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

[Gertie]

I just played with the spreadsheet, and the only way to make it work at 20% cuts is to have each cut last 8-10 days max. 

Versus 25% cuts (with a few at 30%) at about 12 days each. 

Is it better to do 20% cuts for less days, or 25% cuts for more days?

If I only had like 15 extra pills.  But I don't.

 

Also, any thoughts on that California Poppy tincture?                                                          

[Altostrata]

It's better to do 20% cuts for less days, even 10% cuts more often.

 

I don't know what California poppy might do. Some people like CBD oil.

[brassmonkey]

California poppy is an opioid, although milder it can have all the associated problems of the street drug.  It can be useful short term for "normal people" but we don't recommend it for people in ADWD.

[Gertie]

On a positive note, I called all the pharmacies AGAIN in my area and this time one of them had Cipla sertraline in stock, 50mg.  I convince her Dr. (who pretty much thinks I'm a nut job at this point) to send in an Rx for a 3 months supply.  If I make 4 doses out of each 25mg, this gives me close to 2 years (cut each pill in 1/2, which give me 180 pills x 4 doses each = 720 doses) to keep her dose the same if necessary.  We picked up the 90 50mg pills on Friday, and I made the switch back to Cipla sertraline; no more having to convert to Zoloft.  We will deal with converting to Zoloft, if necessary, at a later point in time.  Thank God for that.  One less instability in her CNS.

 

I reworked the Noscapine spreadsheet and can make 10%(-ish) drops, but they will be, on average, every 5 days.  Ugh. She has 4 days remaining on her 150mg dose (a 25% from the original 200mg).  I kept this one for 10 days to try to see if she can stabilize at all.  But when I get to 2.5mg, I have to start decreasing by 20% - 33%.  Jump off will be at .5mg next January.  I can attach the spreadsheet if needed, but I didn't figure you'd need it.  

 

Also, on Friday I started giving her all powder instead of liquid, because the liquid made her feel sick upon taking it, and I thought/was hoping maybe the alcohol in it was causing a problem.

This wasted 150mg, which is still sitting here in liquid form. 

 

Now the problems:  

My scale arrived, and unfortunately I've discovered a large discrepancy in the weight of the noscapine capsules.  An empty capsule weighs .060.  With the supposed 200mg dose inside, the capsules vary in weight from .214 all the way to .318.  (Many are in the 2.4-2.6 range) Subtracting out the .060 capsule, it leaves a pw of .154 to .258 per capsule. That's a HUGE discrepancy!! Up to 100mg fluctuation per capsule!   If there is 200mg ingredient, shouldn't it weigh at least 200mg?  (This pharmacy claims no fillers, which appears to be true).  Otherwise I sometimes have an AIC greater than 1, which doesn't make sense.  So I'm assuming they do a very poor job of filling capsules accurately.

Of course, I have questions (I'm sorry):

1.  If the capsules fluctuate this much, how come she's never gotten sick before with this uneven dosing (I've always given her 1 capsule per day), but now she is?  

 

2.  How the heck am I supposed to get accurate dosing moving forward?  

I was planning to split capsules one at a time; I spent hours calculating each drop, making sure I had enough capsules 

(ex: 33.33mg will be 1/2 of 1/3 capsule; 10mg will be 1/5 of 1/4 capsule, etc).  

As far as I can see I have two options:

     1.  Weigh them ALL (keeping them in the capsule), get a total powder weight (subtracting out the total of the capsules) and just pull that much powder out each day?  I honestly don't have even 1mg of powder to waste.  

     2.  Weigh them all, figure out the mean weight, and then take powder from the larger capsules to fill the smaller capsules so that at the end they all weigh the same.

 

I honestly don't have even 1mg of powder to waste, and I very well may end up with even LESS powder (and I'm assuming therefore fewer mg if there are no fillers) than the 8200mg I thought I had in 41 pills.  Which means jump off will be at a potentially higher number, or dose changes will have to be more frequent.

