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Tips for tapering off Savella (milnacipran)

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AKA milnacipran, Dalcipran, Ixel, Toledomin

From FDA information at http://www.drugs.com/pro/savella.html#s21

Discontinuing Savella
Withdrawal symptoms have been observed in clinical trials following discontinuation of milnacipran, as with other serotonin and norepinephrine re-uptake inhibitors (SNRIs) and selective serotonin re-uptake inhibitors (SSRIs). Patients should be monitored for these symptoms when discontinuing treatment. Savella should be tapered and not abruptly discontinued after extended use [see Warnings and Precautions (5.7)].
Discontinuation of Treatment with Savella
Withdrawal symptoms have been observed in clinical trials following discontinuation of milnacipran, as with other SNRIs and SSRIs.

During marketing of milnacipran, and other SNRIs and SSRIs, there have been spontaneous reports of adverse events indicative of withdrawal and physical dependence occurring upon discontinuation of these drugs, particularly when discontinuation is abrupt. The adverse events include the following: dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesias such as electric shock sensations), anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania, tinnitus, and seizures. Although these events are generally self-limiting, some have been reported to be severe.

Patients should be monitored for these symptoms when discontinuing treatment with Savella. Savella should be tapered and not abruptly discontinued after extended use. If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose but at a more gradual rate [see Dosage and Administration (2.4)].....

Savella has a fairly short half-life (http://www.drugbank.ca/drugs/DB04896) and is usually dosed twice a day, with a maximum daily dosage of 200mg.
Savella is available in

Film-coated, immediate-release tablets in four strengths: 12.5 mg, 25 mg, 50 mg, and 100 mg of milnacipran hydrochloride.

Reduce by 10% per month to start
The 10% rule holds for Savella, just like other psychiatric drugs: To minimize withdrawal symptoms, 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?

Cutting up tablets
You may need a smaller dosage than the 12.5mg tablet to taper gradually. Cut tablets up with a pill cutter, available at any drug store.
Precisely weighing tablet pieces or crushed tablets with an electronic digital scale
To precisely measure your dosage in tablet pieces, use an electronic scale that measures milligrams. These are available for under $30 US. See http://survivingantidepressants.org/index.php?/topic/1596-using-a-digital-scale-to-measure-doses/
Make your own liquid

According to the US National Institutes of Health http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=9970

It is freely soluble in water, methanol, ethanol, chloroform, and methylene chloride and sparingly soluble in diethyl ether.


You can make your own liquid out of tablets and water. See How to make a liquid from tablets or capsules
Use a combination of tablets and liquid
You may wish to gradually convert your dose to a liquid by taking part as a tablet and part as a liquid. This can be more convenient and, for those who are very sensitive, more tolerable than simply switching to a liquid form.
For example, if you are taking 100mg Savella and wish to reduce by 10%, you could get a prescription for 50mg tablets and make the liquid, then take one 50mg tablet and 40mg in liquid form to total a daily dose of 90mg.

Have a compounding pharmacy make up a liquid or capsules of smaller dosages
A compounding pharmacy will accurately make a liquid or weigh small doses and put them into capsules for you. See http://survivingantidepressants.org/index.php?/topic/235-tapering-techniques/page__p__3001#entry3001

Fibromyalgia: Getting off SNRIs with Savella (milnacipran)
Cymbalta and Effexor, SNRIs prescribed for fibromyalgia, are among the most difficult antidepressants to quit. If you have fibromyalgia, a condition of hypersensitivity to nerve pain signals, to begin with, the stress of withdrawal can make this condition worse.

The "Prozac switch" is a method people might use to get off an antidepressant when tapering becomes too difficult. But if you have fibromyalgia, what can you do when withdrawal symptoms become unbearably painful?

I just had a conversation with a knowledgeable doctor who pays attention to the complications of getting people off antidepressants. He said he might switch patients taking Cymbalta or Effexor or another SNRI for fibromyalgia to Savella (milnacipran) and then taper them off the Savella.

He said that Savella is mostly a NRI (norepinephrine uptake inhibitor) and its SRI (serotonin reuptake inhibitor) component is much weaker than Cymbalta or Effexor etc. The NRI component would help dampen the fibromyalgia pain reaction while the SRI part would enable the substitution for a stronger SNRI (Cymbalta or Effexor etc.).

He believes Savella is easier to taper than Cymbalta or Effexor etc. -- but it still requires careful tapering.

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