carefulprayerful: switch to drug with longer half-life before tapering?

June 12, 2018

I read that it is more difficult to withdraw from a drug with a short half life. It is suggested to switch to a different drug with a longer half-life of the same category (i.e., antipsychotic) before tapering off (mind.org.uk).

I have been on Risperidone for 5 years. I started tapering in April at 1.0 mg and am now on 0.70 mg. I am considering asking my doctor about switching to Zyprexa, another antipsychotic, and then tapering off Zyprexa.

Does titrating off one drug and onto another need to be done as slowly as withdrawing from a drug, i.e. 10% every month or something like that? Has anyone had experience titrating off an antipsychotic onto another antipsychotic?

Since Risperidone has a short half-life, I am concerned that it will be hard to switch onto a drug with a longer half life.

According to Medscape, the half-life for Zyprexa is 21-54 hours, and the half-life of Risperidone is 3-20 hours.

Thank you!

June 12, 2018

Welcome, careful.

I believe mind.org.uk's advice mostly applies to antidepressants and benzodiazepines.

Switching drugs should be done only as a last resort. When you switch drugs, you might get withdrawal from the first drug even if you are taking the second drug. You might also get additional adverse effects from the second drug. As the success of switching is not guaranteed, we don't recommend it unless you cannot do a direct taper off the drug.

With its active metabolite, palperidone, risperidone has a fairly long half-life of about 2 days, which is plenty long for tapering.

Please see Tips for tapering off Risperdal (risperidone)

How have you been feeling during your taper?

June 13, 2018

I started with large decrements and was not always able to sustain them because the withdrawal effects were so intense.

That being said, I would like to report: better creativity, more alertness, reduced constipation, better focus, more vivid emotions, normal appetite, etc.

My most recent reduction was from .75 mg to .70 mg of Risperidone (a 7% reduction) a week ago, and it has been very manageable. I have experienced: slight insomnia, mental sluggishness, slight headaches, and an hour of nausea one evening.

I have a few questions:

Is it not suggested by SA to taper more frequently than once a month even if you are feeling good? For example, if you make a reduction of 10% of the previous dose and feel better after one week, is it okay to make the next reduction two weeks later (allowing three weeks between reductions rather than four)?
Is there some room to play around, i.e., reducing by 7% of the previous dose every 3 weeks (instead of 10% every 4 weeks)?
When can you just stop taking the drug? How many decrements of 10% of the previous dose are suggested by SA? For example, if you started with 100 mg and reduced by 10% of the previous dose 87 times, you would be on 1 mg.
I don't remember the source, but I read somewhere that when you get to a really small dose, you should take stay on it for 1 year before stopping taking the drug entirely. Does SA suggest this approach? If so, what would be a really small dose? 1% of the original dose (i.e., 1 mg in the example above)? 5% of the original dose (i.e., 5 mg)?

Thank you!

June 14, 2018

Going from .75 mg to .70 mg Risperidone, in addition to the withdrawal symptoms I mentioned above, I experienced: tiredness and a momentary fluctuation in mood one afternoon. The symptoms since this most recent reduction (6 days ago) have barely been a distraction. I am really encouraged.

June 14, 2018

I would not make a reduction more often than every 2 weeks; you must be vigilant for any withdrawal symptoms -- do not continue tapering if they occur.

We often see people pushing their tapers, ignoring danger signs, and getting into big trouble.

If you have slight withdrawal symptoms, I wouldn't speed up at this point. Get more experience with your symptom pattern.

June 14, 2018

Thank you for the quick repsonse!

June 14, 2018

Whoops! I made a mistake with my numbers. Reducing from 100 mg to 1 mg would require 44 reductions by 10% of the previous dose, if I am not mistaken.

100 mg x (0.90 ^ 44) = 1 mg

Altostrata, thank you for your work as moderator of this site.

June 14, 2018

You're very welcome. Yes, it's a slow, frustrating process. Let us know how you're doing.

June 19, 2018

FYI New Jersey members, please check in here

June 20, 2018

II read on this site that people who do a CT or a FT often encounter strong withdrawal symptoms a few months later. I have done a CT or FT in the past and experienced this myself.

Since January 2018, I have made some significant reductions. In January, I was on 900 mg Lithium, 250 mg Lamotrigine, and 1.0 mg Risperidone. As of now, I am off Lithium, on 150 mg Lamotrigine, and on 0.70 mg Risperidone.

I am experiencing a variety of symptoms, from elevated mood, to sensitivity to light, to nausea, that are changing day to day. I have the sensation that my brain is working pretty hard. I am keeping a journal of the symptoms. I am in the waves and windows pattern, and I have not reached withdrawal normal. (I thought I had reached withdrawal normal for a couple of days, but I experienced a wave lasting 24 hours which mostly passed last night. This morning I am feeling nausea and a headache.)

