Insomnia - What antipsychotics are easiest and hardest to taper off of?

[arwilliams]

Ignoring all other side effects except insomnia what drugs are easiest and hardest to taper of off?

 

Of the antipychotics - Seroquel & Zyprexa are the most sedating and therefore have wicked insomnia withdrawal

 

I am having difficult comparing these drugs to any other drugs because I only have experience with antipychotics.

 

Are antipychotics more difficult then benzos/antidepressants or the other way around?  

[mammaP]

They all need tapering slowly, withdrawal can be avoided by very careful tapering.  There really is no other way.  Withdrawal can be horrendous for all of the classes of drugs. I have been here for 6 years and honestly can't say that one is harder than another because I have seen extreme distress with all of them. 

 

Those tapering anti depressants will say they are the  hardest, those who are tapering benzos feel they are the hardest. Those tapering antipsychotics have had a hard time too. On the other hand there sre some who have tapered quite quickly and been ok but often they end up back on drugs a year or two later. 

 

If you go very slowly you are sneaking the drug away bit by bit so your brain can adjust between drops. This takes a long time but side effects tend to lessen as the dose lowers. 

 

[arwilliams]

So I can only comment on the antipychotic Zyprexa from personal experience, but there are several drugs that cause extreme sedation and therefore likely rebound insomnia as listed here.  

 

[MiguelFreeman]

@arwilliams i had some short time experience whit antipsychotics(quetiapine 150 mg ]and they do suck but if you go slow you will be able to come off but ofc listen to your body don't push true WD symptoms or they will get worse 

I believe in you .

[Altostrata]

ar, you're still looking for that workaround. If there was a free lunch to be had, we'd tell you about it.

 

You can get withdrawal symptoms, as well as horrendous long-term adverse effects, from taking an antipsychotic even if you don't find it sedating it at all.

 

Much as you would like to believe it, antipsychotics are not "sleep drugs", although they are often prescribed, foolishly, off-label for sleep.

 

You don't seem to believe what we tell you here. Please do some Googling about the drug you're taking for sleep and educate yourself.

 

PsychCentral: Seroquel, Atypical Antipsychotics for Insomnia, Dementia?

 

A recent article in the Washington Post:

 

Quote

 

One of America’s most popular drugs — first aimed at schizophrenia — reveals the issues of ‘off-label’ use

by Amy Ellis Nutt and Dan Keating March 30 2018 Washington Post

 

The first warning came a dozen years ago, when the Food and Drug Administration accused the drug company AstraZeneca of “false or misleading” information about health risks in the marketing material for its blockbuster medication Seroquel, an antipsychotic developed to treat schizophrenia but increasingly prescribed “off label” for insomnia.

....

These days, the powerful antipsychotic is used for an expansive array of ills, including insomnia, post-traumatic stress disorder and agitation in patients with dementia. Many of the doctors who turn to it for off-label uses are physicians with minimal training in psychiatry and, medical experts say, too little understanding of the potential downsides. And while the FDA is responsible for oversight of safety issues, it lacks a mandatory reporting system for adverse events that could reveal a more complete picture of problems with a drug.

....

“The range of problems it causes in terms of deteriorating quality of life makes it not worth it,” said David Healy, a British psychiatrist who has written books on psychopharmacology. Healy says he prescribes Seroquel only for his most seriously ill patients “to be able to function.”

 

A Washington Post analysis of more than four years of the most recent data from the FDA’s Adverse Event Reporting System — through the first quarter of 2017 — found about 20,000 cases where Seroquel or its generic equivalent, quetiapine, was listed as the primary or secondary suspect in an adverse event. That included 1,754 deaths in which they were the primary suspect plus 2,309 deaths in which they were a secondary suspect. Overall, 93 percent were apparently the result of off-label prescribing of the drug.

 

Earlier data, analyzed by the nonprofit Institute for Safe Medication Practices, looked at adverse events by category of quetiapine use and found that off-label prescribing accounted for more than a quarter of 5,657 cases from 2004 through September 2010. More than half of the off-label cases were for insomnia and sleep disorders.

 

The numbers could actually be a significant undercount, too, although that’s impossible to determine because the FDA’s voluntary system depends on someone notifying the agency of a complication or death. A drug manufacturer is required to alert the FDA only when a health-care professional or consumer reports an injury directly to the company.

....

