Gertie: Too fast taper off 50mg Zoloft a little over 3 months ago - considering reinstatement

[Gertie]

HI everyone - thank God I just found you!

 

My 19 year old daughter has been on 50mg Zoloft (sertraline) since 2008.  This summer we tapered her off over a 6-week period (which unfortunately I now know was WAY too fast).  She did great, no issues, until last week, almost EXACTLY 3 months later.  Withdrawal symptoms of fatigue, dizziness, syncope, headaches, falling, nausea, stomach pain have been coming and going for 5 days straight.  She's missed two days of school during mid-terms.  It started on the day she got her period so at first I attributed it to that.  Then I thought maybe she had the flu.  Then I thought she was overwhelmed with her first semester of college.  Never dawned on me it was the sertraline.  But when it hit her hard again last night I stayed up all night researching and once I came across this board and read the intro pages I KNEW that's what we are dealing with. It seems to be getting worse each day.  I feel horrible that I didn't research more before doing the taper.   I stupidly trusted her Dr.

 

Now that we are close to a week past the 3-month mark, I'm thinking I need to immediately try reinstatement to see if it will help.  I have a call into her Dr. to call in an Rx, because we used all of hers up when she tapered off.  Since it's a Sunday of a holiday weekend I'm not too hopeful, and am considering taking her to Urgent Care to see if we can get an Rx there to get started today.  I also think he won't believe that these symptoms have anything to do with the sertraline.

 

Based on my reading here I'm guessing that if we try the reinstatement, I would start her at 1mg and leave it there for 1 week?  If symptoms improve, leave it there, but if they don't,  maybe move to 1.5mg?  

Does that sound right?

 

But if she seems worse then do I taper off for about a week, or faster or slower?

 

I'm just sick this is happening to her - I feel totally responsible and like a horrible parent.

Thank you all so much for being here to help those of us who come after you.

 

Edited November 12, 2019 by Shep
added new username to title

[Gridley]

On 11/10/2019 at 11:56 AM, smkroll said:

Based on my reading here I'm guessing that if we try the reinstatement, I would start her at 1mg and leave it there for 1 week?  If symptoms improve, leave it there, but if they don't,  maybe move to 1.5mg?  

Does that sound right?

 

But if she seems worse then do I taper off for about a week, or faster or slower?

 

Welcome to SA, Gertie.

 

Yes, start at 1mg.  It takes about 4 days for a dose change to get to get to full state in the blood and a bit longer for it to register in the brain, so in around a week you should have an idea of whether 1mg is working.  As you said, if symptoms improve, leave it there.  If they don't, you could go to 1.5.  If she's worse, stop immediately.

 

For symptoms to kick in at the three-month mark is remarkably common.

 

You seem to have a good handle on the topic, but here's a link on reinstatement:

 

About reinstating and stabilizing to reduce withdrawal symptoms. -- at least the first page of the topic

 

Here's a link specifically about Sertraline, including how to obtain the small doses you'll need (liquid Sertraline, making your own liquid, weighing with the AWS Gemini-20 scale, available on Amazon.

 

Tips for tapering off Zoloft (sertraline)

 

Good luck!.  We're glad you found your way here.

 

 

 

 

 

Edited November 12, 2019 by Shep
replaced username with new username

[Gertie]

Thank you so much for the reply!

 

Just hung up from her Psychiatrist.  We haven't been to him in over two years - started having her developmental pediatrician monitor her Rx instead, but have not received a return call so I reached out to him.  Super grateful he was willing to return a call to an old patient on a Sunday, but frustrated at the conversation.

 

He is calling in an Rx for 50mg sertraline - wants to put her right back up on her old dose.  I asked if we could at least start with 25, but no.  Said he knows about the hype of Antidepressant Discontinuation Syndrome, but in all his years he's never seen it, so wasn't willing to discuss it with me.

 

So I'm going to break the 50mg in 1/2, then dissolve that 1/2 in 25ml water to make 1mg/ml doses.  

 

He wants to see her this week, and she refuses to lie to Drs so I'm scared he will be angry when he finds out I am only giving her 1mg.

 

Really appreciate your time and help.

[Altostrata]

Welcome, Gertie.

 

If I were you, I'd phone him back and make a firm request for liquid sertraline so you can titrate up. Any doctor can prescribe these drugs. If this psychiatrist isn't any help, you could leave a phone request for your GP or pediatrician to do it.

 

Very few doctors, including psychiatrists, know anything about psychiatric drug tapering or withdrawal, much less low-dose reinstatement. If they did, this site would not exist. I look forward to the day that they do.

 

I would not see this psychiatrist, he sounds like a dinosaurian jerk.

 

Edited November 12, 2019 by Shep
replaced username with new username

[Gertie]

Is it ok to ask follow up questions here?

If so, I have one!

 

I started my daughter on 1mg sertraline yesterday at 3:00pm.   Made a liquid solution of 1mg/ml by cutting his stupid 50mg Rx in 1/2, then dissolving that 25mg in 25ml water.

 

About 3 hours later she noticed her headache was much reduced, and she felt hungry for the first time in days.  Ate her whole dinner without stomach pain.  By bedtime she was starting to feel more dizzy, weak and stronger headache again - but stomach still felt better.  Today she still feels crummy, but not as bad as yesterday before that first dose.

 

I'm taking this as a positive sign.  I read where it says here that "A slight immediate improvement is a good sign, this probably will progress as the drug ramps up to steady-state over a week."

 

However, I also read somewhere on here (which unfortunately now I cannot find again) that doing a reinstatement 3 months out will hopefully help reduce symptoms, but not completely alleviate them.

