler reduction curve than the method Dr. Breggin described above.

 

Read Why taper by 10% of my dosage?

 

 

Edited October 11, 2017 by ChessieCat

[Terry]

Thank you ChessieCat!  Guess I'm too eager to taper, but need to be reminded to slow down.

[Iatrogenesis]

Oh, now I understand why I thought I had misread Breggin's advice when I hadn't. In this thread you recommend tapering by 10% of the current dose and you say Peter Breggin recommends this and link to a thread

where his method is described as tapering by 10% of the original dose.

[Iatrogenesis]

Oh, sorry if this sounded brusque or like a criticism. I only wanted to point out that in that description it sounds like Breggin's method is 10% of the current dose too, which is not the case.

[gdsequoia]

Quote

From correspondence with Dr. Horowitz: "...all pharmacological relationships are hyperbolic so the pattern of exponential reduction that you recommend is likely to apply to any target no matter what it is."

Could someone please explain this for a layman?

 

More specifically:

- "pharmacological relationships"

- "hyperbolic" - does he mean like f(x)=1/x maybe?

- "target"  - maybe this is a synonym for "drug" here?

[Altostrata]

All drugs act this way, with a point of diminishing return where there's no additional benefit from excess dosage. The gradual hyperbolic taper can apply to any drug. (Meaning any drug with withdrawal effects.)

 

Read initial post

 

[Superwoman]

On 8/5/2011 at 4:43 PM, Altostrata said:

If significant withdrawal symptoms appear at any time, STOP TAPERING. Hold at your current dosage for some months, stabilize, then make smaller cuts or go slower. Listen to your body

What about mild withdrawal symptoms? I understand that severe significant symptoms mean you are tapering too fast. Are some mild and manageable withdrawal symptoms expected when doing a 10% taper?  Or does the presence of any withdrawal symptoms (even mild) mean you are tapering too fast?

[Altostrata]

Very mild symptoms might last a few days. If they last longer or are more severe, they are a warning you're going too fast.

[Andie]

Here is the link to what I found on Desvenlafaxine 

 

The total daily dose required to provide 50% SERT occupancy was 24.8 mg for SEP-227162 and 14.4 mg for ODV. In vitro data suggests a ratio of 3.3:1 for binding at human SERT for SEP-227162 relative to ODV. Our study suggests a ratio of 1.7:1, highlighting the value of in vivo imaging in the drug development process.

[getofflex]

Here is a brief and easy to understand (nontechnical) article about why it's important to taper hyperbolically.  

 

Why Taper Hyperbolically

[Yesyes123]

Up until how long after a 10% dose reduction could someone still suffer from WD in the lower dose? Could someone for example, lower the dose and actually feel better for a few weeks and then be hit after like a month with WD symptoms on this lower dose?

[ChessieCat]

1 hour ago, Yesyes123 said:

Up until how long after a 10% dose reduction could someone still suffer from WD in the lower dose? Could someone for example, lower the dose and actually feel better for a few weeks and then be hit after like a month with WD symptoms on this lower dose?

 

This might happen, if nothing else has changed, if a drug has reached tolerance, also known as poop out or tachyphylaxis, which can happen after a person has been taking a drug for an extended time and it loses its effectiveness.  When this happens the doctor may increase the dose and the person starts to feel improvement then after some more time the same thing happens.  See:

 

tolerance-or-poop-out-or-tachyphylaxis

 

and

 

Tachyphylaxis, Reaching Tolerance or as It's Lovingly Known “Poop-Out”

 

Generally withdrawal symptoms after a reduction show up during the first 1 or 2 weeks after the dose is lowered and then they start to reduce.  Tolerance to a drug generally happens gradually over time and one sign that it is tolerance might be that when a reduction is made a person starts to feel better but the longer they hold then the symptoms start to worsen.

[Yesyes123]

Thanks @ChessieCat,

 

How can it be that a person will feel better after a dose reduction if they have reached tolerance? Wouldn't they need more of the drug in order to get that mood improvement?

 

Or is it a paradoxical effect, like when a person will CT and feel great for a while (maybe even manic) before crashing into severe WD?

[ChessieCat]

Please read the links I provided and ask questions in this topic:

 

tolerance-or-poop-out-or-tachyphylaxis

[Yesyes123]

12 minutes ago, ChessieCat said:

Please read the links I provided and ask questions in this topic:

 

tolerance-or-poop-out-or-tachyphylaxis

 Thanks, will do!

[Yesyes123]

How does weight/ metabolism speed affect tapering? I have a fast metabolism and am a bit underweight, even on Lexapro. I wonder what that means for my tapering.

