LexAdvice: In a weird spot following escitalopram reinstatement. Help?

[LexAdvice]

Hi there, I am approaching my one year mark on generic Lexapro following a three month period of severe insomnia (I've been prone to intermittent, but severe, episodes of insomnia my whole adult life, since I was 18). The drug has greatly helped my sleep (and anxiety around sleep), but I don't believe it is a permanent solution and I feel ready to get off it. I started last June on 10 mg and 3 mos. ago (under dr's supervision) dropped to a "maintenance dose" of 5 mg.

 

I sketched out a taper plan which I was looking for feedback on. I will run it by my doc of course, but I believe he will think it is WAY too slow - I don't really care. My system is horribly prone to insomnia, so it's a very modest timeline in order to try to avoid rebound insomnia. Thanks in advance for any pointers/feedback!

 

June 1 - June 15: 3.75 mg

June 15 - July 15: 2.5 mg

July 15 - August 15: 2 mg (switch to liquid formulation)

August 15 - Sept. 15: 1.5 mg

Sept. 15 - Oct. 15: 1 mg

Oct. 15 - Nov. 15: .5 mg

Stop taking on Dec. 15. Or Dec. 31 for the new year??

Edited May 31, 2017 by scallywag
tags

[Shep]

Hi, Lochina. Welcome to the forum. Thank you for filling out your signature already. Please use this thread to update your progress and ask questions. 

 

Lexapro is a very potent SSRI, and from your schedule, it looks like you'll be going from 5 mg to 3.75 mg. This is a 25% drop, which may be too fast. We generally recommend a 10% dosage reduction every 3-4 weeks, with the 10% calculated on the last dosage:

 

Why taper by 10% of my dosage?

 

What is withdrawal syndrome? 

 

Here is more information about how to come off of Lexapro:

 

Tips for tapering off Lexapro (escitalopram)

 

I'm going to leave you with some more information to read on non-drug ways of coping with insomnia. You'll find plenty of support and information here from people going through this. I also suffer from the dreaded insomnia, but it does get better in time. 

 

 

Sleep problems - that awful withdrawal insomnia

 

 

Some people find that magnesium and Omega 3 can be helpful for sleep; however, please use caution with any supplement. Start out with low doses to see how you react. Some people find that their CNS becomes more sensitive during withdrawal and recovery.

 

 

King of supplements: Omega-3 fatty acids (fish oil)

 

Magnesium, nature's calcium channel blocker

 

How are you sleeping and what kind of withdrawal symptoms have you had so far? How did you feel going from 10 mg down to 5 mg? These are the kinds of questions to ask yourself and make note of here so we can help you set up your taper. 

 

Please feel free to ask questions and get feedback along the way. 

 

[LexAdvice]

Hi there,

 

First off this community sounds great. I'll try to keep my history brief. Basically, 1 week ago I reinstated 5 mg generic Lexapro after a "relapse" of the insomnia I was using the medication for. I now believe, due to finding this site, that the "relapse" was a delayed WD after a too-fast taper. I am back on 5 mg and my doc wants me to commit to another long term of 10 mg, but I am not sure that is the correct way to go.

 

Longer history: Last June, following a 3 month episode of crippling insomnia, was Rx'd 10 mg generic Lexapro and Seroquel as needed (50-100mg) for sleep. More or less quickly tapered Seroquel. Lexapro definitely helped with sleep with minimal side effects (weight gain).

Due to distrust of psych meds decided to taper Lex without Dr supervision (he wouldn't approve) starting in December. I though I was being conservative, but I now know it was too fast. As best as I can guess, did 3 weeks 7.5 mg, 3 weeks 5 mg, 3 weeks 2.5 mg and then done.

Was golden for a while! Noticed NO W/D SYMPTOMS during the fast taper - not in mood, not in sleep. About 2 weeks off the meds, hit with insomnia again. Tried to hold out. Didn't want back on meds. Eventually gave in and saw doc again. He said I had a "relapse" and put me back on 5 mg (plus back to the Seroquel 50 mg, he says I can taper that fast). He wants me to go up to 10 mg for 3 months, drop to a maintenance dose of 5 mg after that, and then see where we are. All in all, I was off the Lex for more than two months before reinstating: From mid-Feb to late April.