 

So my question is, after a week at this 1mg dose, if her symptoms are improved but not alleviated, how do I know if we want to keep her at 1mg, or try to increase to 1.5mg?

 

 

[Altostrata]

It will take at least 4 days for the drug to reach steady-state in her bloodstream. She should be feeling more stable as time goes on. I'd give it at least a week.

 

1mg is a very small amount, it could be that she might do better on a little more -- but you'd be surprised how often these very low-dose reinstatements are enough.

 

Please tell your daughter to stop worrying. If it works, it works, and the signs are excellent that it will work. Please ask her to be patient.

 

Why is she taking the other drugs?

 

(Please confirm you want to use your present screen name.)

[Gertie]

OK thank you.  She's now starting feel worse, about 30 minutes after her 2nd dose (around 4:15pm), which is scaring me.  Increased headache and nausea.  Opposite of what happened yesterday.  Could be because she took it on an empty stomach even though I brought her a snack to take it with?  She was already feeling nauseous and headache BEFORE taking it (hence not eating the snack), so it's hard for me to know.

 

She's on the other meds because 3 years ago she was diagnosed with a rare genetic neurological disorder called Hereditary Spastic Paraplegia (HSP).  It is related to ALS and has symptoms similar to MS.  She is basically missing most of a gene that produces a protein her CNS needs to talk properly to her muscles.  Her symptoms appeared hard and fast and needed management - she suddenly was unable to walk.  We started off trying to manage them with cannabis oil, and had some decent results but they were temporary.  So a year into her diagnosis we wound up eventually deciding to go the pharmaceutical route to improve her quality of life.  Those two meds have helped tremendously with her HSP symptoms and aren't something I anticipate she will ever be able to wean off of, barring gene replacement therapy as a future cure.

 

 

[Altostrata]

Perhaps she would do better with only one 1mg dose per day. I'd give it a week, please let us know how she's doing.

 

Please clarify your screen name preference.

[Gertie]

Yes she's currently on 1mg so I will just continue with that for a week and check back in.

 

I sent a message to She per the instructions in the warning I received to change my screen name.

 

Thank you for all of your help.

[Gertie]

 

One-week update and a few questions.  

 

First, I want to say that my daughter is currently doing so much better.  I started the 1mg sertraline reinstate on Sunday afternoon, and we are continuing that protocol.  At day 4 she had about a 60% or so improvement in symptoms.  It continued over the next 3 days, and I'd say she now feels about 80% better than she did one week ago.  I cannot thank you all enough.  Really.

 

Second, @Altostrata, I wound up in an argument on the phone with her psychiatrist and told him we would not be returning.  So as of now I am managing this by myself, and will begin searching for someone who understands what we are really dealing with.   I loved your comment above about him being dinosaurian. 🙂

 

Third, I just want to say thank you to all of you Administrators and Moderators for what you are doing to help all of us.  I have spent the past week reading non-stop and learning from your information and other people's stories on this site.  I have gone back through my daughter's medical and medication history, and I'm truly angry and disgusted with all of the many many many doctors, psychiatrists, neurologists, etc we have seen, all of whom overlooked the timing of her POTS, HSP(Hereditary Spastic Paraplegia) and other neurological symptoms with changes in her Zoloft dosages!!!  I now believe she probably never needed to be put on Amitriptyline to help with nerve pain for her HSP - I think it was all due to a delayed reaction to Zoloft changes made several months prior.  Yet another drug we will most likely need to help her taper off from in the future. ARGH!  But one step at a time.  If I’ve learned anything here it is not to change anything else while tapering.

 

And now for my questions:

 

1.  I am making a 25mg/ml solution by dissolving 25mg sertraline in 25mg water.  I’m making it, using it that day and 3 following days for a total of 4 doses, then tossing the rest and starting over.  Is it possible in those 3 days that some of it can evaporate?  I haven’t seen much on here about that.  If so it would mean my solution is becoming more concentrated over the 3 days.  I know how important consistency is, so I’m a bit worried about this.

 

2.  Along with that would be the idea of the liquid sertraline.  However I’ve read stories of people who make the switch and have waves for a bit.  Since we are already at such a low dose, should I be messing around with that?  This poor kiddo is in her first semester of college trying to keep her grades up while dealing with all of this and I’m trying to keep her symptoms minimized as best I can.   Is it okay to keep dissolving the pills and just keep diluting with more and more water as we taper?

 

3.  As of right now she has daily mild waves of dizziness, nausea, headaches, tremors, tingling/burning, along with pretty moderate steady fatigue and flares in the nausea and headaches at times.  So it's manageable enough that she can get to school, etc.  I read and understand that reinstatement is not to eliminate symptoms but to reduce them.  Therefore I am assuming I just keep her at 1mg for the next 3-4 weeks?  And if she doesn't stabilize here (ie: things get worse) would I consider updosing to 1.25mg or something like that at that time?

 

Thanks for your help, and seriously God Bless You for creating this site.

[marconyc]

On 11/10/2019 at 11:56 AM, Gertie said:

HI everyone - thank God I just found you!

