NattyLee: for my Mom - GAD, meds & tapering help needed

[NattyLee]

Hi, where do I start? I am in desperate need of help with tapering my Mom off of a variety of meds.

So here is our story... We are originally from London, we now live in South Africa. I mam 46 and Mom is 66, I have a son who is 14 and we now share a rented house.

 

My Dad died March 2016. This caused huge emotional trauma for my Mom as you can imagine. My Gran in the UK then became sick so Mom flew over to help (not ideal when you are going through grief and already not coping on a day to day basis, her world had been crushed in one night) So, she went to the UK and it was hard to cope with my Gran being so ill, my Mom had a breakdown, she ended up in a Psychiatric unit (admitted herself) after becoming addicted to Alzam (benzo). She originally was prescribed these here in SA years ago to manage anxiety and panic attacks. Once the emotional stress hit she started taking them more and more each day until she tried to stop, cut them down on her own and that is when the trouble and side effects started. She then went into the Psych unit in the UK. They then put her on to another type of benzo Diazepam, Olanzapine, Mirtazpine and she is also on heart and blood thinners. Once she came out she was not much better, I managed to get her on a flight and back to SA. 2 month later she just got worse, the local Dr and team tried to taper her off of the Diazepam but she is not good with the withdrawal symptoms. After many Drs, therapists, advice, research and suffering alot at home (for all of us) I checked her into a very expensive rehab here. 28 day program. She is now on: Circadin, Trepiline, Rivotril, Solian and heart and blood thinners. The program did not work, the rehab and getting her off the benzos and antipsychotics did not work.

 

What I need advice, help with from anyone is what now? The cost of the rehab was thousands.... Her current state is anxiety all the time, her eyes are large and she looks constantly in fear or amazement, delayed speech, confusion, short term memory is bad, long term not great either, no energy, out of breath, so her quality of life is dismal. She does not go out and has a 'cannot be bothered attitude towards much of life, she lost 17 kg and looks anorexic, she eats but does not put on weight.  I would love to look at tapering but just do not know which one to start with? How much and obviously with her it would need to be slow. Can one start to reduce the antipsychotic first? I know Benzos are highly addictive and Rivotril is one! 

 

Can anyone help?

[NattyLee]

My question is if you are on a cocktail and you are feeling awful, all the time, then how would you know which one to start to taper off of first?

[ChessieCat]

Hi NattyLee and welcome to SA,

 

The first thing we ask all new members to do is to create a drug signature using this format so we can see their drug history at a glance.  Please state at the top that it is your Mom's drug history.  Thank you.

 

A request: Would you summarize your history in a signature - ALL drugs, doses, dates, and discontinuations & reinstatements, in the last 12-24 months particularly?

• Please leave out symptoms and diagnoses.
• A list is easier to understand than one or multiple paragraphs. 

• Any drugs prior to 24 months ago can just be listed with start and stop years.
• Please use actual dates or approximate dates (mid-June, Late October) rather than relative time frames (last week, 3 months ago)
• Spell out months, e.g. "October" or "Oct."; 9/1/2016 can be interpreted as Jan. 9, 2016 or Sept. 1, 2016.
• Link to Account Settings – Create or Edit a signature.

 

SA recommends tapering by no more than 10% of the previous dose followed by a hold of about 4 weeks to allow the brain to adapt to not getting as much of the drug.  The drugs change the brain and it is a physiological dependence, not physical like nicotine and caffeine.

 

Please put all the drugs (please include drugs which are not psych drugs) your mother is currently taking into the Drug Interactions Checker then copy and paste the results in a post here. 

 

Why taper by 10% of my dosage?

 

Dr Joseph Glenmullen's WD Symptoms Checklist

 

Taking multiple psych drugs? Which drug to taper first?
If you're not having an adverse reaction from the other medications, taper the most activating drug first. This is usually an antidepressant or stimulant (ADHD drug).
 

Post #1 of this topic has links to how to taper different drugs:

 

Important topics in the Tapering forum and FAQ

 

I found these helped me to understand SA's recommendations:

 

Brain Remodelling

Video:  Healing From Antidepressants - Patterns of Recovery

 

This is your own Intro topic where you can ask questions and journal your Mom's progress.