[ChessieCat]

The 10% every 4 weeks is a GUIDELINE, not a rule.  Just like every other member on SA listen to your symptoms and taper at a rate which keeps symptoms to a minimum, holding for longer as needed.  There may be some doses during a taper that a member might have more difficulty getting past.  This is an observation, and there is no "rule" for which drug and dose this applies to because there are so many variables and we are all an experiment where N=1.

 

If you keep notes on paper for yourself (and you can also rate your symptoms) you may be better able to see how the taper rate and hold is affected and whether you need to reduce less/hold longer.  Faster metabolisers may need to split their dose, but that is more likely for drugs with a shorter half life than Lexapro.  Lexapro has a fairly long half life.

[Yesyes123]

Thank you very much @ChessieCat hope you are well

[Fallensoul]

Would it be usefull in any case with drugs with short halftimes, when reaching small dosises, to split the intake into two times a day, instead of one to prevent low and teep more steady serum value's? Would this helps a bit with withdrawal?

 

 

[ChessieCat]

6 hours ago, Fallensoul said:

Would it be usefull in any case with drugs with short halftimes, when reaching small dosises, to split the intake into two times a day

 

Yes, if a drug has a half life of less than 24 hours then it may be helpful to split the dose.  Cymbalta is a drug with a 12 hour half life and needs to be taken twice daily regardless of tapering.  If a person is a fast metaboliser and takes a drug that has a half life of about 24 hours or a bit more they might need to split their dose.

 

Keeping daily symptoms notes for yourself can help you to see a pattern.  If you are experiencing interdose withdrawal you will notice a distinct pattern.  Symptoms will ease at about the same time each day when the last dose taken starts to work.  And as it wears off you will notice the symptoms increasing.

 

Sometimes a person will be taking a drug which is extended release and for tapering purposes changes to an immediate release tablet.  If a person needs to crush the tablet or make a liquid from the tablet, then it may be better to split the doses.

 

SA generally suggests moving part of the dose by 1 hour each day and observe your symptoms, noticing if your sleep is being affected.  ADs are generally activating.  It important to try not to disrupt your sleep.

[gdsequoia]

<math nerd hat on>

I'd like to point out that the "reduce by 10% of the current dose per month" rule (advocated by SA.org) yields an exponential curve (0.9^x) and not a hyperbolic one (such as 1/x).

Example:
SA's rule: 1.0, 0.9, 0.81, 0.729, 0.6561...
Hyperbolic: 1.0, 0.5, 0.3333, 0.25, 0.2...

[Yesyes123]

11 hours ago, gdsequoia said:

<math nerd hat on>

I'd like to point out that the "reduce by 10% of the current dose per month" rule (advocated by SA.org) yields an exponential curve (0.9^x) and not a hyperbolic one (such as 1/x).

Example:
SA's rule: 1.0, 0.9, 0.81, 0.729, 0.6561...
Hyperbolic: 1.0, 0.5, 0.3333, 0.25, 0.2...

 

That's interesting... I believe SA suggests the 10% rule to be safer for everyone. But there is research like Mark Horowitz saying that the last option is appropriate to mitigate WD symptoms. 

 

Although it still might be too fast for some.

[Gridley]

12 hours ago, gdsequoia said:

I'd like to point out that the "reduce by 10% of the current dose per month" rule (advocated by SA.org) yields an exponential curve (0.9^x) and not a hyperbolic one (such as 1/x).

Example:
SA's rule: 1.0, 0.9, 0.81, 0.729, 0.6561...
Hyperbolic: 1.0, 0.5, 0.3333, 0.25, 0.2...

Regardless of what it's called, SA's slower method is much safer.  This is particularly so at the lower doses.  It took me 11 months to go from 1.0mg Lexapro (the most potent SSRI on the market) to 0.0025 (at which point I jumped to zero), and the time was well spent in terms of reduced symptoms and a smooth jump to zero.

Edited May 19, 2021 by Gridley

[gdsequoia]

I gave a bad example, sorry.

Here's a better comparison (spreadsheet I made).

I haven't read Horowitz's paper, since I have eye pain from computer screens, but I'm still posting this in the hope it may be useful to some.

 

EDIT: made spreadsheet public so you can all access it

[Yesyes123]

On 5/19/2021 at 4:11 AM, gdsequoia said:

SA's rule: 1.0, 0.9, 0.81, 0.729, 0.6561...
Hyperbolic: 1.0, 0.5, 0.3333, 0.25, 0.2...

 

Isn't the spreadsheet a lot different than what you wrote here?

[gdsequoia]

1 hour ago, Yesyes123 said:

Isn't the spreadsheet a lot different than what you wrote here?

Yes it is; my first example was a bad example, because it showcases a fast hyperbolic taper. But a hyperbolic taper doesn't have to be fast.