 

My 19 year old daughter has been on 50mg Zoloft (sertraline) since 2008.  This summer we tapered her off over a 6-week period (which unfortunately I now know was WAY too fast).  She did great, no issues, until last week, almost EXACTLY 3 months later.  Withdrawal symptoms of fatigue, dizziness, syncope, headaches, falling, nausea, stomach pain have been coming and going for 5 days straight.  She's missed two days of school during mid-terms.  It started on the day she got her period so at first I attributed it to that.  Then I thought maybe she had the flu.  Then I thought she was overwhelmed with her first semester of college.  Never dawned on me it was the sertraline.  But when it hit her hard again last night I stayed up all night researching and once I came across this board and read the intro pages I KNEW that's what we are dealing with. It seems to be getting worse each day.  I feel horrible that I didn't research more before doing the taper.   I stupidly trusted her Dr.

 

Now that we are close to a week past the 3-month mark, I'm thinking I need to immediately try reinstatement to see if it will help.  I have a call into her Dr. to call in an Rx, because we used all of hers up when she tapered off.  Since it's a Sunday of a holiday weekend I'm not too hopeful, and am considering taking her to Urgent Care to see if we can get an Rx there to get started today.  I also think he won't believe that these symptoms have anything to do with the sertraline.

 

Based on my reading here I'm guessing that if we try the reinstatement, I would start her at 1mg and leave it there for 1 week?  If symptoms improve, leave it there, but if they don't,  maybe move to 1.5mg?  

Does that sound right?

 

But if she seems worse then do I taper off for about a week, or faster or slower?

 

I'm just sick this is happening to her - I feel totally responsible and like a horrible parent.

Thank you all so much for being here to help those of us who come after you.

 

Very sorry to hear that. When I was first put on Zoloft, I stayed on for about a year and the was told to taper over a 2-week period. I ended up on 150mg for another 16 years. Then I tried to taper again more slowly, but still pretty fast--maybe 6 months. I went really slowly from 150 to 100 and was doing great, so I dropped to 75 and then 50mg really quickly. I ended up on 200mg of Zoloft and 1mg of Abilify. Looking back, it's pretty clear to me that the withdrawal effects and too-fast tapers resulted in every increasing dosages of meds, and ultimately polypharmacy. 

[Altostrata]

Sad to say, finding a doctor who will understand is very difficult. Dr. Stuart Shipko is in Pasadena.

 

Otherwise, your GP can prescribe the drugs you'll need, it doesn't have to be a psychiatrist.

 

Sertaline comes in a liquid by prescription, that might be easier for you. You'll have to refrigerate the DIY liquid in a tinted bottle; 4 days is a good limit. You'd use a smaller oral syringe to taper, or dilute the liquid.

 

For your daughter, there is no bumpy switch to liquid, the liquid sertraline is "new" to her system.

 

36 minutes ago, Gertie said:

As of right now she has daily mild waves of dizziness, nausea, headaches, tremors, tingling/burning, along with pretty moderate steady fatigue and flares in the nausea and headaches at times.  So it's manageable enough that she can get to school, etc.  I read and understand that reinstatement is not to eliminate symptoms but to reduce them.  Therefore I am assuming I just keep her at 1mg for the next 3-4 weeks?  And if she doesn't stabilize here (ie: things get worse) would I consider updosing to 1.25mg or something like that at that time?

 

You'll need to track her symptom pattern. If she gets progressively better over the next few weeks, she may not need an increase in sertraline.

 

Normally, there are ups and downs, see The Windows and Waves Pattern of Stabilization

 

Is she still taking baclofen? What times of day does she take her drugs, with dosages? Do her symptoms follow any daily pattern?  Please keep daily notes of times of day you take your drugs, their dosages, and your symptoms throughout the day. You can post 24 hours of notes at a time in this topic, with a simple list format with time of day on the left and notation (symptom or drug and dosage) on the right.

 

She needs to keep her drug schedule very, very regular. Inconsistencies can cause symptom flare-ups.

 

[Gertie]

@Altostrata yes I am tracking her symptoms daily and keeping dosing times consistent.  Although each day is a bit different and continues to change as she starts to stabilize, there has been somewhat of a pattern that looks something like this:

 

8:00-9:00am wake up.  Feel a tad nauseous (2). Feel fatigued which lasts all day (7).

9:00am eat breakfast, take 10mg baclofen

late morning - dizzy/nausea or headache/nausea (was a 6-7 but now decreased to a 3).  Lasts for maybe an hour

noon - 2:00pm - eat lunch (depends on school schedule)

3:00 or 4:00pm - dizzy/nausea or headache/nausea (was a 6-7 but now decreased to a 3).  Lasts for maybe an hour

4:00pm - 1mg sertraline

6:00pm - dinner, feeling good, chatty

9:00pm - sometimes headache, but only on days doing homework on computer.  

10:00pm - take 10mg baclofen and 25mg amitriptyline

midnight - 1:00am go to bed.

 

Her baclofen and amitriptyline dosing schedules have been the same since it was prescribed in 2017.  No symptoms until withdrawal from sertraline.

[Gertie]

Quick question for anyone who's available to answer.  My daughter has been somewhat stabilizing over the past several weeks in the windows and waves pattern.  However, about two weeks ago she started having feelings of fullness and not able to eat much - some days that would be her only physical symptom.  Today she had severe stomach pains and vomiting.  It came with a migraine, so I'm assuming it's another wave, but since reinstatement she hasn't really had stomach pains or vomiting; her stomach issues have manly been nausea.  

 

Is it normal to have a "new" symptom during stabilization?  Or does this mean she is not stabilizing and I should consider upping her dose?  

We reinstated at 1mg zoloft on November 10 and have remained there - no changes.  I thought she was doing well with it, but this new development over the past 2 weeks has me concerned.