 

Edited January 20, 2018 by ChessieCat

[NattyLee]

so I need to add the drug history in the signature?

[ChessieCat]

Yes, you've done a good job of listing the drugs.  Thank you.

 

Q:  Was she taking any psychiatric drugs prior to what you have listed?  If so, please add these all on 1 line with drug name, and years taken (eg drug name 2001-2005, drug name, 2003-2008).

[NattyLee]

Yes she was I just added them to the top now, is this correct? Just to keep in mind she suffers from Severe anxiety, currently has anxiety all the time even on all these meds!! Hence me wanting to taper her, I feel lost as after the rehab we are still at the same place. Her quality of life is that of constant anxiety, loss of interest, depressed, her eyes are huge! has no umpf to do anything and is out of breath all the time.

[ChessieCat]

Hi NattyLee,

 

Thank you for adding the additional drugs.  Because they were so recent would you please add the months she took them.

 

Q:  Did she take any psychiatric drugs prior to 2017?   If so, please add these all on 1 line with drug name, and years taken (eg drug name 2001-2005, drug name, 2003-2008).

 

We need to know as much psychiatric drug history as possible.  Going on and off these drugs can sensitise a person's nervous system.

[NattyLee]

Hi that is all that is on the signature now, nothing else no.

[NattyLee]

ok I think I have got it right now in my signature?

[ChessieCat]

I have used the drugs interaction checker https://reference.medscape.com/drug-interactionchecker

 

Trepiline              = amitriptyline

Circadin                 = prolonged-release melatonin

Solian                  = amisulpride 

Rivotril                 = clonazepam

Phenergan             = promethazine hydrochloride

Xarelto                   = rivaroxaban

Bisoprolol Hexal  = bisoprolol

 

 

Serious - Use Alternative

• promethazine + amisulpride

  promethazine and amisulpride both increase QTc interval. Avoid or Use Alternate Drug.

• amitriptyline + amisulpride

  amitriptyline and amisulpride both increase QTc interval. Avoid or Use Alternate Drug.

Monitor Closely

• promethazine + amitriptyline

  promethazine and amitriptyline both increase QTc interval. Use Caution/Monitor.

• melatonin + rivaroxaban

  melatonin increases effects of rivaroxaban by anticoagulation. Use Caution/Monitor. Melatonin may decrease prothrombin time.

• amisulpride + promethazine

  amisulpride and promethazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Use Caution/Monitor.

• promethazine + clonazepam

  promethazine and clonazepam both increase sedation. Use Caution/Monitor.

• promethazine + amisulpride

  promethazine and amisulpride both increase sedation. Use Caution/Monitor.

• promethazine + amitriptyline

  promethazine and amitriptyline both increase sedation. Use Caution/Monitor.

• promethazine + melatonin

  promethazine and melatonin both increase sedation. Use Caution/Monitor.

• clonazepam + amisulpride

  clonazepam and amisulpride both increase sedation. Use Caution/Monitor.

• clonazepam + amitriptyline

  clonazepam and amitriptyline both increase sedation. Use Caution/Monitor.

• clonazepam + melatonin

  clonazepam and melatonin both increase sedation. Use Caution/Monitor.

• amisulpride + amitriptyline

  amisulpride and amitriptyline both increase sedation. Use Caution/Monitor.

• amisulpride + melatonin

  amisulpride and melatonin both increase sedation. Use Caution/Monitor.

• amitriptyline + melatonin

  amitriptyline and melatonin both increase sedation. Use Caution/Monitor.

Minor

• melatonin + bisoprolol

  melatonin decreases toxicity of bisoprolol by pharmacodynamic antagonism. Minor/Significance Unknown. Melatonin may correct beta blocker induced sleep disturbances.

• amitriptyline + promethazine

  amitriptyline, promethazine. Either increases levels of the other by decreasing metabolism. Minor/Significance Unknown. Additive anticholinergic effects.