How would you handle this?

 

3.  She is still experiencing side effects at night, right about 10 hours after taking the noscapine.  So I guess the 2nd 1/2 life is when it hits.   Now it's including dizziness, confusion, lightheadedness in addition to the nausea (although the stomach cramping seems better.) and lasts for about 2-3 hours.  I  know nobody knows for sure, but do you anticipate this to get better, stay the same, or ramp up as I start to decrease her dosage at the 10% every 5 day rate?  I'm worried that she is going to get really bad, that it will be all day, etc.  

I will put her daily log below for the past 2 days.

 

4.  Can I give her a tiny bit of benadryl for the nausea?  I've read conflicting stuff on that on this site.  I also have ondansetron here (I went thru chemo a few years ago and have some left over), but I read here that it affects serotonin receptors, and she's still on sertraline AND amitriptyline, so that seemed like not a great idea. 

 

Thanks, as always, for your time.

 

Friday 4/24

11am wake up, feel fine

11:30am eat soup, take 10mg baclofen, 150mg noscapine (switch to all powder)

noon chiropractor

1pm Walgreens (pick up Cipla sertraline)

3pm rest

4pm - 6pm watch TV

6pm eat dinner, take 1mg sertraline (back to all Cipla brand - last two days I had do .9mg Cipla + .1mg Zoloft)

8pm - 11pm bath

10pm-midnight dizzy, confusion, seeing shapes, slurred speech, lightheaded.  No stomach issues

11pm took 10mg baclofen, 25mg amitriptyline

12:30am to bed

 

Saturday 4/25

noon wake up, a little dizzy

1pm eat soup,  take 10mg baclofen, 150mg noscapine

3-4pm went on a drive with Dad

5:30 - 6:15pm, headache

7:00pm eat dinner, take 1mg sertraline

7-9pm play games

9pm 30min walk 

10pm take 10mg baclofen, 25mg amitriptyline

10:30pm-1am nauseous, dizzy, shaky,  Haven't talked to her since then so may have lasted longer.  She's sill asleep

11pm to bed, I still heard her up at 2:30am.  I think she fell asleep around 3am

 

 

 

[Gertie]

Nevermind question 2.  I weighed every Noscapine pill, then subtracted the .06 capsule weight for each one.  Then took an average.  If I redistribute the powder evenly among all the pills, they will each have 188mg (instead of 200mg).  But that way I can keep my spreadsheet the same as far a diving capsules; I just need to readjust the dosage.  So for example right now she's taking 3/4 capsule.  I thought that was 150mg, but it will now be 141mg.  I'm just going to assume that as her current dose (because I have no idea what the pills weighed that I used the past 6 days), and do the same cuts per capsule as before.  So next cut will be to 2/3 capsule.  I thought I was moving from 150mg to 133.33mg (11.11%), but it will actually be from 141mg to 125.33mg (11.11%).  So the percentage stays the same.  That makes sense, right?

[brassmonkey]

Do not give her any of the ondansetron.  It can cause dangerous interactions with antidepressants. There is a lot of information on dealing with nausea scattered through out the site.  Please do a site search to find it.

 

The inconsistent amounts in your capsules is one reason we don't like OTC supplements.  They are unregulated so you never know exactly what you are getting. I would calculate an AIC using a very large sample of capsules to determine the average pill weight, and use that to determine the weight of the dose you want to use.  Then treat the original capsules as a "stock pile of materials" and not as individual capsules.

 

Actually your post above make sense and does pretty much what I just said. I would go by a measured weight and not just 2/3 of a capsule.

[Altostrata]

2 hours ago, Gertie said:

I reworked the Noscapine spreadsheet and can make 10%(-ish) drops, but they will be, on average, every 5 days.  Ugh. She has 4 days remaining on her 150mg dose (a 25% from the original 200mg).

 

This could be okay, you'll have to see.