[Gertie]

@Altostrata @Gridley @brassmonkey @Shep @Sassenach anyone available to answer my question posted above?  I've been reading so many different stories, and some people benefit from holding, others benefit from updosing, others have terrible response with updosing and then can't get back to stability.  I'm not sure what the next move should be.  My daughter had a solid week-long window the end of  Nov to early Dec and I thought she was stabilizing.  Then Dec 3 she started feeling bloated, full and not hungry, which has progressed to stomach cramping and vomiting starting yesterday.  Just not sure if we should ride it out a few more days, weeks, etc (a wave with a new symptom) or consider updosing?  We reinstated at 1mg sertraline on Nov 10 and have not changed that dose.  Nothing else is different.

[Altostrata]

Gertie, does your daughter previously suffer from migraines?

 

Has she accidentally skipped any doses of any of her drugs?

 

What is her current daily drug and symptom pattern?

[Gertie]

Thank you @Altostrata for the reply.

1.  No she has no history of migraines.

2.  she DID accidentally skip one dose on 12/10!!  

3.  From 11/25 to 12/1 (a whole week) she was in a window - she had a few days with a little spaciness, a few mild headaches, and spotty memory, but almost complete clear windows otherwise - extremely manageable and feeling close to "normal."  I thought she was stabilizing.

 

On 12/2: Nothing we did changed, but symptoms did.

8:00am wake up, eat soup, take 10mg baclofen

10:30am in class, suddenly a wave of confusion, extreme nausea and stomach pain; lasted 5 minutes then was gone.

1:00pm headache (level 4) lasted rest of day

3:00pm eat lunch

4:00pm 1mg sertraline

6:00pm eat dinner

11:00pm take 10mg baclofen / 25mg amitriptyline

 

The feeling full/bloated/not hungry started on 12/3.  She describes it as uncomfortable, thick, "not right" - as opposed to pain (**see notation below).  

From 12/3 to 12/13 it's been pretty much like this every day:

8:00am wake up feeling nauseous

8:30am eat soup, take10mg baclofen

between 9am - 10am get stomach discomfort that lasts the rest of the day along with mild nausea

3:00pm eat lunch (soup, pasta, other softer easily digestible foods)

4pm take 1mg sertraline (except on 12/10 when she forgot to take it)

sometimes nap from 4pm-5pm

6pm eat dinner

11pm take 10mg baclofen / 25mg amitriptyline

Usually falls asleep anywhere between 12am - 2am

Many of these days she has complained about short-term memory issues in class, but she says it's on-and-off.  Class is from 10am to 2:30pm most days, so during those hours.  (Had memory issues once before after a concussion, otherwise never until sertraline withdrawal).

 

Then the past few days ramped up:

12/14:

had insomnia the night before so never went to sleep

9:00am headache, nausea and stomach discomfort that lasted all day. Ate soup, took 10mg baclofen.

11:00am complained of short-term memory issues while trying to study.

noon:  had friends over for christmas gift exchange/cookie bake.   I was gone all day. She reported she ate a few cheese and crackers but that was all she could "get down" due to headache, nausea and stomach discomfort.

4:00pm 1mg sertraline

9:00pm severe stomach pains, lasted until she fell asleep

10:00pm vomited

11:00pm 10mg baclofen / 25mg amitriptyline

12:00am fell asleep

 

12/15:

slept until noon.  woke up with extreme stomach cramping/pain and leg cramping, but no nausea!

12:30pm at soup, took 10mg baclofen.

2:00pm - stomach went from cramping to a dull thick pain that lasted all day.  Put heating pad on tummy for large part of day.  Ate some saltines.

4:00pm - took 1mg sertraline

6:00pm - ate soup.

7:00pm - headache and stomach cramping

9:00pm - headache subsided, cramping reduced a little, became nauseous.

11:00pm - took 10mg baclofen / 25mg amitriptyline

1:00am - fell asleep

 

today 12/16:

8:00am woke up feeling much better.  Stomach feels "not right," but no pain or nausea

8:30am eat soup, take 10mg baclofen

11:00am sudden burst of strong stomach pain and nausea.  Don't know if she still has it or it passed?

She is in finals so I haven't had more contact with her - the last piece of info was a text.  She said she'd check in after her final.

 

She's in her first semester of college and finals, and her best friend is moving away next week.  I know stress can add to symptoms.  But not sure we should just chalk it up to stress alone?  The gastroparesis-like symptoms started before the skipped dose, but is it possible that one skipped dose inflamed those symptoms?  If so I'm assuming we just hold for at least another week and see what happens...

 

**She had gastroparesis many years ago and this is how it started then - same feeling.  It turned out to be caused by too many eosinophilic cells in her stomach from a mild dairy allergy.  Steroids cleared it up and she has been careful with dairy ever since and never had a reoccurrence until now.  I believe the sertraline withdrawal is causing gastroparesis-like symptoms.  Just scared how long it will continue.

[Gertie]

today 12/16 continued:

noon: pain reduced to "discomfort," nausea subsided

1:30pm pain and nausea returned strong

2:00pm just walked in the door and ran to the bathroom to vomit.  Now laying down due to pain and nausea.

[Altostrata]

What drug did she skip on 12/10? What was her daily symptom pattern on 12/11, 12/12, and 12/13?

 

It looks like the disruption caused insomnia night of 12/13 and maybe symptoms on 12/14. She needs to be very regular in her drug schedule.

 

I would look up adverse effects of amitriptyline. Please put ALL your drugs in the Drug Interactions Checker https://www.drugs.com/drug_interactions.php
and copy and paste the results or a link to them in this topic.