• amitriptyline + promethazine

  amitriptyline, promethazine. Either increases levels of the other by pharmacodynamic synergism. Minor/Significance Unknown. Additive anticholinergic effects.

[ChessieCat]

NattyLee thank you for clarifying all the information about your mother's drugs.  I've asked the other mods, who have more knowledge about polydrugging, for their assistance.

[NattyLee]

Thanks. Would love some help?

[Shep]

Hi, NattyLee.

 

Welcome to SA from me, too. Your mother is very lucky to have you researching and being her advocate. 

 

Is she able to post herself and ask questions? If so, she is more than welcome to join, too. 

 

The best way to help your mom is to work with her to get a drug and symptoms journal. This will help you know which drug to taper first, if she is experiencing any adverse reactions, and to see which drug is helping with sleep and which drug may be stimulating and making her anxiety worse. This is a great format for keeping a journal:

 

Keep notes on paper about your drug dosages and daily symptom pattern

 

As you do this over the coming days, we will be able to help you set up a taper. Please get as much input as possible from your mom and encourage her to report how she's feeling before and after taking each of her meds throughout the day. 

 

22 hours ago, NattyLee said:

So, she went to the UK and it was hard to cope with my Gran being so ill, my Mom had a breakdown, she ended up in a Psychiatric unit (admitted herself) after becoming addicted to Alzam (benzo). She originally was prescribed these here in SA years ago to manage anxiety and panic attacks.

 

Please add the information about her Alzam use to your signature, as best as you can remember. 

[NattyLee]

I will do that. I can tell you that she takes meds four times a day. Sleeping pill and Rivotril 10pm and Rivotril 7am with other meds. She reports feeling worse early morning. Then at her best later at night before taking last dosage meds at 10pm. During the day she is demotivated, tired, breathless, confused, broken speech. Regular bladder infections too. 

[Shep]

Is she now or has she recently taken any antibiotics for the bladder infections?

 

The fluoroquinolone antibiotics can be extremely harmful to people on benzos. 

 

I'm placing some links below for more information on this. Even if she hasn't been exposed to them, this is good information to give to her and her doctor in case this comes up in the future. 

 

The antibiotics that people in benzo withdrawal should avoid if possible are the fluoroquinolone antibiotics, as they affect the same receptors cites as benzos and can displace benzodiazepines from their binding sites on GABA-receptors. These can precipitate acute withdrawal in people taking or tapering from benzodiazepines. Many people have severe setbacks. 

 

Here is more information:

 

Safer Pills.org - Fluoroquinolones

 

And for people with current or even prior benzo use, they are particularly dangerous - 

 

Benzodiazepine tolerance, dependency, and withdrawal syndromes and interactions with fluoroquinolone antimicrobials

 

Here's a list of the fluoroquinolone antibiotics which should be avoided if possible during withdrawal and well after: 

 

Fluoroquinolone antibiotics

 

Here is the thread on SA about antibiotics that may be helpful:

 

Cipro, Levaquin, Azithromycin (Z-Pack), and other antibiotics

[NattyLee]

Mum was prescribed antibiotics yrsfor urinary infections. I have to get a list of which ones as she had been given a few in the past. 

 

I spoke to her about keeping a journal. She said, and I agree, she's taking the drugs together so it's difficult to journal as we would not know which drug is causing her to feel unwell. 

 

She feels at her worst first thing in thing the morning and better late at night. I can list what her doeses are and when?

[Altostrata]

Hello, NattyLee.

 

Is the sleeping pill Circadin?

 

It seems likely that your mother is suffering from benzodiazepine withdrawal syndrome brought on by changing her dosage back in 2016 and perhaps adverse effects of all the other drugs that have been dumped on her.

 

How often she takes the clonazepam and how much is very important here. Why was she switched from diazepam?

 

When did she start getting urinary tract infections?

 

Solian seems to me to be causing potentially dangerous heart effects. My guess is that is the one to reduce first -- after stabilizing the benzo dosing.