I cannot go back on Lithium--because of the kidney damage, I was told I could never take it again. I am thinking about partially re-instating the other two, perhaps moving up to 200 mg Lamotrigine and 0.75 mg Risperidone. I don't feel terrible, but I don't want things to decline over the next few months. I am considering either staying at the same doses until 2019 or partially re-instating as I just mentioned and waiting until 2019 to make any more changes.

I had some tough days in April when I made such large decreases that I had to re-instate or partially re-instate. I didn't start this process off right, but I would like to use the 10% taper approach going forward after as long a pause as necessary.

Does SA have a suggestion for people in my situation (people who started a fast taper but would like to continue with the 10% taper method)?

I think I saw it mentioned that there is a list of symptoms on this site, but I couldn't find it when I searched for it. Could you provide me with a link?

Thank you!

June 20, 2018

I also think I read somewhere on the site that after re-instating, you should wait 6 months to do another reduction. Could you provide me with a link to that page if you can find it?

June 20, 2018

I decided to do the partial reinstatement and wait 6 months (at least). I am practicing honest and patience.

June 21, 2018

Now I am working on cleaning my gut!

July 19, 2018

I apologize for not reading this entire thread.

I got off Lithium cold turkey because of serious side effects in January thanks to an accidental double dose of Lamotrigine, which dispelled the mania. I felt like I was on the verge of withdrawal psychosis.

In April, I reduced Risperidone from 1.0 to 0.75 mg and Lamotrigine from 250 mg to 150 mg. I made some attempts at reducing my drugs in May and June but ended up updosing. I moved the Lamotrigine back up to 175 mg.

Now I am at 0.75 mg Risperidone and 175 mg Lamotrigine. In the course of the last two months, I noticed the Risperidone withdrawal symptoms were milder before I had begun reducing the Lamotrigine. I was considering moving the Lamotrigine back up to 200 mg to make it easier to get off the Risperidone, which is a more risky drug. For now, I have decided to stay at 175 mg Lamotrigine and 0.75 mg Risperidone and let my brain rest. I have decided not to increase the Lamotrigine any further. Note I am only experiencing mild withdrawal symptoms at this time. I am just wondering if increasing the Lamotrigine will make the process of coming off Risperidone any easier. I would welcome suggestions from anyone, but I think the best thing I can do now is wait and heal and get my life ready for this process. I am following the preparation steps outlined on theinnercompass.org and reading Dr. Glenmullen, Dr. Doidge, and Dr. Breggin as well as SA. I am planning to begin a micro taper.

I know this thread is about using Lamotrigine post-discontinuation, but I just thought it might be worth it to post my question (i.e., should I updose the Lamotrigine further to minimize potential future withdrawal symptoms of Risperidone?). My doctor asked me to think about this. I don’t think it’s a good idea. Curious for feedback. Thank you.

July 19, 2018

I want to get off the Lamotrigine ultimately as well, just working on the Risperidone first.

July 19, 2018

I am moving this to my Introductions thread.

July 19, 2018

Hello, carefulprayerful, I moved your posts here.

What times of day do you take your drugs, and their dosages? Please keep daily notes on paper about your symptoms, when you take your drugs, and their dosages. Use a simple list format with time of day on the left and notation (symptom, drug and dosage) on the right.

You may get more benefit from the lamotrigine if you take it in divided doses 12 hours apart. You might move 100mg an hour or two at a time until you are taking it 12 hours later, in the evening.

Please update your signature with your current drug intake.

July 21, 2018

Hello Altostrata,

I take Synthroid around 6am and Lamotrigine, Risperidone, and Vienva (oral contraceptive) around 9pm.

I keep a daily log of my symptoms in an appointment book.

As mentioned, I got off Lithium in January.

April 9, 2018: I cut Risperidone from 1.0 mg to 0.5 mg and had moderate to severe symptoms one week later: anxiety and negative memories. I updosed to 0.75 mg.

April 16, 2018: I cut Lamotrigine from 250 mg to 200 mg and then four days after that cut it from 200 mg to 150 mg . I did not experience any pronounced symptoms, just felt off.

May 4, 2018: I cut the Risperidone from 0.75 mg to 0.50 mg. If only I could! At first I felt fantastic--sharp short-term memory, felt alive. Five days after the cut, it was as though I fell through a manhole. At my desk at work, I swooned and felt as though I was going to fall asleep standing up. I noticed the beginning of withdrawal psychosis. It was very difficult for me, but I kept a tight grip for the rest of the day and updosed back to 0.75 mg that night.

June 7: I cut Risperidone from 0.75 mg to 0.70 mg. At first the symptoms were slight. Then after two weeks had gone by, I experienced: mood swings (i.e., elevated mood), split-second rage upon which I did not act but which was frightening to me and outside of my nature, intense brain zaps which made it very difficult to be productive at work, brain fog, headache, nausea, sensitivity to light, and involuntary tongue movements. I updosed to 0.75 Risperidone and 200 mg Lamotrigine.