[Gertie]

1.  She skipped the sertraline on 12/10.

 

2.  12/11-13 are pretty much identical to what's posted in 12/3 - 12/13 above:

12/11:

8:00am wake up feeling nauseous

8:30am eat soup, take10mg baclofen

10am stomach "discomfort" 

3:00pm eat pasta with butter

4pm take 1mg sertraline

6pm eat dinner (baked potato)

11pm take 10mg baclofen / 25mg amitriptyline

Asleep 1:30pm

 

12/12:

8:30am wake up feeling nauseous

8:45am eat soup, take10mg baclofen

10:30am stomach "discomfort" 

2:00pm eat jamba juice

4pm take 1mg sertraline

6pm eat dinner (soup/bread)

11pm take 10mg baclofen / 25mg amitriptyline

Asleep 1:00pm

 

12/13:

9:00am wake up feeling nauseous, stomach discomfort

10:00am eat soup, take10mg baclofen

2:00pm eat soup

4pm take 1mg sertraline

6pm eat dinner (pizza)

11pm take 10mg baclofen / 25mg amitriptyline

Never fell asleep

 

I'll do the drug interaction next

 

[Gertie]

 

Here's the info.  The only thing is that she's never had a problem with these symptoms until now.  The last time she had gastroparesis she was not yet on amitriptyline, and in the 2.5 years she's been on it she hasn't had a problem until now, and we haven't changed any dosing except for sertraline....  so does it make sense it has to do with the sertraline????

Wondering the following sertraline possibilities:

1.  Skipping that one dose of sertraline on 12/10 caused an uptick in her wave.  Not sure what to do about it if that's true.

2.  She used to always take her sertraline in the morning, but when I reinstated I did it at 4pm because that's when the new prescription came through and i didn't t want to wait another day.  Perhaps slowly backing up the sertraline would help, maybe closer to noon, so it's not as close to the amitriptyline?

3.  We should slightly updose the sertraline?  That I didn't reinstate at high enough dose?  Although that long window seems to indicate otherwise, right?

 

If you think it has to do with the amitriptyline, what would we do?  I know it's not good to mess around with doses of two different drugs at the same time.  We figured in 3-4 years after tapering off sertraline we'd start trying to reduce the amitriptyline - I'm scared to make things worse by playing around with that before she's stable on the sertraline....

 

This report displays the potential drug interactions for the following 3 drugs:

• sertraline
• amitriptyline
• baclofen

Interactions between your drugs

Major

Before taking amitriptyline, tell your doctor if you also use sertraline. You may need dose adjustments or special tests in order to safely take both medications together. This combination may increase the effects of amitriptyline in your body. You should notify your doctor if you have symptoms of sedation, dry mouth, blurred vision, constipation, or urinary retention. You might also have altered consciousness, confusion, poor muscle coordination, abdominal cramping, shivering, pupillary dilation, sweating, high blood pressure, and high heart rate. It is important that you tell your healthcare provider about all other medications that you are using including vitamins and herbs. Do not stop using your medications without first talking to your doctor first.

 

 

Moderate

Using amitriptyline together with baclofen may increase side effects such as dizziness, drowsiness, confusion, and difficulty concentrating. Some people, especially the elderly, may also experience impairment in thinking, judgment, and motor coordination. You should avoid or limit the use of alcohol while being treated with these medications. Also avoid activities requiring mental alertness such as driving or operating hazardous machinery until you know how the medications affect you. Talk to your doctor if you have any questions or concerns. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor.

 

 

Moderate

Using sertraline together with baclofen may increase side effects such as dizziness, drowsiness, confusion, and difficulty concentrating. Some people, especially the elderly, may also experience impairment in thinking, judgment, and motor coordination. You should avoid or limit the use of alcohol while being treated with these medications. Also avoid activities requiring mental alertness such as driving or operating hazardous machinery until you know how the medications affect you. Talk to your doctor if you have any questions or concerns. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor.

 

 

 

[Altostrata]

My guess is missing the Zoloft dose produced a ripple effect that caused the sleeplesness and symptoms on 12/14. Does her increase in symptoms coincide at all with her menstrual cycle?

 

See amitriptyline adverse effects. Many gastrointestinal symptoms, including nausea. Over time, our bodies respond differently to drugs. It may be that your daughter has become sensitive to amitriptyline's anti-cholinergic effects. Did you add an allergy or cold drug recently?

 

Also please look up adverse effects of baclofen.

[Gertie]

Thank you so much for all your time today and helping me figure this out.  I'm trying to learn quickly, but we're only a month in so I'm still stumbling a bit.

 

1.  Yes her symptoms do uptick during her menstrual cycle, which she actually had last week - I didn't think about that.

 

2.  We have not added any cold or allergy med or any other med or supplement.  Not even a tylenol for the headaches.  She's so scared to make anything worse.

 

3.  Crap  - so if she's becoming sensitive to amitriptyline, would we start trying to taper that now too?  That scares me so much.  

They put her on it to help with nerve pain, but also because of her history of gastroparesis; it's listed as one of the drugs that's supposed to HELP with gastroparesis symptoms!  Dr. figured if they were going to give her something for nerve pain, might as well also have it possibly help ward off another gastroparesis episode. It's  also used a lot for people with abdominal migraines.  I'm so annoyed because now I wonder if her nerve pain had more to do with sertraline dosage changes, and NOT her neurological condition!!!!  Maybe she never even needed it.  But we aren't sure.  Which is why we thought about trying to taper it in a few years, after she's done with sertraline.  Ugh!!