 

My question is this: what do I do? My doc (and family, btw) think I had a "relapse," but I think it was only W/D now that I've found this site. I'm due to increase to 10 mg tomorrow. I am going on a big trip with my boyfriend at the end of the month and I want to be stable (sleeping) before and during. So I'm reluctant to play around with meds too much. I suppose I had resigned myself to doc's plan (10 mg for 3 months) in order to be stable for a while. After that, I could begin a VERY slow taper, the 10 percent per month recommended by this site. How does that sound to people? Or should I not up to 10 mg tomorrow and stay at 5 mg? I'm concerned that won't be enough to control the rebound insomnia and the biggest factor for me is the trip I'm going on in 3 weeks.

 

Thanks in advance for any advice!

 

 

 

[LexAdvice]

By the way, in case it's relevant, I've felt AWFUL restarting the Lex. SO SO TIRED, worse than the first time around, even though I'm sleeping much much better again. It's like starting all over again, which makes me think the drug was pretty well out of my system by the time I reinstated. :/

[nz11]

Welcome Lex.

Gee i cant believe doctors are giving ssris for insomnia. Do you have any ideas what may have suddenly bought insomnia on in 2015 ?

There are some good links here on non drug methods for coping with insomnia.

If i were you i definitely would not updose tomorrow. 

You are correct you suffered withdrawal symptoms...well i guess you had insomnia to start with right so it is a little confusing but your sig says no wdl symptoms...they can be delayed and one is insomnia...there could be a lot more to come or maybe not.

Is insomnia the only symptom you are experiencing? if so then you are very lucky and i would even consider going down to 2.5 immediately. Be interesting to hear some of the other opinions.

You don't want to be on this drug for longer than you have to. Believe you me life could be a lot worse for you than insomnia due to exposure to these drugs.

Here is a checklist  to consider

Dr. Joseph Glenmullen's withdrawal symptom checklist

Are you experiencing any of these?

Did you ever take psychotropic drugs prior to June 15? Is the pdoc referring to a relapse of insomnia or something else?

 

You didn't put seroquel in your sig are you still taking it.?

 

It is very easy to assume that drugs from a doctor are safer than they are. It is hard to believe that a doctor could prescribe something that  may be harmful. Even when we ask all the right questions we may be given misinformed information. Adverse effects are not mentioned or seriously understated. One or two mentioned when in fact there are hundreds.

[LexAdvice]

Hi! Thanks for your response. To be fair, the Lexapro really did help my sleep almost immediately. I have a history with both Lex and Seroquel. At the age of 18 I had a similar crippling episode of insomnia (and anxiety) when I went away to college (too many changes). The episode last year was similar, a new job that I hated, plus a breakup. After the college incident I tapered off both drugs no problem and was more or less fine until last year (that's more than 10 years!). So it's not altogether crazy that I was Rx'd both drugs again.

 

I'm still taking the seroquel, mostly out of fear that the Lex alone won't work. I take 50 mg and looking to reduce soon due to side effect of daytime drowsiness.

 

I'm hoping a moderator will weigh in soon! As I said, my primary concern is maintaining sleep until and through my trip at the end of the month. After that, I could very slowly (10%) taper my meds. Thanks!

[LexAdvice]

If possible, I'd also like some advice about which drug to taper first. When I did it in college (again not under dr. supervision- once they give you the drugs they don't care what happens later), I did Lexapro first. I took Seroquel (low dose) for quite a while thereafter to help maintain sleep, then went off it in what would be considered a rapid taper and had NO W/D. Maybe since I was only 19 my CNS was able to bounce back faster...?

 

Last time I tapered, I did Seroquel first, as in, I wasn't on it at all for months, solely using Lexapro. But since it wasn't successful, maybe the way to go here is get down to a low maintenance dose of Seroquel for the time being, then leave it alone. Taper super-slow the Lex, then turn to the seroquel after. What do people think? Thanks so much!