The next night, the symptoms had improved slightly, but I had panic attack and vomited throughout the night. After a few days, wondering if the Lamotrigine had caused the vomiting, I moved the Lamotrigine back down to 175 mg.

July 21, 2018

A month has gone by at 0.75 mg Risperidone and 175 mg Lamotrigine, and my symptoms are minor. They have included eye twitch, faster resting heart rate (it has gone from 56 to 93), inability to exercise more than leisurely walks, inability to tolerate high temperatures, agitation, nausea, dizziness, eye twitch, brain fog, slightly elevated mood, chest tightness (recurrent, momentary), nausea, headache, slight anxiety/fear. The past 24 hours have been symptom-free.

I am planning to begin a micro-taper instead of using the cut-and-hold method after waiting a little longer, maybe another month.

I realize that my brain has experienced a lot of change since getting off Lithium cold turkey in January. I am open to increasing the Lamotrigine just to ease getting off the Risperidone. Once I began reducing the Lamotrigine, reducing the Risperidone got harder to do. For now I am keeping it stable.

July 22, 2018

I have also experienced flu like symptoms in the past month.

July 22, 2018

I am also a little out of shape, which could contribute to my low tolerance for exercise, and I re-checked my resting heart rate and got 78.

July 22, 2018

Yes, too much lamotrigine at once can cause nausea.

On 7/19/2018 at 10:22 AM, Altostrata said:

....

You may get more benefit from the lamotrigine if you take it in divided doses 12 hours apart. You might move 100mg an hour or two at a time until you are taking it 12 hours later, in the evening.

....

You've made quite a few drug changes recently. After you divide the lamotrigine dose, you may wish to hold on changes for at least a couple of months.

If I were you, I'd taper the lamotrigine after you go off risperidone, which is a much more destructive drug. If you're not taking too high a dose, lamotrigine can help keep your nervous system stable while you taper, too.

Please put ALL your drugs in the Drug Interactions Checker https://www.drugs.com/drug_interactions.php
and copy and paste the results in this topic.

July 23, 2018

Thank you for this site, Alto.

I have heard that the tortoise wins the race.

My drug interactions are below.

Drug Interaction Report

Drug interactions for the following 4 drug(s):

My Interactions List: (Unsaved)
Lamictal (lamotrigine)
Risperdal (risperidone)
Synthroid (levothyroxine)
Vienva (ethinyl estradiol / levonorgestrel)

Consumer
Professional

More

Major (0)

Moderate (4)

Minor (0)

Food (4)

Therapeutic Duplication (0)

Interactions between your drugs

Moderate

ethinyl estradiol levothyroxine

Moderate Drug Interaction

Applies to: Vienva (ethinyl estradiol / levonorgestrel), Synthroid (levothyroxine)

MONITOR: Estrogens may increase serum thyrotropin concentration, which could be harmful in patients with thyroid cancer receiving thyroxine for thyrotropin suppression or increase dosage requirements in patients with hypothyroidism receiving thyroxine for replacement therapy. Estrogens are known to increase serum thyroid-binding globulin concentration in a dose-dependent manner. Consequently, there may be a reduction in unbound, or free, thyroxine available for hormone activity, which, in turn, leads to an increase in serum thyrotropin concentration. Normally, thyroxine secretion can increase to compensate for this effect, but patients with hypothyroidism lack the mechanism to adapt. Limited evidence suggests that transdermal estrogen therapy may not affect thyroid-binding globulin concentrations; however, more data are required to confirm that.

MANAGEMENT: In patients treated with thyroxine, serum thyrotropin should be measured approximately 12 weeks after estrogen therapy is initiated, changed or discontinued, and the thyroxine dosage adjusted accordingly. Patients should be advised to contact their physician if clinical manifestations of hypothyroidism occur, such as fatigue, cold intolerance, constipation, unexplained weight gain, depression, joint or muscle pain, thinning hair or hair loss, dry skin, hoarseness, and abnormal menstrual periods.

References

Chetkowski RJ, Meldrum DR, Steingold KA, et al. "Biologic effects of transdermal estradiol." N Engl J Med 314 (1986): 1615-20
Utiger RD "Estrogen, thyroxine binding in serum, and thyroxine therapy." N Engl J Med 344 (2001): 1784-5
Arafah BM "Increased need for thyroxine in women with hypothyroidism during estrogen therapy." N Engl J Med 344 (2001): 1743-9
"Product Information. Synthroid (levothyroxine)." Abbott Pharmaceutical, Abbott Park, IL.