 

4.  I looked up baclofen adverse effects.  Vomiting and nausea can be side effects, but nothing about stomach pain.  She needs baclofen for her medical condition, so I'm not sure there's much we can do about that.  She has a lot of spasticity due to her neurological conditon, and needs the baclofen to help her walk.  It literally made the difference of her being in a wheelchair or not.

 

5.  I've read here that for dose changes, it takes 4-7 days for the body/brain to recognize it.  Would that also be true for missing a dose?  If so, 12/14 would have been day 4, and today would be day 6.  That would give me hope that it will settle down soon.

 

So it seems very possible that the timing of getting her period last week and missing a dose of sertraline at the same time could have caused this stomach pain/vomiting episode?  If so, I'm guessing we should hold everything for now and see if it calms back down?

 

She's had "discomfort" and mild nausea since 3:00pm today, but no more pain or vomiting.  Was able to keep down apple sauce, 2/3 of a jamba juice and a bowl of soup without escalating symptoms.  Maybe it will continue to improve....

[Gertie]

ps: I see you are in SF.  My Dad lives near Palo Alto and my brother is in San Jose - heading up your way right after Christmas 🙂

[Gertie]

Need some guidance PLEASE!!!!

 

Since we reinstated my daughter on 1mg sertraline back in Nov 2019, we have made no changes and things have continued to improve - I'd say her waves are mildish at this point and she's mostly stable.   I've been feeling so hopeful and like we've got this.  We planned to not make any changes except to slowly start reducing the 1mg sertraline, but now we don't have that choice.

 

Unfortunately, two changes HAVE to be made immediately, and I'm sort of panicking and looking for some guidance if possible.

 

1. She has been on the generic brand of sertraline Cipla.  Suddenly this month there is no pharmacy in my area that has Cipla brand.  I spent two days calling around.  So her Dr. prescribed brand name Zoloft.  In the long run this will hopefully be better, so that we don't have to worry about switching generics each month. 

My quesition, though, is how to switch her to the brand name now? 

Please note that I get the whole 10% or 20% or 25% at a time (ex: 80:20 generic:brand, then 60:40, then 40:60, then 20:80, then 0:100).

My question is more along the lines that I've read that different generics may be less potent than their brand name counterpart.  So I'm worried that if I assume the pills are the same dosage (25mg generic = 25 mg brand), I may be actually INCREASING her dose by the time we switch her over, if the brand name is in fact more potent.   And she's on a low dose so I'm guessing it would be felt.  I've got 20 Cipla pills remaining.

And with the change I have to make below, I'm concerned.

Does anyone have knowledge experience with this? I hunted around on the site but haven't been able to find info on switching from generic to brand name.  If there is, I apologize and would appreciate the link.

(I currently dissolve 25mg in 25ml water, in case that matters). 

 

2.  To make matters worse, her Noscapine is ordered from outside the country.  Unfortunately due to COVID19 it is not getting through customs.  I have tried twice with no luck.  We have 42 200mg capsules left and no way of obtaining more that I am aware of.  This means I have to taper her with those 42 capsules and hope for the best.  There is not a lot of information available about Noscapine regarding withdrawal that I can find.  I am not sure what to expect, but am feeling very concerned.  I also would love tips on dissolution, as it's not dissolvable in water.  Yesterday I used Vodka which worked so-so, well enough to add water, but there are tons of particles/sediment floating around.  I'm also confused because I added 36ml of liquid, but it turned into only 30ml after mixing.  I'm positive.  So the powder absorbed some of the liquid?  Not sure the right way to compensate for that.  Anyone know anything?

 

Need to start these changes today or tomorrow, so hoping to hear back.

Thank you for all you do for all of us

xoxo

 

[Altostrata]

Hello, Gertie. Is this still current:

Quote

*Currently taking:     Sertraline 1mg / Amitriptyline 25mg / Baclofen 20mg / Noscapine Base 200mg

 

Are you making a liquid from sertraline tablets? Since you have to make the switch, you might find using the prescription liquid to be easier. You'll have to check coverage with your insurance.

 

This is the correct way to do the crossover:

7 minutes ago, Gertie said:

Please note that I get the whole 10% or 20% or 25% at a time (ex: 80:20 generic:brand, then 60:40, then 40:60, then 20:80, then 0:100).

 

I would not worry about relative strength of the two sertraline formulas. A lot of people don't feel the difference. See how your daughter does with the change. If she feels the new liquid is too strong, you can always reduce the dosage slightly.

 

About noscapine: I don't know anything more than what I read about it. Its half-life is very short, under 5 hours. How many times a day does your daughter take noscapine? If several times a day, most likely you'll want to taper it graduall, as it's neuroactive. If once a day, tapering should be less difficult.

 

Although it's not very soluble, we have many people making suspensions from drugs that are technically not soluble, see How to make a liquid from tablets or capsules

 

It's too bad you may be forced to make changes in 2 drugs at the same time. Have you talked to the specialist treating your daughter for HSP about the noscapine difficulty?

 

[Gertie]

Hi Alto,

Thank you for the prompt reply!

 

1.  Yes, signature is still current. We literally didn't change a thing; we were just thinking about starting her first sertraline taper.

 

2.  Yes I am making liquid from sertraline tablets.  We had difficulty with insurance, so I am having to pay cash for either the liquid OR for brand name tablets.  It is more cost effective for me to use the tablets, because since she's at such a low dose and the liquid expires, we'd be tossing so much of it.  I already filled the Rx and have it in my hand - planning to start the switch tomorrow.

 

3. Re: Noscapine: she takes it once per day.  It's one 200mg capsule filled with powder.  I don't have an option to taper gradually, since I can't get any more.  That's why I'm worried.