[Shep]

Hi, LexAdvice. Welcome to the forum. You'll find lots of support for coming off your drugs AND dealing with insomnia. That's really common around here.

 

Please add the Seroquel information to your signature (dose, length of time on it, etc).

 

Also, please place all your medications into a medication checker and copy and paste the results. There are heart rhythm complications that can occur with Seroquel and certain SSRIs, so please be mindful of this.

 
Drug Interactions Checker -- use it to reduce your drug burden

 

This information is important as it will help guide you in setting up the right taper. Please also see:

 

Taking multiple psych drugs? Which drug to taper first?

 

Here are some links to read over:

 

Why taper by 10% of my dosage?

 

Tips for tapering off Lexapro (escitalopram)

 

Tips for tapering off Seroquel (quetiapine)

 

 

NZ11 also linked you to Dr. Glenmullen's symptom checklist which is also a great resource.

 

Once we have this information, we can help better set up a game plan for you. Lexapro is a very potent SSRI and it looks like your previous taper was way too rapid. This link on reinstatement may help you place this into context. It's possible your CNS is a bit destabilized now and you'll want to try to minimize further risks.

 

About reinstating and stabilizing to reduce withdrawal symptoms

 

Again, welcome to the forum.

[LexAdvice]

Hi Shep! Thanks! I'll do that right away.

 

I'm assuming that I should not updose like my Dr. wanted me to. I believe I'll stick with 5 mg (reinstated one week ago after being "clean" [ha, ha] for about 10 weeks). Does that sound right?

 

Again, thanks for the warm welcome. Most of the people in my life have continually urged me to get and stay on these drugs, but the more research I do the scarier they sound to me.

[LexAdvice]

The "which to taper" link you shared seems to suggest getting off the Lexapro first, which makes sense to me (now) given that that is how I did it back in college. Of course my dr. suggested the other way around...

[LexAdvice]

Interactions between your selected drugs

Major quetiapine  escitalopram

Applies to: Seroquel (quetiapine), Lexapro (escitalopram)

Using escitalopram together with QUEtiapine can increase the risk of an irregular heart rhythm that may be serious and potentially life-threatening, although it is a relatively rare side effect. You may be more susceptible if you have a heart condition called congenital long QT syndrome, other cardiac diseases, conduction abnormalities, or electrolyte disturbances (for example, magnesium or potassium loss due to severe or prolonged diarrhea or vomiting). Talk to your doctor if you have any questions or concerns. Your doctor may already be aware of the risks, but has determined that this is the best course of treatment for you and has taken appropriate precautions and is monitoring you closely for any potential complications. You should seek immediatemedical attention if you develop sudden dizziness, lightheadedness, fainting, shortness of breath, or heart palpitations during treatment with these medications, whether together or alone. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor.

[Shep]

Thank you for placing the interaction here, LexAdvice.

 

You'll get some feedback from a more experienced moderator later, but I'm thinking you're right and the Lexapro should be reduced first if it's more "activating".

 

But let's get that feedback first.

 

In the meantime, please read over the previously listed links, and I'm going to give you a link for information on non-drug ways of coping with insomnia:

 

Sleep problems - that awful withdrawal insomnia

 

This is my favorite:

 

Guided Meditations: Calming Videos, Sleep Hypnosis

 

Since you had insomnia prior to using any medications, these non-drug ways of coping are really important to master as you decrease your meds. The goal is not only to be medication free, but also to have the coping skills you need for the future.

[LexAdvice]

Thank you, Shep - just having started this discussion has made me feel more at ease about the situation I'm in.

 

When another mod comments later, I'd love to get ideas about what kind of timeline to work with - other than my trip this month I have a wedding weekend in Vermont in August which will be a whole thing. I want to make sure I'm sleeping and feeling well for these events.

 

Also, some ideas about how to talk to my psych would be welcome. Last I saw him I "signed off" on another long-term course of Lex 10 mg, so he will be surprised to hear about my change of plans. I will want him to Rx liquid Lexapro to help with my taper and not sure if he will be willing but I think it's possible (maybe he won't care at all). Thanks!

