mjean: Intro - Help to taper daughter from duloxetine (Cymbalta)

[mjean]

My 19 year old daughter has been on 60 mg of duloxetine (generic Cymbalta) for 6 months (July 2017) for depression & anxiety.  The medication had an immediate positive effect on her mood, but she has been having tremors in her hands, legs, etc. which concerns me greatly. She discussed it with her doctor who was unconcerned. Lately, she has felt nauseous, a bit dizzy, sweating, hot flashes and is often fatigued, so I’ve been in research mode to look for help.  Oh, how I wish I knew about the dangers of Cymbalta & withdrawal before she started this medication, but now I'm more informed, so I plan to start her on a taper per your recommendations, but I need a few questions answered first.

 

Her duloxetine is manufactured by Apotex, but yesterday the pharmacy supplied her with duloxetine manufactured by Citron because they no longer have access to Apotex.  The research I did indicated it is always best to stay with the same manufacturer when doing a taper, so I called every pharmacy in town, but no one has Apotex, so tomorrow she’ll start taking Citron.   

 

1) How long should she be on Citron before I start her taper?  I’ve heard some people have side effects from switching to a different manufacturer, so if I start the taper now, I won’t know if side effects are due to the change in manufacturers or due to the tapering of her meds. On the other hand, it may not matter because if she has side effects from changing to Citron, I don't have the ability to put her back on Apotex.  Still, I would appreciate your advice as I'd like to start the taper ASAP.

 

2)  I’d like to begin her on supplements (Magnesium, B vitamins, fish/krill oil), but I read in “The rule of 3KIS: Keep it simple. Keep it slow. Keep it stable” -- Do not ADD more than one drug or supplement at a time which makes sense to me.  Is there a link to help me understand which supplement to add first as well as when I can introduce a 2^nd supplement, etc?  Are there links for recommendations for affordable quality supplements since there are numerous brands? I’ve been doing lots of research, and I’m on overload, so I’d love to glean from your experiences.

 

Thanks in advance for any help you can provide.  I’m grateful this forum exists, and I am especially thankful for those who take time to share your knowledge to help newbies like me because there is a huge learning curve involved.

[Altostrata]

Welcome, mjean.

 

Yes, it does sound like your daughter is suffering adverse effects from duloxetine. Her doctor has been remiss.

 

Here is our topic about tapering Tips for tapering off Cymbalta (duloxetine)

 

Thank you for reading and following 3KIS. I would make sure there are no adverse effects from the change in manufacturer -- give it two weeks, at least, before tapering.

 

I would try the magnesium first, then fish oil. I would put off B vitamins for a bit, make sure everything is okay.

[mjean]

22 hours ago, Altostrata said:

 

 

 Thanks Altostrata for your input.  My instinct was to hold my daughter on the med from the new manufacturer for two weeks before trying to begin the taper, so I appreciate your confirmation.   

 

Since Apotex, the brand of duloxetine she was originally prescribed contains numerous tiny flakes that are not consistent in size, and the new manufacturer (Citron) has consistently sized beads, should I weigh the contents of an Apotex capsule and then make sure the weight of her Citron capsules match during this transition?  I would like to have her 60 mg dose remain as consistent as possible during this switchover, and I've heard that Citron capsules often do not contain the same number of beads, so the last thing I want to do is accidentally increase her dose as we are making this unexpected switch to a new manufacturer.   

 

If she does experience side effects from the switch to a new manufacturer (I've read several people experience this), what is your best guesstimate as to how long it takes for those side effects to kick in?  3 days? 4 days?   Thanks again!

[Altostrata]

 mjean, the best way to make a switch to a new brand is to take half the dose in the old brand and half in the new. You could do this by weight if you have a good scale.

 

Use the absolute weight of the contents of capsules from each manufacturer, divide in two. You might want to get some large, empty gelatin capsules for this division.

 

Your daughter would take 50% from each until the old prescription runs out, then go on 100% of the new prescription.

 

If she's going to have an adverse reaction, I would expect it in a day or two. But many people do switch generic brands without problems.