[NattyLee]

Hi

 

Yes the sleeping pill is Circadin but it does not make her sleep straight away and does not last the whole night, she wakes up early!

 

I have to gather more info. Mum was in a rehab now 18 Dec 2017 to 20 Jan 2018 and they took her straight off of Diazepam 13mg per day down to zero alongside all the other meds (continued). Then because of the severe anxiety, appetite loss and other symptoms they then put her on Rivotrol, then they withdrew that, same again symptoms so they put her back on a week and a half ago onto 1.5mg per day. This all happened in the last month the Alzam was taken daily around 2017 Feb onwards and then diazepam replaced the alzam in say August 2017.

[NattyLee]

How often she takes the clonazepam and how much is very important here. Why was she switched from diazepam?

 

Answer: she takes 0.5mg 3 times per day.

[NattyLee]

Urinary tract infections have been ongoing now for about 2 years or so...

 

What does the Solian actually do???

[Shep]

12 hours ago, NattyLee said:

What does the Solian actually do???

 

Solian (Amisulpride) is an antipsychotic. Do you know why she was prescribed it? Does it her sleep? 

 

As you are able, please list your mom's symptoms and drug journal. We still don't have enough information to give her any tapering advice yet. Please see my post here. 

[NattyLee]

My Mum cannot do a drug Journal, due to the fact that she is taking so much medication and her symptoms are constant. She cannot write, she cannot type msgs on a phone. This is the best I can do to explain:

Mornings are the worst, she does eat, shakes, she has extreme GAD and does not function well in the morning her first dose is 7.30am 

Midday - up to noon she is pretty much out of if, tired, breathless, depressed, sad, not motivation, huge anxiety

Night - The same until about 10pm? then she needs to take a sleeping pill and takes the Rivotril last thing at night with a sleeping pil and I think the anti histamine too...

 

I feel that the anxiety is only excaberated by these meds (which one though?)

 

I feel that perhaps tapering off the Solian now? To start with will help? a very slow reduction?

 

 

[NattyLee]

Solian (Amisulpride) is an antipsychotic. Do you know why she was prescribed it? Does it her sleep? 

 

Solian replace Olanzapine previously prescribed at a lower dose of 20mg. To help with anxiety maybe?

[Shep]

1 hour ago, NattyLee said:

My Mum cannot do a drug Journal, due to the fact that she is taking so much medication and her symptoms are constant. She cannot write, she cannot type msgs on a phone. This is the best I can do to explain:

Mornings are the worst, she does eat, shakes, she has extreme GAD and does not function well in the morning her first dose is 7.30am 

Midday - up to noon she is pretty much out of if, tired, breathless, depressed, sad, not motivation, huge anxiety

Night - The same until about 10pm? then she needs to take a sleeping pill and takes the Rivotril last thing at night with a sleeping pil and I think the anti histamine too...

 

I feel that the anxiety is only excaberated by these meds (which one though?)

 

 

 

 

Please list the time of day and the name and dose of each drug that she takes using this format:

 

Keep notes on paper about your drug dosages and daily symptom pattern

 

The order that she'll come off will depend on how the drugs effect her. Please see:

 

Taking multiple psych drugs? Which drug to taper first?

 

1 hour ago, NattyLee said:

I feel that perhaps tapering off the Solian now? To start with will help?

 

What time does she take Solian? How many hours a night is she sleeping? 

[Altostrata]

NattyLee, melatonin (Circadin) is not really a sleeping pill. It's the hormone that triggers sleep. It's very mild.

 

As Shep said, we need to know the benzo schedule.

[NattyLee]

Morning 0.5mg Rivotril

Midday 0.5mg Rivotril

Night 0.5mg Rivotril and Trepiline dose

 

[Shep]

6 hours ago, NattyLee said:

Morning 0.5mg Rivotril

Midday 0.5mg Rivotril

Night 0.5mg Rivotril and Trepiline dose

 

 

Thanks for providing more information, Natty.

 

Please update your signature because it has only 1 mg Rivitrol listed but she is actually on 1.5 mg a day. 