View all 4 references

Moderate

ethinyl estradiol lamotrigine

Moderate Drug Interaction

Applies to: Vienva (ethinyl estradiol / levonorgestrel), Lamictal (lamotrigine)

MONITOR: Coadministration with estrogens or progestins may decrease the plasma concentrations and pharmacologic effects of lamotrigine due to induction of lamotrigine glucuronidation. One group of investigators cited seven suspected cases of this interaction in women treated with oral contraceptives that contained either ethinyl estradiol in combination with desogestrel or norethindrone or norethindrone alone. The contraceptives reduced plasma levels of lamotrigine by 41% to 64%, and a deterioration in seizure control was observed several days to two months after initiation of contraceptive use, necessitating an increase in lamotrigine dosage or discontinuation of the contraceptive. In some cases, contraceptive discontinuation led to lamotrigine toxicity that required dosage reduction. A pharmacokinetic study also reported similar reductions in lamotrigine plasma levels in patients on combination oral contraceptives, with lamotrigine clearance 2.5 times greater than in controls. The interaction is further supported by the fact that changes in hormone levels are known to influence the pharmacokinetics of glucuronidated drugs in humans, and elimination of lamotrigine is significantly increased during pregnancy. However, a population pharmacokinetics study in patients newly diagnosed with epilepsy and receiving oral lamotrigine monotherapy for up to 48 weeks found no significant effect of oral contraceptive use or dose on the oral clearance of lamotrigine. Lamotrigine also has been shown to have little or no effect on the pharmacokinetics of contraceptive hormones, although measurement of serum FSH, LH, and estradiol has indicated some loss of suppression of the hypothalamic-pituitary-ovarian axis. The clinical significance is unknown. Measurement of serum progesterone indicated no hormonal evidence of ovulation.

MANAGEMENT: Pharmacologic response and plasma lamotrigine levels should be monitored more closely whenever estrogen- and/or progestin-containing drugs are added to or withdrawn from therapy, and the lamotrigine dosage adjusted as necessary. The manufacturer's labeling should be consulted for detailed dosage recommendations. Patients should be advised to contact their physician if they experience loss of seizure control or symptoms of lamotrigine toxicity such as ataxia, nystagmus, increased seizures, irregular heartbeat, and changes in mental status. In patients receiving oral contraceptives, gradual transient increases in lamotrigine levels will occur during the pill-free week for women not also taking an enzyme-inducing drug (e.g., carbamazepine, phenytoin, phenobarbital, primidone, rifampin). The increase in lamotrigine levels will be greater if the dose of lamotrigine is increased in the few days before or during the pill-free week. Although diminished contraceptive efficacy has not been reported, the possibility should be considered. Patients should be instructed to promptly report changes in their menstrual pattern.

References

Wilbur K, Ensom MHH "Pharmacokinetic drug interactions between oral contraceptives and second-generation anticonvulsants." Clin Pharmacokinet 38 (2000): 355-65
Holdich T, Whiteman P, Orme M, Back D, Ward S "Effect of lamotrigine on the pharmacology of the combined oral contraceptive pill." Epilepsia 32(Suppl) (1991): 96
Ohman I, Vitols S, Tomson T "Lamotrigine in pregnancy: pharmacokinetics during delivery, in the neonate, and during lactation." Epilepsia 41 (2000): 706-13
Sabers A, Buchholt JM, Uldall P, Hansen EL "Lamotrigine plasma levels reduced by oral contraceptives." Epilepsy Res 47 (2001): 151-4
Tomson T, Ohman I, Vitols S "Lamotrigine in pregnancy and lactation: A case report." Epilepsia 38 (1997): 1039-41
O'Brien MD, Guillebaud J "Contraception for women with epilepsy." Epilepsia 47 (2006): 1419-22
"Product Information. Lamictal (lamotrigine)." Glaxo Wellcome, Research Triangle Park, NC.
Miners JO, Mackenzie PI "Drug glucuronidation in humans." Pharmacol Ther 51 (1991): 347-69
Hussein Z, Posner J "Population pharmacokinetics of lamotrigine monotherapy in patients with epilepsy: retrospective analysis of routine monitoring data." Br J Clin Pharmacol 43 (1997): 457-65
Sabers A, Ohman I, Christensen J, Tomson T "Oral contraceptives reduce lamotrigine plasma levels." Neurology 61 (2003): 570-1

View all 10 references

Moderate

levonorgestrel lamotrigine

Moderate Drug Interaction

Applies to: Vienva (ethinyl estradiol / levonorgestrel), Lamictal (lamotrigine)