 

There is an infinite number of possible hyperbolic tapers, and an infinite number of possible exponential tapers.

 

Example of 2 different exponential tapers:

Reduction by 10% of the current dose (aka "SA's rule"): 1.0, 0.9, 0.81, 0.72, 0.65...

Reduction by 5% of the current dose (aka "what many SA members do"):  1.0, 0.95, 0.90, 0.86, 0.81...

 

Example of 2 different hyperbolic tapers:

A fast hyperbolic taper can be: 1.0, 0.5, 0.3333, 0.25, 0.2...

A slower hyperbolic taper (like in the spreadsheet) can be: 1.0, 0.89, 0.8, 0.73, 0.67...

 

Hope it's clearer now.

[Yesyes123]

@gdsequoia how do you make the calculations for a slow hyperbolic taper?

 

I think since it's so similar to the "10% of current dose" guideline, advising a slow hyperbolic taper would only further complicate things and confuse people, as opposed to the 10% guideline being easier to measure and easier to grasp for beginners in here. 

 

I do understand there might be a word mistake on the original post because the 10% rule isn't exactly hyperbolic, but it's extremely close to it so it's not really a big deal

[gdsequoia]

6 hours ago, Yesyes123 said:

how do you make the calculations for a slow hyperbolic taper?

The dose for the current month is:

originalDose / (currentMonth/8+1) 

 

For example, if you started your taper with dose 50mg, and you're on the third month of your taper, you should be taking 50 / (3/8+1) which equals 36mg.

 

You can change the "8" to another number, for a slower or faster hyperbolic taper.

 

6 hours ago, Yesyes123 said:

I think since it's so similar to the "10% of current dose" guideline, advising a slow hyperbolic taper would only further complicate things and confuse people, as opposed to the 10% guideline being easier to measure and easier to grasp for beginners in here. 

Yeah, I guess you're right. I will stop advocating for the hyperbolic taper (at least until I'm able to actually read the Horowitz paper! )

[Yesyes123]

On 5/19/2021 at 4:11 AM, gdsequoia said:

Hyperbolic: 1.0, 0.5, 0.3333, 0.25, 0.2...

 

Horowitz actually suggests this exact rate. First reduction is half the dose, and so on...

 

So interesting, there are many other nuances to pay attention to like SERT Occupancy

[InvisibleUnless]

i wasnt sure where to post this question, so the sticky about tapering speed seemed like the best fit after i did some poking around and google searches.  is there a thread on SA dedicated to discussing the management of coming off short-term use of any particular drug class?  the class of greatest interest to me overall is antipsychotics, because they tend to have a steeper increase in severe and potentially lasting adverse effects than drugs like antidepressants or benzodiazepines when you take them for something like 2 months or 3 rather than 1 or less.

 

for people wanting to quit after just 2-6 weeks of antipsychotic use where a 10% taper is usually a bad fit, i am not sure where to point patients and dont have a personal base of anecdotes to draw from in creating accountable ideas.  perhaps ive missed where this has been discussed?  i understand some people do still need a slow taper even after shorter periods of exposure, but a lot of people are either okay to hop off quicker or are wanting to make the plunge even with the understanding things might go badly.

[Altostrata]

For psychiatric drugs other than benzodiazepines, the general rule is if you've taken the drug a month or longer, you'll need to taper. Unfortunately, people can become physiologically dependent on benzos a lot sooner, so they require even more care in tapering.

 

Rate of taper is always a negotiation with your own nervous system, it's not a rule that allows exceptions. We have seen most people can handle a 10% per month exponential reduction with minimal withdrawal symptoms.

 

You might be able to go faster or slower, there's no way to predict that in advance. If your nervous system sends up signals of withdrawal symptoms, you're going too fast. It is dangerous to ignore these communications from your nervous system even if you want badly to be off the drug.

 

If you are getting withdrawal symptoms upon a dosage reduction, it doesn't matter how long you've taken the drug. Your nervous system has become accommodated and you need to set up a tapering schedule that doesn't cause withdrawal symptoms.

 

[Vasherr]

I was reading many users topics, and noticed that crashing while tapering sometimes bears resemblance to honeymoon and crash after CT.

 

From what I've seen it is often that a person is reducing by standard 10% or less a month with no problems for several months and then suddenly crash with a strong wave.

 

Maybe there is a similiar mechanism at play as in honeymoon, so it would be good to take a breather once in a while even if there are no alarming WD symptoms.

 

Of course I understand that most of us wants to get off as fast as possible, so it is just a thought to be considered, so to not make yourself suffer when You don't need to

 

Wishing You all a lifelong window!

V.