 

She went from 20 mg diazepam down to 13 mg prior to rehab, which took her off completely.  And then she went on 1.5 mg Rivitrol. Rivitrol is 20 times more potent than diazepam, so the 1.5 mg Rivitrol dose would be equivalent to 30 mg diazepam. This may be causing her problems because it's much higher than what she was on previously. 

 

Questions:  How many hours a night is she sleeping? Is the Rivotril making her feel sedated and / or dizzy? 

Edited January 26, 2018 by Shep

[NattyLee]

Hi so sorry my mistake she is one 0.5mg twice a day I got that wrong. just checked script. 

 

She sleeps only 4 hours on all that medication! 

[NattyLee]

 

DOSAGES

 

MORNING: 

10 mg bisoprolol

20 mg xarelto

solian 5 mg

0.5 mg rivotril

 

NOON:

solian 50 mg

 

NIGHT:

25 mg trepiline

2 mg circadin

50 mg solian

25 mg phenegran

0.5 mg rivotril

 

I hope this is better?

 

 

 

[NattyLee]

Shep: You said:

She went from 20 mg diazepam down to 13 mg prior to rehab, which took her off completely.  And then she went on 1.5 mg Rivitrol. Rivitrol is 20 times more potent than diazepam, so the 1.5 mg Rivitrol dose would be equivalent to 30 mg diazepam. This may be causing her problems because it's much higher than what she was on previously. 

 

SO:In effect Mum is back on 20mg of Diapzepam? So why the withdrawal symptoms? Are the other cocktail of meds effecting her?

[Shep]

1 minute ago, NattyLee said:

If she is taking Rivotril 1 mg total dose per day how much is that in Diazepam terms?

 

Thanks for clarifying her dose. It's good she's on a lower dose. 

 

1 mg Rivotril is equal to 20 mg diazepam.

 

 

[Shep]

4 minutes ago, NattyLee said:

 

DOSAGES

 

MORNING: 

10 mg bisoprolol

20 mg xarelto

solian 5 mg

0.5 mg rivotril

 

NOON:

solian 50 mg

 

NIGHT:

25 mg trepiline

2 mg circadin

50 mg solian

25 mg phenegran

0.5 mg rivotril

 

I hope this is better?

 

 

 

 

Yes, much better. She may only be getting 4 hours of sleep because she's on so many sedating drugs taken at one time at night that it's causing a paradoxical reaction.

 

I'm going to ask Alto and the other mods for their thoughts. 

[NattyLee]

Super, yes please. She says she feels like a huge pressure is over the top of her, pushing her down during the day. No energy, no motivation, breathless, tired but cannot sleep.

[Altostrata]

She is taking a lot of drugs.

 

This could be the reason for that daytime sensation -- but there are a lot of interactions among her drugs that increase sedation.

 

On 1/20/2018 at 4:08 PM, ChessieCat said:

clonazepam + amisulpride

clonazepam and amisulpride both increase sedation. Use Caution/Monitor.

 

She's taking 50mg amisulpride in the morning? She will need to minimize those drugs. My guess is amisulpride is a good place to start.

 

Can you get Solian oral liquid to start tapering? A doctor will have to prescribe it. What have they said when you told them your mother was excessively sedated?

 

Was she agitated in the psychiatric hospital?

[NattyLee]

Hi I have been very quiet, trying to work this all out...... The Dr has changed my Mums meds to the following (with almost immediate withdrawal symptoms even though the dose of dizepam has been increased now:

 

New meds:

Valium 5mg x 3 per day

Largactyl 50mg x 1 at night

 

Still taking the same:

Phenergan (antihistamine) 25mg Aug 2017 to today at night

Xarelto (blood thinner) 20mg longterm

Bisoprolol Hexal (heart meds) longterm

[NattyLee]

Please also now help me change my signature to reflect all of this, I am learning all of this...

 

Can you also advise on support for carers of benzodiazepine users and anxiety patients? I take no drugs, it is my Mom and I am having such a hard time trying to stay positive, compassionate when she is so negative, tired, unhappy, depressed, physically drained, med wrecked...... I also need some support to support her.