[Shep]

Sure, here are some links to get you started on how to talk with your doctor: 

 

How do you talk to a doctor about tapering and withdrawal?
 
What should I expect from my doctor about withdrawal symptoms?

 

The best advice I can give you is to go ahead and start the using the non-drug coping skills and make a list of everything you're doing (such as mindfulness, yoga, or whatever) and show that to him. That makes a more compelling argument for you.

 

Also, you may want to read Robert Whitaker's book:

 

"Anatomy of an Epidemic" 

 

This link is on Whitaker's website which has a lot of great articles against the use of these drugs from a scientific standpoint. You'll find a lot of information there.

 

The more scientific information you have, the easier it may be. But in the end, you simply need to get the medication in order to taper, regardless of your doctor's ability or inability to grasp this.
 

[LexAdvice]

Thanks! Yeah, he seems like a reasonable man, just hope he'll be ok with calling in the Rx for the Lexapro liquid.

[SquirrellyGirl]

Hi L,

 

Shep gave you all the pertinent info you need to successfully taper, but I wanted to add this paper on occupancy to illustrate why it is so important to do the 10% taper, especially as you get lower in dose.  

 

http://ils.unc.edu/bmh/neoref/this.dir.unneeded/schizophrenia/review/tmp/352.pdf

 

These drugs block serotonin receptors (occupancy, in this paper) and this is dosage dependent.  Though escitalopram is not one of the drugs in the paper, the trend appears to be consistent that the minimum effective dose of SSRIs occupies receptors at 80%.  The occupancy plateaus at around 92% or so not matter how high you go in dosage.  So, you may get away with a faster taper above the MED (or not, depends on the person!) but going below that dosage too quickly or too fast gets people in to troubled waters.  Small dosage changes cause BIG drops in occupancy which means destabilization.

 

This destabilization causes a host of emotional and physical symptoms, neuro emotions AND rebound insomnia being possible if the pace is too fast for the nervous system to keep up with.  

 

You won't know if you are one of the sensitive ones who must taper this slowly or not until you find out by cutting too steeply too quickly, but once is enough to cure most people of their desire to go faster!  In our opinion it is best to never test those waters :-)

 

Either way, we are here to support you! Welcome to SA!

 

SG

Edited May 8, 2016 by JanCarol
username confusion

[SquirrellyGirl]

Hi LexAdvice, 

 

I just wanted to weigh in supporting you to stay at 5 mg lexapro as it sounds like it is doing the job of helping you sleep.  There is no point in going higher and it would just get you further hooked (more remodeling which would need to be undone as you come down again).  It's about the minimum amount of drug for the desired effect.  Shep and nz11 were dead on about using non-drug techniques in the future, but since you are already back on the lexapro and seroquel, what you need now is stability.

 

Hold until your schedule is clear and you can focus on tapering.  The goal of the 10% method is to keep you as comfortable and functional as possible while reducing, so that you can live your life!  You must listen to your body vs following a set schedule.  Rebound insomnia is a risk of tapering, and if you feel any perturbations of your sleep it could be a sign that you need to taper even more slowly, maybe 5%.  Once people lose their sleep while tapering, it is hard to get it back, and we all need our sleep while healing.  

 

I can also attest to the delayed onset of withdrawal, since I didn't have anything notable for some time after coming off of Effexor too quickly.  Did you have any other withdrawal symptoms other than insomnia?

 

Welcome to SA!

SG

[LexAdvice]

Hi SG! Thanks for your reply!

 

The problem here is that it's tough to diagnose W/D insomnia from my "regular" insomnia, which is something I've been prone to my whole adult life (with long periods of "normalcy" in between, though). I didn't notice any other symptoms other than rebound insomnia coupled with perhaps higher than usual anxiety and panic over the situation.

 

When you say to hold until my schedule is clear, do you mean just after this trip at the end of the month? Or after the wedding on August 22? My next appointment with the psych is on August 1 or something like that. At that point, I feel I could get the liquid Lexapro from him. Is that too long to wait?