 

 

[mjean]

Excellent advice!  Today is Day 2 with Citron (the new manufacturer) because I didn't think she had any of the Apotex left to take, but lo and behold, today she discovered that she had some in her medicine cabinet, so I can make up some 50/50 capsules from both manufacturers per your recommendation to have on hand if she reacts negatively to the Citron.  BUT since you mentioned an adverse reaction to the new (Citron) could occur in a day or two, I'll see what tomorrow holds (Day 3).  If she seems to do okay on the new, should I continue with it for two weeks before beginning the taper, OR do you think it is best that I do the 50/50 mixture during the transition to the new manufacturer? If you say, yes, I should do the 50/50 mix instead, do I still have to hold her for 2 weeks, or can I begin the taper right now?  I'm anxious to get the taper underway, but I will wait if needed.

 

It's good to hear that some people transition to a new manufacturer without issues.  I only heard negative stories, so your words encouraged me. THANK YOU!!!!

[Altostrata]

If she seems okay with the Citron tablets, no need to go to the trouble of taking the tablets half and half. Or, she can alternate the two brands until the old one runs out, to use up the old capsules, no need to keep them around.

 

If all is well, she can start tapering in a couple of weeks. Are the beads in a Citron capsule very small and round or are there 4 or 5 beads in all?

[mjean]

Citron capsule has approx 360 small round beads in a 60 mg capsule.  Apotex has very tiny flakes that are inconsistent in size, so they would be difficult to count.  

[Altostrata]

Might as well use up the Apotex capsules by alternating them with the Citron capsules.

 

You seem to understand the principles of tapering very well!

[mjean]

If I understand anything at all, it is only due to YOUR efforts and to info on Cymbalta Hurts Worse Facebook as I've been devouring information this week.  I do have an additional question.

 

Once we begin tapering, how many days after a drop in dosage do folks tend to experience side effects? I’ve read some say it occurs for them on day 3-4, then they feel better as the week progresses.  I’m asking because my dd is a college student determined to stay in school, and she will have classes on Tue & Thur, so would it be good to consistently try to do her drops on a Wednesday, so that if she experiences side effects, they’ll occur over the weekend instead of on a day she has class?  Or is there really no rhyme nor reason as to how soon possible effects kick in after a drop? Obviously, I hope that side effects will be minimal, but I’m trying to get a consensus, given her school schedule, if there is an optimal day of the week to begin doing her drops.

 

I'm anxious to get this junk out of her system,  so I'd like to try her on a 10% drop initially and hold for 3 weeks,  but I also want to be wise in the process, so would it be better to start her at 5-7% initial drop?  She's been on 60 mg for 6 months. 

[mjean]

Altostrata,

 

If my daughter alternates days with Apotex (original manufacturer) and Citron (new manufacturer) to use up her old prescription, when can I start her taper?   I have a 30 day supply of each brand, so 60 days total.  Can I start the taper right away? Or do I still need to wait for 2 weeks to begin her taper since she will be switching to Citron?

 

Thanks for your help!

[mjean]

I’m giving my daughter 3 weeks to adjust to changing duloxetine to a new manufacturer (Citron).  Next week, I’ll begin her taper off of 60 mg, so I need advice before I begin. She is a college student, so she needs to be able to function to keep up with school, so I'm  trying to determine the best way to proceed to get her off of this med as quickly and safely as possible. Although, when I insert the numbers into the tapering chart, it looks like a slow taper could possibly take a couple of years, so  I'm wrapping my head around that hard reality. It’s so frustrating that a medicine she’s only been on for 6 months will take 2 years to wean off. 

 

Rather than starting at 10% drop per month for 2 months per SA recommendations, which I've heard folks say can be too harsh, I thought I'd do a 7.5% drop for 2 months, and if she does well, I'll try to decrease the time between the drop to 3 weeks, etc.  OR I wondered if she does well after dropping at 7.5% for 2 months, can I attempt a 10% drop and hold for a month?  Or is it unwise to increase the % of a drop once the taper has begun?  Or should I bite the bullet and start her at 10% taper for a month?   I'm scared about withdrawal effects she might experience because she is determined to stay in school which I fully support. 