MONITOR: Coadministration with estrogens or progestins may decrease the plasma concentrations and pharmacologic effects of lamotrigine due to induction of lamotrigine glucuronidation. One group of investigators cited seven suspected cases of this interaction in women treated with oral contraceptives that contained either ethinyl estradiol in combination with desogestrel or norethindrone or norethindrone alone. The contraceptives reduced plasma levels of lamotrigine by 41% to 64%, and a deterioration in seizure control was observed several days to two months after initiation of contraceptive use, necessitating an increase in lamotrigine dosage or discontinuation of the contraceptive. In some cases, contraceptive discontinuation led to lamotrigine toxicity that required dosage reduction. A pharmacokinetic study also reported similar reductions in lamotrigine plasma levels in patients on combination oral contraceptives, with lamotrigine clearance 2.5 times greater than in controls. The interaction is further supported by the fact that changes in hormone levels are known to influence the pharmacokinetics of glucuronidated drugs in humans, and elimination of lamotrigine is significantly increased during pregnancy. However, a population pharmacokinetics study in patients newly diagnosed with epilepsy and receiving oral lamotrigine monotherapy for up to 48 weeks found no significant effect of oral contraceptive use or dose on the oral clearance of lamotrigine. Lamotrigine also has been shown to have little or no effect on the pharmacokinetics of contraceptive hormones, although measurement of serum FSH, LH, and estradiol has indicated some loss of suppression of the hypothalamic-pituitary-ovarian axis. The clinical significance is unknown. Measurement of serum progesterone indicated no hormonal evidence of ovulation.

MANAGEMENT: Pharmacologic response and plasma lamotrigine levels should be monitored more closely whenever estrogen- and/or progestin-containing drugs are added to or withdrawn from therapy, and the lamotrigine dosage adjusted as necessary. The manufacturer's labeling should be consulted for detailed dosage recommendations. Patients should be advised to contact their physician if they experience loss of seizure control or symptoms of lamotrigine toxicity such as ataxia, nystagmus, increased seizures, irregular heartbeat, and changes in mental status. In patients receiving oral contraceptives, gradual transient increases in lamotrigine levels will occur during the pill-free week for women not also taking an enzyme-inducing drug (e.g., carbamazepine, phenytoin, phenobarbital, primidone, rifampin). The increase in lamotrigine levels will be greater if the dose of lamotrigine is increased in the few days before or during the pill-free week. Although diminished contraceptive efficacy has not been reported, the possibility should be considered. Patients should be instructed to promptly report changes in their menstrual pattern.

References

Wilbur K, Ensom MHH "Pharmacokinetic drug interactions between oral contraceptives and second-generation anticonvulsants." Clin Pharmacokinet 38 (2000): 355-65
Holdich T, Whiteman P, Orme M, Back D, Ward S "Effect of lamotrigine on the pharmacology of the combined oral contraceptive pill." Epilepsia 32(Suppl) (1991): 96
Ohman I, Vitols S, Tomson T "Lamotrigine in pregnancy: pharmacokinetics during delivery, in the neonate, and during lactation." Epilepsia 41 (2000): 706-13
Sabers A, Buchholt JM, Uldall P, Hansen EL "Lamotrigine plasma levels reduced by oral contraceptives." Epilepsy Res 47 (2001): 151-4
Tomson T, Ohman I, Vitols S "Lamotrigine in pregnancy and lactation: A case report." Epilepsia 38 (1997): 1039-41
O'Brien MD, Guillebaud J "Contraception for women with epilepsy." Epilepsia 47 (2006): 1419-22
"Product Information. Lamictal (lamotrigine)." Glaxo Wellcome, Research Triangle Park, NC.
Miners JO, Mackenzie PI "Drug glucuronidation in humans." Pharmacol Ther 51 (1991): 347-69
Hussein Z, Posner J "Population pharmacokinetics of lamotrigine monotherapy in patients with epilepsy: retrospective analysis of routine monitoring data." Br J Clin Pharmacol 43 (1997): 457-65
Sabers A, Ohman I, Christensen J, Tomson T "Oral contraceptives reduce lamotrigine plasma levels." Neurology 61 (2003): 570-1

View all 10 references

Moderate

risperidone lamotrigine

Moderate Drug Interaction

Applies to: Risperdal (risperidone), Lamictal (lamotrigine)

MONITOR: A case report suggests that lamotrigine may increase the plasma concentrations of risperidone. The mechanism of interaction is unknown. The case patient was a 26-year-old woman with schizophrenia who had been treated with clozapine 550 mg daily for 5 years and risperidone 8 mg daily for 4 weeks. Lamotrigine was added due to inadequate response. The patient's risperidone plasma level was 69 ng/mL while receiving lamotrigine 175 mg/day; 284 ng/mL when lamotrigine was increased to 200 mg/day; and 412 ng/mL at lamotrigine 225 mg/day. The patient complained of dizziness and tiredness. Risperidone dosage was reduced to 2 mg/day and discontinued a week later. Pharmacodynamically, additive central nervous system depression may also occur when these drugs are used in combination, resulting in impairment of judgment, thinking, and/or psychomotor skills.