If you have time, can you explain more about the half life?   I, too, read that is has a 4-5 hour half life, and I get the gist of what that means, but I don't get it in terms of how it affects people in withdrawal.  Is that better? Worse?

 

4.  Yes I agree this is terrible timing.  Unfortunately even though her neurologist knows she is taking Noscapine, he cannot prescribe it or advise me on it because it's not FDA approved.  It's available OTC in nearly every other country except USA.  So I can't get it here; have to import it, and now Customs has clamped down because of COVID19.  I've been ordering it from Israel or Japan from a reputable pharmacy.  There is a clinical trial with it for her disorder happening in Australia, and a large group of us decided to use it  - it has very high probability of stopping the progression of her disease and a long history of safety.  Probably wouldn't be such a problem if she hadn't just gone through sertraline withdrawal in November.  It may not even be a problem, I just have no idea. 

 

This is the Noscapine schedule I came up with.  What do you think?

Noscapine Dosing and Tapering
1 capsule=	200mg		Remaining:
1/2capsule=	100mg		42 capsules
1/4capsule=	50mg		= 8,400 mg
1/8 capsule=	25mg
To make this daily dose in mg	dissolve this much Noscapine	in this much liquid	to make this many doses	at this many mL each		take for this many days	which uses this many pills	and uses this many mg
150	3capsules	36mL	4	9mL		8	6	1200
100	1 capsule	12mL	2	6mL		14	7	1400
75	3capsules	32mL	8	4mL		16	6	1200
66.67	1 capsule	18mL	3	6mL		9	3	600.03
50	1 capsule	24mL	4	6mL		8	2	400
33.33	1 capsule	18mL	6	3mL		18	3	599.94
25	1 capsule	16mL	8	2mL		16	2	400
20	1 capsule	20mL	10	2mL		20	2	400
16.67	1/2 capsule	12mL	6	2mL		24	2	400.08
14	1/2 capsule	14mL	7	2mL		28	2	392
12.5	1/2 capsule	16mL	8	2mL		32	2	400
10	1/2 capsule	20mL	10	2mL		30	1.5	300
7.67	1/2 capsule	26mL	13	2mL		26	1	199.42
5	1/4 capsule	20mL	10	2mL		30	0.75	150
4	1/4 capsule	12.5mL	12.5	1ml		25	0.5	100
3.13	1/4 capsule	32mL	16	2mL		33	0.5	103.29
2	1/4 capsule	25mL	25	1mL		25	0.25	50
1	1/8 capsule	25mL	25	1mL		25	0.125	25
0.75	1/8 capsule	33mL	33	1mL		33	0.125	24.75
0.5	1/8 capsule	25mL	50	.5ml		50	0.125	25
						running total:	41.875	8369.51

 

[Altostrata]

What a great plan!

 

Half-life indicates the amount of time it takes for the drug to be metabolized. Generally, there's a decrease in effect when the drug is metabolized by half.

 

Theoretically, this means the body develops less physiological dependency on a short half-life drug, because it gets used to the drug vanishing fairly quickly. Does your daughter show any increase in symptoms 6-8 hours after she takes the daily noscapine dose?

 

Metabolization slowly removes the drug from the body. "Washout" is the amount of time it takes for the drug to entirely leave the body, estimated at 6 half-lives. (In reality, probably traces remain.)

 

If a drug has a half-life of 5 hours, it would wash out in 30 hours. This means any reduction in noscapine dosage would reach steady-state in less than 2 days.

[Gertie]

Well that's somewhat encouraging.

 

She's never had any side effects from Noscapine that we are aware of.  Started her right off at 200mg and never made a change and there was no adjustment that we noticed.  

She takes it in the morning upon wakening (8am school days / close to noon weekends).  But now are keeping it at noon for consistency.

 

Sorry if I'm asking annoying questions, but I still have another one re: half-life if you don't mind.  I just looked up sertraline and found this (which I know you already know):

"Zoloft’s average elimination half-life is 24 to 26 hours.  This means that after you’ve taken just one dose of the drug, it takes a full day thereafter for your body to clear half of that dose.  For complete systemic clearance of Zoloft (Sertraline), it will take (on average) between 5.5 and 6 days; slightly less than 1 full week.  However, just because the active ingredient Sertraline will have been eliminated doesn’t mean the chief (pharmacologically active) metabolite “Desmethylsertraline” will have been cleared.  Desmethylsertraline has an average elimination half-life of 66 hours, indicating that it stays in your system for a longer duration than Sertraline.  Complete systemic clearance of Desmethylsertraline takes an average of 15.13 days following your final dose."

 

So my question is: she didn't show symptoms of sertraline withdrawal for almost 3 months after our CT/FT, even though this article says washout was at 15 days.  That's because her body was trying to compensate over the next two months, and then finally couldn't keep up, right? 

Or what about the examples of people who taper just a little too fast (let's say 12-15% per month) and feel great for many many months and then BOOM it catches up with them.  I don't quite get it.

So is it possible that will happen with Noscapine too?  Or does a much shorter half life mean it's not very likely?

 

[Altostrata]

We don't know why some people experience delayed withdrawal. Could be the action of active metabolites, could be they had slight symptoms but thought they were from something else, like a cold or not getting enough sleep.

 

I can't tell you anything about noscapine. I've never heard of it until today. From what I can tell, not much is known about it. If she's not having interdose withdrawal from it after it wears off, her body may not miss it much when it's decreased.