 

I also read about the BrassMonkey Slide method of cushioning the blow by dropping 2.5% every week for 4-weeks, then holding for 2 weeks. It seems like a gentler method, but it means she’ll be on this medication for another 4 years due to the 2 week hold before doing another drop.  It's difficult for me to grasp keeping her on this poison any longer than possible, so I really need help in determining the best way to do her taper, so I welcome input from those who have dealt with tapering from duloxetine!

[brassmonkey]

Hi MJane-- I'm going to answer your PM here so there will be a better record of it and the answer won't get lost.  First off welcome to SA, it's wonderful to have a concerned mother doing good research trying to help her daughter.  Even with the symptoms that she is experiencing she is in a good position to make a very successful taper.  the CT from prozac is unfortunate but should not cause any problems. Being on only one medication and for a relatively short time is a great plus.  Even though it's only been six months, that's been plenty of time for the drug to get really well established and will require a long slow taper.  I really hate the idea of having to taper for several times the amount of time a person has been on the drug, but it is one of the physical realities of the tapering process.

 

As you have discovered there are a number of ways to approach doing a taper and you seem to have a good grasp of them.  But you wanted to know about the Brassmonkey Slide Method.  I came up with it specifically to keep withdrawal symptoms at a minimum.  By spreading the 10% reduction out over several week you allow the symptoms to manifest and then resolve in smaller batches that don't hit as hard.  In the mean time you are able to keep up a fairly aggressive taper rate of 10%. The method calls for doing a 2.5% reduction every week for four (4) weeks and then an additional hold of two (2) weeks.  We have a large number of members who have adopted this method for their tapers and are having great success with it.

 

The typical pattern is for the symptoms to start to manifest 2 or 3 days after the drop. They then start to decrease and frequently have returned to your WDnormal baseline by the end of seven (7) days.  Just in time to do the next drop.  This pattern repeats itself for the first four (4) weeks and then the last dose is held for an additional two (2) weeks.  This is very important because even though the symptoms are not being felt there is a lot of healing work going on in the background that needs to be sorted out before the next taper can be started. So even if one is feeling well at the end of the four (4) week the hold is necessary. There will be symptoms, but they should stay at a manageable level.  I was in much, much worse shape than your daughter when I started to taper, but using this method I was able to maintain my career as a Research and Development Engineer and provide as sole bread winner for my family.

 

The disheartening side of doing any taper is the length of time that it takes.  However, the alternatives can be much worse.  I had a very uneventful taper and was able to maintain my 6 week schedule the entire time.  To taper from 40mgai took me five and a half years. Because the initial drops are rather large tapering from 60mgai will only add 24 to 30 weeks to that. That sound like an incredibly long time, but it is amazing how fast it goes. By making adjustments to the dose almost weekly it gives a feeling of being very proactive in the reduction and progress is visible at regular short intervals.

 

The SA recommended minimum taper is 4 weeks, and some people are successful doing that, however many do run into the problem of the background healing getting all bunched up and causing a crash.  That crash is a sudden onset of sever acute symptoms and can take months to stabilize from before the taper can be resumed. Any taper faster than the four (4) weeks practically guarantees that there will be a crash.  In the end any attempt to go faster than the recommended taper causes things to take much longer that the taper would have taken and the ride will be much more unpleasant. 

 

Okay, I've blithered on for quite a long technical post here, so I will stop and give you a break.  I know there will be questions so please ask.

 

Brassmonkey

[mjean]

6 hours ago, brassmonkey said:

The typical pattern is for the symptoms to start to manifest 2 or 3 days after the drop. They then start to decrease and frequently have returned to your WDnormal baseline by the end of seven (7) days. 

Is this the typical pattern for brassmonkey slide only,  or would it also be a typical pattern even if we do 7.5% taper every 4 weeks?  I wondered how quickly symptoms might present after a drop, but no one addressed my previous question, so thank you.  If we try 7.5% drop initially, and we immediately run into issues, do we ride it out at 7.5%, or do I bump her back to 60 mg and hold for a while, then restart the taper later?

 

6 hours ago, brassmonkey said:

The SA recommended minimum taper is 4 weeks, and some people are successful doing that, however many do run into the problem of the background healing getting all bunched up and causing a crash.  That crash is a sudden onset of sever acute symptoms and can take months to stabilize from before the taper can be resumed. Any taper faster than the four (4) weeks practically guarantees that there will be a crash.  In the end any attempt to go faster than the recommended taper causes things to take much longer that the taper would have taken and the ride will be much more unpleasant. 