MANAGEMENT: Until more data are available, caution is advised if risperidone must be used in combination with lamotrigine. Pharmacologic response and serum risperidone levels should be monitored more closely whenever lamotrigine is added to or withdrawn from therapy, and the risperidone dosage adjusted as necessary. Patients should be advised to notify their physician if they experience potential signs and symptoms of risperidone toxicity such as excessive sedation, dizziness, tachycardia, seizures, and extrapyramidal symptoms. Ambulatory patients should also be counseled to avoid activities requiring mental alertness (e.g., driving or operating hazardous machinery) until they know how these agents affect them.

References

Bienentreu SD, Kronmuller KT "Increase in risperidone plasma level with lamotrigine." Am J Psychiatry 162 (2005): 811-2

No other interactions were found between your selected drugs.
Note: this does not necessarily mean no interactions exist. Always consult with your doctor or pharmacist.

Other drug and disease interactions

Lamictal (lamotrigine) interacts with more than 200 other drugs and 7 diseases.
Risperdal (risperidone) interacts with more than 500 other drugs and more than 20 diseases.
Synthroid (levothyroxine) interacts with more than 100 other drugs and 5 diseases.
Vienva (ethinyl estradiol / levonorgestrel) interacts with more than 500 other drugs and more than 20 diseases.

Drug and food interactions

Moderate

levothyroxine food

Moderate Drug Interaction

Applies to: Synthroid (levothyroxine)

ADJUST DOSING INTERVAL: Consumption of certain foods as well as the timing of meals relative to dosing may affect the absorption of T4 thyroid hormone (i.e., levothyroxine). T4 absorption is increased by fasting and decreased by foods such as soybean flour (e.g., infant formula), cotton seed meal, walnuts, dietary fiber, calcium, and calcium fortified juices.

MANAGEMENT: Preparations containing T4 thyroid hormone should be administered on a consistent schedule with regard to time of day and relation to meals so as to avoid large fluctuations in serum levels. Foods that may affect T4 absorption should be avoided within several hours of dosing if possible. When administered to patients receiving continuous enteral nutrition for more than 7 days, some experts recommend that the tube feeding should be interrupted for at least 1 hour before and 1 hour after the dose of levothyroxine is given and to monitor patients' thyroid function.

References

"Product Information. Armour thyroid (thyroid desiccated)." Forest Pharmaceuticals, St. Louis, MO.
"Product Information. Synthroid (levothyroxine)." Abbott Pharmaceutical, Abbott Park, IL.
Wohlt PD, Zheng L, Gunderson S, Balzar SA, Johnson BD, Fish JT "Recommendations for the use of medications with continuous enteral nutrition." Am J Health Syst Pharm 66 (2009): 1438-67

Moderate

risperidone food

Moderate Drug Interaction

Applies to: Risperdal (risperidone)

GENERALLY AVOID: Risperidone oral solution is not compatible with either tea or cola. In addition, alcohol may potentiate some of the pharmacologic effects of risperidone. Use in combination may result in additive central nervous system depression and/or impairment of judgment, thinking, and psychomotor skills.

MANAGEMENT: Risperidone oral solution should not be mixed with tea or cola. It may be taken with water, coffee, orange juice, or lowfat milk. Patients should also be advised to avoid consumption of alcohol.

References

"Product Information. Risperdal (risperidone)." Janssen Pharmaceutica, Titusville, NJ.

Moderate

lamotrigine food

Moderate Drug Interaction

Applies to: Lamictal (lamotrigine)

GENERALLY AVOID: Alcohol may potentiate some of the pharmacologic effects of CNS-active agents. Use in combination may result in additive central nervous system depression and/or impairment of judgment, thinking, and psychomotor skills.

MANAGEMENT: Patients receiving CNS-active agents should be warned of this interaction and advised to avoid or limit consumption of alcohol. Ambulatory patients should be counseled to avoid hazardous activities requiring complete mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.

References

Warrington SJ, Ankier SI, Turner P "Evaluation of possible interactions between ethanol and trazodone or amitriptyline." Neuropsychobiology 15 (1986): 31-7
Gilman AG, Rall TW, Nies AS, Taylor P, eds. "Goodman and Gilman's the Pharmacological Basis of Therapeutics. 8th ed." New York, NY: Pergamon Press Inc. (1990):
"Product Information. Fycompa (perampanel)." Eisai Inc, Teaneck, NJ.
"Product Information. Rexulti (brexpiprazole)." Otsuka American Pharmaceuticals Inc, Rockville, MD.