Paul Pennock, a New York City lawyer whose practice focuses on defective drugs and devices, has spoken with dozens of people who alleged their lives were harmed by Seroquel. Along with a group of other lawyers, he represented 2,200 plaintiffs who were diagnosed with Type 2 diabetes and other related disorders, and who became part of a nationwide, $520 million civil settlement joined by the federal government. The case involved allegations of illegal marketing and payments to doctors; AstraZeneca denied any improper actions.

 

“Off-label use was the mountain where the billions were made,” Pennock said. “That was the problem with Seroquel.”

....

David Conley, 43, wasn’t thinking about any possible harm when his primary-care doctor suggested in 2013 that he take Seroquel. Seroquel works like an antihistamine at low doses, with mild sedation as a side effect. That sounded good to Conley, who couldn’t remember when he’d last had a full night’s sleep.

 

In fact, insomnia had been a constant nearly all his life, as far back as his childhood in the Midwest. Restless, his mind always “on,” he slept a fitful couple of hours a night, every night, even through his college years, when he played linebacker on a Division 1 football team. Conley was proud of maintaining his fitness after graduating and visited the gym almost daily. But lack of sleep made him increasingly miserable.

 

An internist first prescribed 100 milligrams of Seroquel, a moderate dose to be taken at bedtime. Conley says the doctor never told him it was an antipsychotic drug.

The pill “knocked me out,” he recounted from his home in the Phoenix area, where he works in human resources for a local nonprofit. “I’d never slept like that.” Yet within weeks, he began gaining weight and his blood-sugar level started to climb. “My hands were swelling at night. . . . I’m taking 200 milligrams two years in, and I notice heart palpitations, pools of sweat at night, stabbing pain in my feet and arms.”

 

Despite working out, Conley gained 40 pounds. He became pre-diabetic and began taking blood-pressure medication. He was also seeing more doctors, including a cardiologist for an irregular heartbeat that once frightened him so much he called 911 from a gas station.

“I knew I had to get off this drug,” he said.

 

As he tried to slowly taper his dosage, however, the symptoms sometimes seemed to worsen. “They say it’s not addictive, but your whole body gets used to it,” Conley said. “I was back and forth to the hospital . . . 25, 30 times with anxiety attacks and heart palpitations.”

 

When he asked the internist in 2015 why he had prescribed the drug given all the side effects, he remembers being told, “Because you needed to sleep.”

 

Even with physicians’ greater awareness of the side effects, they wrote nearly 9 million prescriptions of Seroquel and its generic versions in 2015, the latest year for which data are available through the federal Medical Expenditure Panel Survey. (The survey does not reflect Seroquel use by members of the military or Americans in institutional settings such as psychiatric facilities and nursing homes.) Many doctors turned to the drug for reasons other than its FDA-approved uses, which have expanded to bipolar disorder and as an adjunct to the treatment of major depression.

 

A Post review of data provided last year by SERMO, a social network for physicians, found that of 764 non-psychiatrists who said they had prescribed Seroquel or quetiapine, 84 percent did so for off-label uses. Insomnia was one of the top reasons cited, despite the lack of clinical studies on its efficacy. Other reasons doctors cited for giving patients Seroquel ran the gamut: obsessive compulsive disorder and autism, nausea and poor appetite, even erectile dysfunction.

....

Initially, Seroquel seemed to have few side effects or complications, making it appealing as an alternative to the highly addictive benzodiazepines approved for insomnia and anxiety, among other conditions. But expert opinion has shifted.

 

“The risks are far greater than I think has been represented,” said Mark Olfson, a research psychiatrist at Columbia University and the New York State Psychiatric Institute.

Facebook, Instagram, message boards and blogs are replete with warnings from people who described serious side effects after they started taking Seroquel or its generic equivalent. And though the website askapatient.com rates the average patient opinion of Seroquel as “satisfied” across a range of FDA-approved and nonapproved uses — “This is the only medication that has ever truly helped me sleep,” a 42-year-old woman posted in 2016 — many other comments reveal distress sometimes bordering on despair. [Several quotes from others follow.]

....

In Arizona, Conley keeps trying to rid himself of Seroquel. After he began reducing the dosage, it took him a year to go from 200 milligrams to 25. He held firm even when the insomnia returned.

 

“Coming off, you’re seriously worse. I was struggling through, day by day,” he said. “You’re throwing up, shaking, cold sweats, itching all over my body.”