 

What about trying to reduce the seroquel 50 mg dose? Or do you think I should hold off on that? The Lexapro seems to be helping me sleep, and I'd rather be taking only 25 mg of seroquel if possible. THANK YOU!

[LexAdvice]

The reason I'd like to get down to 25mg Seroquel is because I think it will be possible, and will also help with some daytime drowsiness I've had, and also will be easier to manage during travel with my bf than the dose I'm at now. But the only way I could reduce would be to cut the pills (in the past this has worked fine for me - 37.5 mg then 25 mg) or make a liquid at home, which seems tricky. 

[LexAdvice]

Actually, I have refills left on my current Seroquel (generic)...would I be able to have the refill transferred to a compounding pharmacy? I don't think my insurance will cover it until the 24th though.

[SquirrellyGirl]

I'll start off by saying that when a person has tapered too fast and has reinstated, we recommend holding for a couple of months to allow for stabilization, since the nervous system is in disarray from going without for two months, in your case, and then being put back on - woosh!  You reinstated at a higher dose than we would usually suggest, but didn't appear to have an adverse reaction to the reintroduction - it has been about three weeks that you have been on the 5 mg?  So, to tinker with that now would be adding more destabilization.  Best to keep steady.

 

You could hold here until July (a couple of months) and then do a 10% cut and hold there until after the wedding, just an idea.  Never anything wrong with holding longer and letting stabilization set in nice and solid before challenging the nervous system.  I am reluctant to suggest any changes to the Seroquel because as I said, stability is what you need right now.  As I said, we suggest holding and getting stable for a couple of months before starting tapering.  I am including the following links for your consideration as I've got to run and will be back later...The last one is something we request people do to see if it 

 

About reinstating and stabilizing to reduce withdrawal symptoms

Taking multiple psych drugs? Which drug to taper first?

Taper more than one drug at a time?

 

SG

[Altostrata]

Welcome, LexAdvice.

 

If I were you, I'd stay at 5mg Lexapro for a good while, and not increase. If it's helping you sleep, that's the whole point, isn't it?

 

What time of day do you take Lexapro and Seroquel? How long have you been taking 50mg Seroquel regularly?

 

The weight gain from Lexapro was not a trivial side effect, it means that dosage was affecting your insulin metabolism. Seroquel is infamous for this as well.

 

Please let us know how you're doing.

[LexAdvice]

Hi! I've only been taking the seroquel regularly since it was re-prescribed: about one week. I take it 30 minutes before bed. Do you think I should hold off on reducing it? I called a compounding pharmacy and I think I can get a liquid formulation to gradually reduce to 25 mg.

 

I take the lex in the morning when I eat breakfast.

 

Thanks again for all your advice!

[LexAdvice]

Altostrata, when do you think I should start my slow lex taper?

[Altostrata]

If I were you, I'd minimize the Seroquel first.

 

As you've been on it only about a week, I would reduce it by half a tablet, to 25mg, and see how you do.

 

Does the Lex make you sleepy after you take it in the a.m.?

 

Your nervous system has had a shock from Lexapro withdrawal. You need to let it settle down for some months before making changes in the Lexapro.

 

(merged your two Intro threads)

[LexAdvice]

Thank you so much. I too want to reduce the seroquel. You don't think I need to switch to a liquid to do so?

[LexAdvice]

Typically the lex doesn't make me sleepy after I take it. But it's hard to tell because all this week since reinstating I've felt WIPED all day, a symptom I did have when starting lex last year. I'm scared to take my dose at night though since it's known to be activating.

[LexAdvice]

Sorry, a symptom I DIDN'T have last year.

[JanCarol]

Hey Lex, welcome to SA!

 

You said:

 

 

When another mod comments later, I'd love to get ideas about what kind of timeline to work with - other than my trip this month I have a wedding weekend in Vermont in August which will be a whole thing. I want to make sure I'm sleeping and feeling well for these events.