View all 4 references

Minor

ethinyl estradiol food

Minor Drug Interaction

Applies to: Vienva (ethinyl estradiol / levonorgestrel)

Coadministration with grapefruit juice may increase the bioavailability of oral estrogens. The proposed mechanism is inhibition of CYP450 3A4-mediated first-pass metabolism in the gut wall induced by certain compounds present in grapefruits. In a small, randomized, crossover study, the administration of ethinyl estradiol with grapefruit juice (compared to herbal tea) increased peak plasma drug concentration (Cmax) by 37% and area under the concentration-time curve (AUC) by 28%. Based on these findings, grapefruit juice is unlikely to affect the overall safety profile of ethinyl estradiol. However, as with other drug interactions involving grapefruit juice, the pharmacokinetic alterations are subject to a high degree of interpatient variability. Also, the effect on other estrogens has not been studied.

References

Schubert W, Eriksson U, Edgar B, Cullberg G, Hedner T "Flavonoids in grapefruit juice inhibit the in vitro hepatic metabolism of 17B-estradiol." Eur J Drug Metab Pharmacokinet 20 (1995): 219-24
Weber A, Jager R, Borner A, et al. "Can grapefruit juice influence ethinyl estradiol bioavailability?" Contraception 53 (1996): 41-7

Therapeutic duplication warnings

No therapeutic duplications were found for your selected drugs.

July 23, 2018

Thanks. If you keep the Synthroid, Vienva, and lamotrigine dosages steady, the interaction to watch is lamotrigine-Risperidone.

What times of day do you take your drugs, and their dosages?

August 31, 2018

Thank you everyone for posting on this thread. Concerning tardive dyskinesia (TD), Dr. Peter Breggin, MD, writes: "In many cases, however, abnormal movements become apparent or worsen only when the patient is reducing or stopping the drug" (p. 193, Your Drug May Be Your Problem, 1999) and "Early TD symptoms are masked (suppressed) by antipsychotic drugs while the underlying disorder develops and worsens" (p. 46, Psychiatric Drug Withdrawal, 2013).

Unfortunately since I have begun to reduce Risperidone, I have begun to experience subtle facial tics (tongue twisting and curling, jaw clenching, lip licking, eye twitch). I am concerned about how quickly TD progresses once it has started if the drug is not discontinued quickly. Nonetheless, I am planning to continue a slow taper. From what I've read on these sites, it seems that those who push their CNS too far end up with more set backs and end up taking the drugs longer or give up trying to withdraw all together.

I'm going to work on my poker face. (All kidding aside, the movements are difficult to stop.)

August 31, 2018

More info: "Nearly all of the antipsychotic drugs, including Risperdal and Zyprexa, suppress function of the dopamine nerves and therefore can cause tardive dyskinesia. An occasional unscrupulous report claims that the newer antipsychotics can 'improve' tardive dyskinesia because they tend to suppress the symptoms. In reality, any drug that suppresses tardive dyskinesia is likely to cause it as well. This phenomenon is called masking" (p. 198, Your Drug May Be Your Problem).

September 1, 2018

Hey Carefulprayerful. I'm really sorry to hear this. AP WD can be lethal and continue for years, so indeed discontinuing it too quickly may not be the best idea. I don't think going more quickly is a bad idea in general, but only if you don't experience any symptoms to (perhaps) mild symptoms. I've read in your thread you're already experiencing some... So yeah, it might not be exactly safe to speed up too much at this point. During my 2nd withdrawal, from Zoloft, the symptoms were much more severe, I just ignored them because I wasn't expecting the taper to fail, really. During the 1st one they really weren't disruptive, I guess that was the difference for me. So indeed, while I think trying a quicker taper is not a bad idea at all in general, you do have to watch for those warning signs... I've experienced 3 CT withdrawals, pretty much, and so I'm totally against trying to live with a bad WD. And it seems if you mess up your taper, you end up in pretty much the same state as if you had CTed.

September 1, 2018

careful, please post your updates in your Introductions topic. This keeps your case history all in one place.

Also, be sure to answer questions from the staff, such as

On 7/23/2018 at 9:54 AM, Altostrata said:

What times of day do you take your drugs, and their dosages?

When did you reduce Risperdal, and by how much? Please update your signature.

What happened after you updosed Lamotrigine to 175mg in July?

If you review the drug interactions you posted above, you will see the lamotrigine has an additive effect to Risperdal.

When did these movements start? What is your daily symptom pattern? Please keep daily notes on paper about your symptoms, when you take your drugs, and their dosages. Use a simple list format with time of day on the left and notation (symptom, drug and dosage) on the right.

September 1, 2018

latrogenesis, thank you for your reply. I believe I need to face the music (no pun intended) and go at a pace I can manage, letting my symptoms be my guide.

Altostrata, thank you for the follow-up. I will update my introductions topic.

September 2, 2018

I have been on 0.75 mg Risperidone since April, which I take at 9 p.m. I have been on 175 mg Lamotrigine since late June. I split the dose of Lamotrigine (after a gradual transition) and since the first week of August have been taking 100 mg at 7 a.m. and 75 mg at 9 p.m.