 

3

 

I shared with my daughter that by using your method, it could take 5-6 years to wean her to 0, but perhaps her symptoms would be more manageable, but the length of time was disheartening for her to hear.   I'd like to attempt to at least try to get her dosage lowered by doing higher drops initially (7.5% - 10% for 4 weeks ) per SA recommendations as a "trial" to see if she is one of the fortunate ones whose nervous system can handle a drop every 4 weeks,  BUT I don't want things to pile up, so she crashes and burns down the road.  It is quite the dilemma filled with unknowns. 

 

[brassmonkey]

We end up having to talk in generalities when it comes to tapering because each individual reacts differently to each different drug.  In general, symptoms start to present themselves with in two or three days after a reduction.  Some sensitive people can feel changes within a few hours while others won't feel anything for several weeks.  For a straight 10% reduction the symptoms hit full force right away, continue for a few weeks and then slowly resolve.  Many find that hit to be quite debilitating and end up house bound or bed ridden.  It's also a major source of anxiety and secondary panic which can make people feel even worse and can lead to making poor judgments about increasing their doses or adding other drugs to quell the symptoms.  The same pattern exists no matter what the percentage of the decrease is, the only difference is that, in general, the smaller the decrease the  milder the symptoms (with mild being a relative term).  The trade off is that the smaller the decrease the longer it takes to complete the taper.  This is one reason we stress not to taper to a calendar schedule, but rather to "listen to your body" and make adjustments accordingly. 

 

Jumping around with the dose is not a good idea.  Unless the symptoms are totally debilitating and unbearable it is best to ride them out and then make a smaller reduction the next time.  Frequent changes in dosage and updosing to alleviate symptoms plays havoc with the body and can greatly increase ones sensitivity to  the drug and to changes in dosage.  Once the body is sensitized extreme care must be taken when making changes and the length of the taper is greatly increased.

 

If you do a taper at a specific reduction at a specific interval then it's going to take a certain amount of time.  It's just simple mathematics.  Trying to accept the answer you get is much harder.  For a young person five to six years can feel like a life sentence.  For most people though it's not going to be five or six years of suffering.  Even though WD and recovery are nonliner, there will be Windows of feeling great and Waves of heavy symptoms, the overall trajectory is feeling better.  After a few drops there should start to be an improvement in the WDnormal baseline which will get better as time goes on.  After a while, if all goes well, doing a reduction becomes quite routine and life goes on around it.  That's what we're aiming for, maintaining quality of life while getting off of the drugs as quickly and safely as possible.

 

Every method of tapering has it's pros and cons and it all comes down to what the person doing the taper is comfortable with and only they should make the final decision about how to proceed.  No taper is set in stone, adjustments can and should be made along the way.  Going into it well informed is much better than scrambling for answers along the way.  I know a lot of what I say can be disheartening and down right scary but if you start out in control and stay in control it doesn't have to be.

 

 

 

[mjean]

Brassmonkey,  I'm grateful for you taking the time to reply.  It helps to dialogue with someone who is already walking this journey because my mind is flooded with questions.  

 

Quote: Any taper faster than the four (4) weeks practically guarantees that there will be a crash.

 

I've not heard this statement before, so I found it rather shocking. Am I correct in understanding that you think that no matter the % you drop, you should generally stay on that dose for a minimum of 4 weeks because I was hoping that if her first two drops held for 4 weeks were successful that we might be able to make a drop every 3 weeks instead of 4 thus speeding up the taper slightly.

 

On Cymbalta Hurts Worse FB page they say the following: Start at 10% or less and hold for 3-4 weeks to see how your body reacts. If it is tolerated, then hold for 10-14 days between decreases and see how that goes.  A lot of people don't tolerate 10% and need to slow to 7.5% or 5%. Some do 2.5% decrease and hold for 7-10 days.  Listen to your body and adjust accordingly. 