The man who once took pride in being fit long after his college football career now despairs of getting his health back. Every time he gave in and took a pill — to steal a few hours of sleep — he knew he’d wake in the morning with his heart pounding. And on the nights he didn’t take Seroquel, he would lie in bed and try to force his body to release, praying for a slumber that rarely came.

 

 

 

That poor man needs to come here.

 

Quote

 

Am J Health Syst Pharm. 2014 Mar 1;71(5):394-402. doi: 10.2146/ajhp130221.

Quetiapine for insomnia: A review of the literature.

Anderson SL1, Vande Griend JP.

 

Abstract at https://www.ncbi.nlm.nih.gov/pubmed/24534594

 

PURPOSE:

The safety and efficacy of quetiapine for the treatment of insomnia in adults are reviewed.

 

SUMMARY:

Quetiapine was developed for the treatment of psychiatric disorders, but its antagonism of histamine H1- and serotonin type 2A receptors has the added effect of causing sedation. As such, quetiapine is widely used off-label as a treatment for insomnia. Due to quetiapine's potential adverse effects, guidelines for the treatment of insomnia have recommended the drug's use only in patients with specific comorbid psychiatric disorders. The use of quetiapine for the treatment of insomnia in the absence of comorbid conditions has been evaluated in only two clinical trials of 31 patients in total, and very few studies have evaluated quetiapine use in patients with insomnia and other comorbidities. No trials have been conducted comparing quetiapine with an active control (e.g., zolpidem); the data that exist compare quetiapine to a placebo or there is no comparison and all patients are treated with quetiapine. Very few studies have evaluated quetiapine's efficacy in the treatment of insomnia using sleep objective testing, another limitation of the available data on quetiapine.

 

CONCLUSION:

Robust studies evaluating the safety and efficacy of quetiapine for the treatment of insomnia are lacking. Given its limited efficacy data, its adverse-effect profile, and the availability of agents approved by the Food and Drug Administration for the treatment of insomnia, quetiapine's benefit in the treatment of insomnia has not been proven to outweigh potential risks, even in patients with a comorbid labeled indication for quetiapine.

 

 

Quote

 

Sleep Med. 2016 Jun;22:13-17. doi: 10.1016/j.sleep.2016.04.003. Epub 2016 May 11.

Atypical antipsychotics for insomnia: a systematic review.

Thompson W1, Quay TAW2, Rojas-Fernandez C3, Farrell B4, Bjerre LM5.

 

Abstract at https://www.ncbi.nlm.nih.gov/pubmed/27544830  Free full text at https://www.sleep-journal.com/article/S1389-9457(16)30012-0/fulltext

 

BACKGROUND:

Observational evidence suggests that atypical antipsychotics such as quetiapine are increasingly being used to manage insomnia. This is concerning given the uncertain efficacy and potential adverse effects associated with these medications.

 

OBJECTIVES:

The objectives of this study are to evaluate the benefits and adverse effects of atypical antipsychotics used specifically for insomnia.

 

METHODS:

The methods used in this study are systematic review and narrative synthesis.

 

DATA SOURCES:

The data were collected from PubMed; EMBASE; Cochrane Library; PsycINFO; grey literature; and the manufacturers of risperidone, quetiapine and olanzapine.

 

PARTICIPANTS AND INTERVENTIONS:

Adult patients ≥18 years of age using atypical antipsychotics specifically for primary or co-morbid insomnia for ≥ 1 week were compared to those receiving active intervention or placebo.

 

APPRAISAL AND SYNTHESIS METHODS:

Two independent reviewers screened titles, abstracts and full-text articles; extracted data; and conducted risk-of-bias analysis. Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment was completed.

 

RESULTS:

One double-blind randomized controlled trial (n = 13) met the eligibility criteria. Statistically significant differences were not observed from baseline between quetiapine and placebo after 2 weeks for primary insomnia in terms of total sleep time (mean difference (MD) 52.68 min, 95% CI -27.27 to 132.6), reduction in sleep latency (MD 72.44 min, 95% CI -2.65 to 147.5) or improved sleep satisfaction measured with a visual analogue scale out of 100 (MD 6.16, 95% CI -12.32 to 24.64), despite a trend towards improved sleep parameters. The study was rated as very low quality.