 

2 hours ago, Gertie said:

Also, on Friday I started giving her all powder instead of liquid, because the liquid made her feel sick upon taking it, and I thought/was hoping maybe the alcohol in it was causing a problem.

This wasted 150mg, which is still sitting here in liquid form. 

 

Have you tried mixing it in food?

 

Here is your earlier drug interactions report, from December 2019. Are you able to add noscapine to it?

 

[Gertie]

I just tried the drug interaction checker.  It does not recognize noscapine, and says it has no suggestions.

Yes we tried putting the liquid in food.  Because she's already nauseous, it made her gag/dry heave.  I'm fine with switching to powder, just sad about the 150mg I lost.

 

Thanks for the clarification on the Zofran - that's what I thought I was reading but wanted to make sure.  I've been searching and reading about nausea and it's all over the map.  Just wondered  if the benadryl could help because some people had some success.. But not others.  I don't want to make thing worse, but I want to help her.

 

She woke up nauseous and blurred vision and "out of it" feeling today which lasted for about 1.5 hours.  Usually she gets symptoms about 10hours (midnight ish) AFTER taking a dose (2pm ish), but wakes up feeling okay.  So it seems to be getting worse.  Didn't you guys think it would be leveling out by now?  Today is day 7.  We didn't even know if her body would notice the loss.  It's more extreme than I expected.  I only have enough for 3 more days at this dose and then have to start tapering.  I'm guessing that's going to make it worse???

 

[Altostrata]

It is possible noscapine interacts with the other drugs, with a reduction in noscapine "unmasking" the interaction, which usually is in liver metabolism.

 

It may be your daughter has to cope with 1.5 hours of wooziness each day until she's off the drug.

 

I don't know what adding a 4th drug for nausea would do. Do any of your doctors know anything about drug interactions? (This is almost a rhetorical question, because few do.)

 

How about chewing a little ginger, does that help the nausea?

 

We actually don't provide support for tapering noscapine here. As I said before, this is the first I've heard of it. While a psychotropic, it's not a psychiatric drug.

 

[Gertie]

I did some research and found that Amitriptyline uses the CYP2C19 enzyme to metabolize in to it's active ingredient nortriptyline.

Noscapine is a strong CYP2C19 inhibitor.

So when I decreased the Noscapine, CYP2C19 became less inhibited, and I'm assuming Amitriptyline was able to metabolize more to nortriptyline - which I"m guessing would feel like a dose increase.

This could indeed cause these side effects.

 

I know you can't speak to Noscapine.  But generally when a person has conflicting metaboilzation like this with any drug and amiitriptyline, I'm assuming I should try to decrease her amitriptyline.  Do you think it's ok to start with a 10% drop? I'd like to do it immediately with tonight's dose, but just wanted to run the science by you to make sure that makes sense.

[Altostrata]

Good work, Gertie. Few are willing to wade into the P450s.

 

I'm inclined to agree with your theory. She may be sensitive to the increased nortriptyline. We have a few people here to appear to have similar adverse reactions to the stronger metabolite.

 

Changing 2 drugs at once is a tough call. However, you seem to have the chops of a psychopharmacist. You might try a 5% reduction of amitriptyline but off cycle with noscapine. Amitriptyline has a much longer half-life, so cross fingers this is a gentle slope down that won't cause withdrawal symptoms.

[Gertie]

Thank you for getting back so soon.  OK I'll start with 5%.  I"m sorry, I might be being stupid, but what do you mean by "off cycle" with noscapine?  You mean at a different time of day than what I'm currently doing?  She currently does noscapine around 1pm and amitriptyline around 10pm.

[Altostrata]

No, I mean if you're reducing noscapine every 5 days, reduce the amitriptyline on the 4th day so you can see what's going on with the noscapine reduction. Hopefully, a 5% reduction will be so small, it won't perturb the next noscapine cycle.

[Gertie]

Oooohhhh!  That makes more sense  - duh.

Thank you