 

My desire is to get her 60 mg dosage reduced in the quickest, but safest way possible in the hope that it might reduce some of the side effects she is currently experiencing because I've heard that lower doses can sometimes help side effects (or is that misinformation?).  For example the other day she told me her tremors were so bad that she was unable to hold her phone to text, so a friend had to do it for her.  It scares me to keep her on this poison for an additional 5-6 years if I do the brassmonkey slide when I already see the damage it is doing to her nervous system after only 6 months.  

 

I know I am not supposed to be bound to a rigid calendar, but it helps me wrap my head around the reality of how long this taper might last, so I did a quick calculation and if my math is correct then in 53 weeks, she could possibly be at the following dosage which I find somewhat encouraging because it is a big reduction from 60 mg:

10% every 4 weeks = 13.7 mg

7.5% every 4 weeks = 20.1 g

2.5% weekly + 2 week hold = 24.1 mg

 

Quote:  For a straight 10% reduction the symptoms hit full force right away, continue for a few weeks and then slowly resolve.  Many find that hit to be quite debilitating and end up house bound or bed ridden.

 

She already is extremely fatigued, so when she is at home, she sleeps A LOT!  She can't afford more time in bed now that college classes have resumed. She needs to be able to function for class and her part-time job of caring for two small children. 

 

So knowing what I've shared, if she were your daughter, what would you do?  Would you try her at 7.5% or 10% every 4 weeks to get her dosage reduced  more quickly over this next year hoping to mitigate some of her current side effects?  Or would you do brassmonkyslide because it could make this next year's ride smoother in terms of withdrawal effects?

 

 

[brassmonkey]

Cymbalta (duloxetine) is a selective serotonin and norepinephrine reuptake inhibitor antidepressant (SSNRI). 

 

This means that it works by causing an excess of both neurotransmitters to build up in the brain and nervous system.  That excess "makes us feel good". To cause the excess to build up the drug basically plugs up the drains by shutting off the receptors responsible for removing the neurotransmitters.  This however, throws the brain chemistry out of balance.  The brains natural response is to get back in balance however it can.  But as long as the drug is present this response is overpowered and the drains stay closed.  It doesn't take too long before the brain just shuts those drains down for good, but it has to have the drug there telling it do do so.  It only is a matter of a few weeks before the brain has removed those drains from it's "to do list" because they are being controlled by the drug and the brain has more important things to do.

 

It doesn't take a lot of the drug to control a very large number of drains.  According to physical studies of the SERT Loading (the technical term for shutting down the drains) the equivalent of 10mgai of Paxil is enough to shut down about 87% of them. By the time the dose reaches 60mgai only a few more have been shut down, bring the total to about 93%.  However the brain becomes accustomed to that amount of drug and has to have it to maintain equilibrium.

 

Because the drug has been handling things the brain has physically rewired itself to not be concerned with the drains,  If the drug is abruptly removed the brain suddenly has to work on it's own, but it is no longer equipped to do the job.  The brain then goes into chaos trying to figure out how to make all these drains work and what to do with all that neurotransmitter that is sloshing around.  This chaos unleashes all the symptoms that we associate with tapering.

 

On the other hand, if the amount of drug is slowly reduced the brain has time to sort things out.  It can undo the physical changes in an orderly manner with a minimum of disruption to all the systems.  Because it's not just the neurotransmitters that are affected.  Every system in the body has had changes made to it: the brain, the CNS, the Autonomic Nervous System, the Endocrine System, Hormone levels to name a few.  Each one has to be inspected, adjusted and rewired by the body.  It's a major task to say the least, and that is why it is so important to  taper at a very slow and controlled pace.

 

It's not a matter of getting the drug out of a persons system.  That happens in a matter of days when the drug is stopped.  It's all the rewiring of billions and billions of connections, testing and retesting them all the while trying to keep the body alive and functioning in society.  If it isn't done in a controlled orderly manner the body rebels with overpowering expressions of anxiety, panic, pain and a huge list of other symptoms.

 

I hope that addresses your questions, and it will probably raise even more questions.  I'm a huge advocate of The Brassmonkey Slide Method, not because I invented it, but because myself and many others here know it works and works well.

[Altostrata]

mjean, all you can do is reduce by 5% or 10% and see what happens. We can't make a plan for a faster taper until we see how your daughter tolerates a reduction.

 

If you're feeling hesitant, try 5%. If you're feeling more confident, try 10%.