After I updosed the Lamotrigine, my symptoms have continued to improve.

In my post 7/21, I mentioned the symptoms I was experiencing around that time.

The eye twitch began in July, and I have been noting the mouth movements daily since 8/21.

Roughly 7/21-8/21, I experienced the following symptoms (mild) which all subsided:

what I call brain strain
what I call hot air balloon head
what I call floaty brain
nausea
neck stiffness
body stiffness
agitation
fatigue
back pain
sensitivity to heat, light, and sound (almost entirely)
mood shifts (momentary fear or panic)
restlessness

In the past 10 days, I have experienced the following symptoms (mild):

headache (this has been a constant since April but has gotten milder)
momentary chest or abdominal pain (has come and gone since July, lasts for seconds and is not daily)
weepiness (once) (has happened before)
the feeling that a mood shift is coming on that doesn't
facial tightness
lip licking
tongue twitch
jaw clenching
eye twitch (which is very minor)

My brain function has improved in the following ways:

drastically improved short-term memory
ability to feel more
ability to follow a train of thought
concentration
creativity
sense of humor

My plan is to wait two months since splitting the dose of Lamotrigine and consider beginning my taper again (this time a microtaper) in early October.

I am considering these methods for my microtaper:

a 0.1 mg digital scale (maybe something like this: https://www.joyfay.com/catalog/product/view/id/52917?gclid=EAIaIQobChMIqP2w85Kb3QIV0JCfCh0DqAY0EAkYBSABEgJAVfD_BwE )
a home-made liquid mixture (I consulted a well-informed pharmacist about how to suspend the drug in water)

Your feedback is always appreciated.

September 2, 2018

Wow, what an encouraging post Careful,

Im so glad that a lot of your symptoms have subsided or are mild. That’s wonderful news.

Wishing u allthe best with the rest of your taper💚

September 2, 2018

Thank you for your message, Carmie. How wonderful that you have tapered off so much of the Seroquel! I am so grateful to be able to connect with other people who are doing this. Wishing you all the best as well 🌈

September 2, 2018

7 minutes ago, carefulprayerful said:

Thank you for your message, Carmie. How wonderful that you have tapered off so much of the Seroquel! I am so grateful to be able to connect with other people who are doing this. Wishing you all the best as well 🌈

Thanks Careful,

I was so happy to read all the positivity in your account too. It helps a lot when people read how someone is in a bit of a window n not doing too bad, it’s encouraging people on this site. Writing down some of our woes too helps others as well as they can see they aren’t alone in this boat n what they’re experiencing is similar to other people.

Yes, I’m grateful too to be able to connect with people on this site. Unless someone is going through withdrawals themselves they have absolutely no idea how horrific it is.

Here’s to taking a moment at a time n moving forward slow n steady. We can do this!💚

September 2, 2018

On ‎6‎/‎11‎/‎2018 at 10:41 PM, Altostrata said:

With it's active metabolite, palperidone, risperidone has a fairly long half-life of about 2 days, which is plenty long for tapering.

Just wanted to post in my introductions topic the information from the drug label on DailyMed concerning half-life:

"The apparent half-life of risperidone was 3 hours (CV=30%) in extensive metabolizers and 20 hours (CV=40%) in poor metabolizers. The apparent half-life of 9-hydroxyrisperidone was about 21 hours (CV=20%) in extensive metabolizers and 30 hours (CV=25%) in poor metabolizers. The pharmacokinetics of risperidone and 9-hydroxyrisperidone combined, after single and multiple doses, were similar in extensive and poor metabolizers, with an overall mean elimination half-life of about 20 hours."

(Copied from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=43aa2a4f-1123-4f86-800b-9218882f7bcd.)

September 3, 2018

On 9/1/2018 at 9:30 PM, carefulprayerful said:

brain function has improved in the following ways:

So So hopeful to read this! Great news! thanks for your post!

September 3, 2018

22 hours ago, carefulprayerful said:

Just wanted to post in my introductions topic the information from the drug label on DailyMed concerning half-life:

"The apparent half-life of risperidone was 3 hours (CV=30%) in extensive metabolizers and 20 hours (CV=40%) in poor metabolizers. The apparent half-life of 9-hydroxyrisperidone was about 21 hours (CV=20%) in extensive metabolizers and 30 hours (CV=25%) in poor metabolizers. The pharmacokinetics of risperidone and 9-hydroxyrisperidone combined, after single and multiple doses, were similar in extensive and poor metabolizers, with an overall mean elimination half-life of about 20 hours."

(Copied from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=43aa2a4f-1123-4f86-800b-9218882f7bcd.)

Always a good idea to research your drugs. An active metabolite is a product of the drug's being metabolized and can extend the effect of the drug.

carefulprayerful: switch to drug with longer half-life before tapering?

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