 

This is another reason we only taper by 10%.  And we hold a lot.  You can choose your times for "withdrawal symptoms" and if you have a big family event, or a job or house change, you can hold for a little longer and enjoy the stability before you choose to taper again.

 

It sounds like you can come down to 25 mg seroquel pretty easily (like Alto said), then hold there, and hold on the 5 mg lexapro too (I like SG's idea of holding until July, but you may settle down sooner).

 

Wait to stabilize.  What you call insomnia may have other contributing factors - lexapro withdrawal (for example) can cause problems up to 3 years out, as it restructures your brain.  When doctors say "it's relapse" or "original condition" or "drugs for life," they fail to recognize how much the drugs contributed to the problem in the first place!

 

You were wise, on your former tapers, to save the tiny dose of seroquel to last, as it will cushion some of the blows from coming off lexapro. (ain't it funny how the doc said the opposite - as if he didn't care how well you sleep?)

 

Take your time, it is better to go slowly and successfully, than it is to get off quickly and run into trouble.  You might be someone who doesn't have problems, but you've had an indicator that - problems await you.  So isn't it better to control them?  Resist the urge to hurry this process.  The potential benefits far outweigh the potential risks when you slow taper.

 

You were wise, on your former tapers, to save the tiny dose of seroquel to last, as it will cushion some of the blows from coming off lexapro.

[LexAdvice]

Hi JC, thanks for weighing and in a huge congrats on being psych drug free!

 

I'm totally with you guys on the slow taper and it makes sense to me. I'm willing to wait. My next appt. with my psych is on August 3rd, so that could be a good time to explain my taper plan and ask for the generic liquid.

 

Last night I took 37.5 mg seroquel with success, so I think it's a good indicator that I can come down to 25. Now if only I could have controlled the thunderstorm that woke me up at 7:30! Haha

 

I have two more questions: what do people think of the extreme fatigue I've been experiencing since reinstatement? I didn't have this problem when I went on Lex last year, and it's frustrating to be feeling this way after sleeping so much. Also, re: continuing with the seroquel: last year I phased it out entirely around the 4 month mark of being on the drugs, using only Lex, and was sleeping great on only lex until a few weeks after the failed taper. Is there anything to say that wouldn't work this time (only lex)? The thinking here is that I'm going to be on the lex for the long haul, and then if the seroquel later has to be tapered too, that's a looooooong time to be taking these drugs...let me know! Thanks!

[LexAdvice]

By the way, please refer to my second post in this thread for a more accurate history of med use. My two intro threads were merged and this second one is way more detailed. Thanks!

[LexAdvice]

Hi,

 

I calculated my taper schedule were I to start in August and it's loooooong.

 

August 4.5 mg

September 4 mg

October 3.6 mg

November 3.2 mg

December 2.9 mg

January 2.6 mg

February 2.3

March 2.1

April 1.9

May 1.7

June 1.5

July 1.4

August 1.2

September 1.1

October 1

November .9

December .8

January .7

February .6

March .5

April .4

May .3

June .2

July .1

 

Am I correct in understanding that at the higher doses it might be possible to go faster but at the lower doses it's more important to go slow? Could I test the waters of, for example, tapering every two weeks in the beginning and then slowing down to month-long holds later on? Thanks!

[Altostrata]

The fatigue is probably from the Seroquel at night.

 

Yes, you can make a cut in the tablet to half a tablet (25mg). You will want to fine-tune the taper with a liquid later.

 

Please do not worry about how long it will take you to get off these drugs. It is the way it is, unfortunately. The key is to do it in a way that is least painful.

[LexAdvice]

Thanks for responding! Yes I have 25 mg tablets so I will work my way down to that. Will I have to take the seroquel the whole time I am on the lex to be tapered after? As I said, before the crash and burn, I was on only lex for months and sleeping fine. Thanks!

[Altostrata]

If I were you, I'd get off the Seroquel as soon as possible, to limit the risk of dependency. When is your trip scheduled?

[LexAdvice]

I'd like to do that, too. My trip is May 30 through June 6. Maybe get down to 25 before the trip and off when I come back?