[brassmonkey]

Noscapine is a non narcotic cough medication that works by stimulating the Sigma Opioid receptors. It is not a controlled substance, is said to be nonaddictive and according to some studies to be ineffective. Because of it's effects on the Sigma Opioid receptors I would be careful about CTing it after extended use. I would suspect that a fast taper of 25% every two weeks should work fine.

[Gertie]

Thank you both very much

[Gertie]

@Altostrata @brassmonkey wondering your thoughts. 

We started the noscapine taper and Zoloft switchover this week.   She's having nausea and stomach pain in sort of a pattern, but I can't figure out why.  Here's her daily log:

(note: the noscapine comes in a 200mg capsule filled with powder.  I made 4 150mg doses by diluting 3 pills (600mg) in 36mL liquid (12mL vodka (to dissolve it) and 24mL water), so each 150mg dose would be 9mL).

 

Monday 4/20

8:00am wake up, feel fine

8-9am online Fall semester registration

10am breakfast, take 10mg baclofen

back to bed

1pm eat lunch, take 150mg noscapine in 9mL liquid suspension of 2parts water and 1part vodka

2pm-4pm felt nauseous and almost threw up a few times (I assumed because of the taste plus the vodka)

4pm-6pm homework, feeling better

6pm dinner, took 1mg sertraline (liquid solution (pill with water), same since we reinstated last Nov)

7pm-10pm played games, watched TV, walked dog

10pm took 10mg baclofen and 25mg amitriptyline

10pm-midnight homework

midnight to bed

 

 

Tuesday 4/21: 

8:00am wake up, feel fine

8:30-10am online class

10am breakfast, take 10mg baclofen

11am-noon Physical Therapy (via zoom)

1pm eat lunch, take 150mg noscapine in 9mL liquid suspension of 2parts water and 1part vodka

1pm-6pm felt nauseous, stomach pain, slept on and off

6pm feel much better, ate dinner, take 1mg sertraline

7pm-midnight games, walked dog, homework

10pm took 10mg baclofen, 25mg amitriptyline

midnight to bed

 

Wednesday

10am wake up, feel fine, eat breakfast, take 10mg baclofen

11am-1pm online class

1pm eat lunch, take 150mg noscapine, but this time take 100mg powder and 50mg in 3mL solution. I bought veggie gelcaps and squirted the solution into them so that she wouldn't have to taste it.

1:30 - 2:30pm felt a little queasy and mild stomach pain

3 - 4pm  Zoom therapy session

4 - 6pm, hang out

6pm dinner, take 1mg sertraline: started switch to zoloft brand from generic sertraline.  Took .9mg generic + .1mg Zoloft

7pm - 10pm games, walk dog, homework

10pm took 10mg baclofen, 25mg amitriptyline

midnight became extremely nauseous, stomach pain 2 hours

2am to sleep

 

Thursday 4/23: 

8:00am wake up, feel fine

8:30-10am online class

10am breakfast, take 10mg baclofen

11am - noon back to bed

1pm eat lunch, take 150mg noscapine 100mg powder + 50mg in 3mL solution, in veggie gel caps.

1:30pm-3pm felt queasy and mild stomach pain

3pm - 6pm feel better, do homework

6pm eat dinner, take 1mg sertraline Took .9mg generic + .1mg Zoloft

7pm-11pm games, walked dog, homework

10pm took 10mg baclofen, 25mg amitriptyline

midnight became extremely nauseous, stomach pain, moderate headache 2 hours

2:30am (now) she's in bed trying to go to sleep.  Starting to feel better

 

Based on timing, it appears to me that the nighttime nausea is due to the switchover to Zoloft.  But I'm doing it in such a tiny amount. 

Or do you think it's the reduction in noscapine?

Either way it sucks because we are running out of both noscapine AND Cipla brand sertraline, so I don't really know what else to do. 

Tomorrow I'm going to give her the entire dose of noscapine in pill/powder form to see if that helps.  I ordered a scale and it just arrived today.

Thank you for your time

 

[Altostrata]

On 4/21/2020 at 6:21 PM, brassmonkey said:

Noscapine is a non narcotic cough medication that works by stimulating the Sigma Opioid receptors. It is not a controlled substance, is said to be nonaddictive and according to some studies to be ineffective. Because of it's effects on the Sigma Opioid receptors I would be careful about CTing it after extended use. I would suspect that a fast taper of 25% every two weeks should work fine.

 

I agree with brassmonkey.

 

Good idea to put the liquid in gel caps, that can make it more tolerable.

 

I doubt the nighttime stomach pain, nausea, and headache are from the Zoloft change. Rather, the noscapine half-life of ~5 hours is wearing off. That would be noscapine withdrawal. It should go away in a few days.

 

Perhaps the next noscarpine decrease should be 15% rather than 25%.

[Gertie]

Ok thank you.  Shoot.

 

Unfortunately I don't have enough Noscapine to do 15% cuts.  If I do that she'll have a HUGE jump off at the end.  I tweaked the chart I made above to try to make more symmetrical 25% jumps, (150mg to 120mg to 88mg to 66 2/3mg to 50mg, etc... but in order to do that without running out, each one is only for 12 days.  Just not sure how to really go any slower.  

 

I saw on Superwoman's story that she is using some kind of a tincture called California Poppy.  I don't really know what it is, and I know you don't usually recommend adding anything new, but I wondered if this was something that might help at night with the stomach pains and nausea, since Noscapine comes from the poppy, and since I have no access to Noscapine to be able to slow down the taper...

 

 

 

[Altostrata]

Maybe 20% decreases?