 

Be sure to keep daily notes on paper about symptoms, when she takes her drugs, and their dosages.

[mjean]

Brass,  Thanks for the detailed explanation of how Cymbalta affects the brain.  It was very helpful!  I'm going to have my daughter read it.  

Alto, You are right in saying we won't know how fast a taper my daughter can tolerate until we get started and see how she reacts, so it is time to jump into the deep end of the pool by getting started. 

 

My goal is to get her off  1) as quickly as possible, and 2) with minimal withdrawal effects, so she can function in school, etc., but those two goals feel incompatible.  2.5% weekly + 2-week hold seems to provide hope for fewer withdrawal effects which is a huge plus in my mind, but at this rate the taper will take 5+ years to complete, so it negates goal #1 of getting her off quickly. 

 

She’ll be at home attending community college for a few years before she transfers out-of-state, so I can provide help & support by preparing her capsules for tapering. After she leaves home, my concern is that she’ll grow weary of a long taper and will jump off cold turkey like she did while on Prozac, and then we’ll really have a mess.  According to my daughter, her CT from Prozac was noneventful, but I know that duloxetine is an entirely different beast. 

 

Since she has voiced opposition to doing a long taper (5+ years), I think we’ll try her at 10% for 4 weeks per SA guidelines to see what happens and then adjust accordingly. Maybe she'll be one of the fortunate ones who can tolerate a faster taper of 10%.   I'll keep you posted!  Thanks for your advice. 

[JenJen]

I went off Cymbalta abruptly several years ago.  I didn't know stopping that way was a problem as my Pdoc did nothing to warn me.  I am just wondering how old your daughter is and if she is competent to take part in her own recovery.  If she can she should.  It will be easier for her to understand what is happening and take care of herself.  My daughter is a teen and I am trying to help her become independent. It kind of sucks because if your child does become independent they leave.   

[mjean]

Jen, Jen,  Sorry to hear that you weren't given correct advice on how to get off of Cymbalta.  Sounds like it is quite common that doctors know zilch about tapering.  

 

My daughter is 19 years old, so yes she is certainly old enough and competent enough to take part in her own recovery. I'm the "researcher" in the family, so I've been passing along what I've learned about Cymbalta, its dangers, how difficult it is to get off of it, how she needs to taper and not cold turkey, etc..  all of which I've only  learned recently after I started researching some of the side effects she is experiencing.  Truth-be-told, she'd probably just endure the side effects and stay on the medication, but after the research I've done on antidepressants, I think she is onboard with the necessity to get off of it, but time will tell as to how committed she will be in seeing it through when the going gets tough.

 

It was her choice to remain at home to do community college to save some $$ instead of heading away to school.  I would have been fine with her going away to college, but now in retrospect, with getting ready to undergo tapering, I'm glad she is home, so I can help her with it.  

 

 

[SDOE]

mjean,

I see you are getting ready for your daughter's taper. Honestly, I skimmed a lot but I can tell you a bit about how my taper went and hopefully your daughter's taper goes much better.  She is younger and hasn't been on the drug as long as I was so I would assume she will do better. I was dealing with a limited amount of meds because I had a falling out with the prescriber as she did not want me to taper.

 

My Cymbalta contained the 12 mini-pills (5mg each.) I bought gelatin caps to put them in and I also used the empty Cymbalta capsules.  It was difficult for me to do an exact 10% reduction each time but I tried my best ( I would cut them as small as quarter which is 1.25 mg-at the end was only 2.5mg, I think.) 

 

Each month I did a drop I would have insomnia most nights out of the week but by the time I got to the 4th week of the month I was able to sleep about 5 nights out of the 7.  I took that as my sign I was ready to drop more. I don't know if that was the right way but that is what I thought/think stabilizing is.  Perhaps someone else can let you know if I am incorrect. By the time I got down to 10mg, I got stuck.  I kept thinking my sleep would stabilize on 10mg but it didn't.  I got to the point where I was going to run out of meds so I had to continue with the taper which I'm sure is why my insomnia continues. 

 

Overall, I think I'm doing decent compared to what some others are going through but if I had more meds and the type of Cymbalta with beads I would have been better off.