 

CONCLUSIONS AND IMPLICATIONS:

Very low quality evidence suggests that quetiapine does not significantly improve sleep parameters compared with placebo in primary insomnia, despite a trend towards clinical improvements. Atypical antipsychotics should be avoided in the first-line treatment of primary insomnia until further evidence is available.

 

 

Quote

 

Adverse Effects of Antipsychotic Medications

JOHN MUENCH, MD, MPH, Oregon Health & Science University, Portland, Oregon

ANN M. HAMER, PharmD, BCPP, Oregon State University College of Pharmacy, Corvallis, Oregon

Am Fam Physician. 2010 Mar 1;81(5):617-622.

 

The use of antipsychotic medications entails a difficult trade-off between the benefit of alleviating psychotic symptoms and the risk of troubling, sometimes life-shortening adverse effects. There is more variability among specific antipsychotic medications than there is between the first- and second-generation antipsychotic classes. The newer second-generation antipsychotics, especially clozapine and olanzapine, generally tend to cause more problems relating to metabolic syndrome, such as obesity and type 2 diabetes mellitus. Also, as a class, the older first-generation antipsychotics are more likely to be associated with movement disorders, but this is primarily true of medications that bind tightly to dopaminergic neuroreceptors, such as haloperidol, and less true of medications that bind weakly, such as chlorpromazine. Anticholinergic effects are especially prominent with weaker-binding first-generation antipsychotics, as well as with the second-generation antipsychotic clozapine. All antipsychotic medications are associated with an increased likelihood of sedation, sexual dysfunction, postural hypotension, cardiac arrhythmia, and sudden cardiac death. Primary care physicians should understand the individual adverse effect profiles of these medications. They should be vigilant for the occurrence of adverse effects, be willing to adjust or change medications as needed (or work with psychiatric colleagues to do so), and be prepared to treat any resulting medical sequelae.

 

[READ FULL TEXT HERE]

 

 

[Spideygsm]

On 5/28/2018 at 3:35 PM, Altostrata said:

ar, you're still looking for that workaround. If there was a free lunch to be had, we'd tell you about it.

 

You can get withdrawal symptoms, as well as horrendous long-term adverse effects, from taking an antipsychotic even if you don't find it sedating it at all.

 

Much as you would like to believe it, antipsychotics are not "sleep drugs", although they are often prescribed, foolishly, off-label for sleep.

 

You don't seem to believe what we tell you here. Please do some Googling about the drug you're taking for sleep and educate yourself.

 

Altostrata,

 

Very informative. I'm reading a lot of information today because I've had a setback in my Zyprexa withdrawal.

 

arw:

 

I do wish you well. I believe that a rebound effect such as rebound insomnia is completely different than what you're referring to. I've had moderate insomnia which I've lived with since I was a kid. Even before I was given Ritalin at 8 years old. The Ritalin made me sleep even less while I was taking it. So I have an established history of insomnia which I've lived with untreated until I started taking Zyprexa. Zyprexa was very sedating and made me feel very drugged but I could not sleep while taking Zyprexa. I was on Ambien for years because my insomnia got so bad while on Zyprexa. I tapered off Ambien several years ago because my body built up a tolerance and it quite working. When I started my Zyprexa taper, my insomnia was indescribable. This is a result of the brain reacting to not have Zyprexa controlling it's normal functions. I would describe it as if my brain were in shock. Completely different than my underlying insomnia condition before Zyprexa.

 

It's my understanding that rebound insomnia or any other issue such as anxiety that is experienced before taking Zyprexa (an underlying condition) can return or rebound after discontinuing the drug. I don't know if antipsychotic drugs can cause permanent insomnia or other symptoms. I know I have read that underlying conditions will usually come back after discontinuing the Zyprexa.

 

Unfortunately you were given Zyprexa for sleep. You'll more than likely experience insomnia during withdrawal, and then rebound insomnia which was an underlying condition. Either way, you get to deal with it. How you do it is your business but I wouldn't use any antipsychotic.

 

Good luck.

[Altostrata]

I want to correct my comment about a free lunch: Melatonin for sleep is as close to a free lunch as you can get. It does not incur dependency (though one would be well advised to go off it gently, so you can trust the process). Starting at low dose is best, too much won't work.

 

We do often recommend it, along with room-darkening, to improve sleep. It will not overcome a bad habit such as staying on the computer late at night.