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Taking multiple psych drugs? Which drug to taper first?


Altostrata

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I was on Effexor for 6 weeks 15 years ago. For me, it was a huge accelerator. I had so many side effects on that drug I just stopped taking it. Back then, I didn’t know any better.  Now I know tapering is definitely  necessary. A 10% taper every 4 weeks MAY work for you, if you are one of the lucky ones. Just listen to your body and respect what is telling you. If it were my choice, tapering Effexor first would be it.  So few people are on Buspar. This is the first time I have read anything about it here, though you could search for others’ experiences. I hope you can “ chip away” at Effexor steadily and with w/d symptoms relatively controllable. 

 

Grace

 

 

 

amitriptyline from 1980-2002, along wi/ intermittent, infrequent use of benzos over 2 decades

2002-2010 Klonopin 1-2 mg., ambien 10--20, mg, remeron 4 mg. and  trileptal 300 mg

2011 Stopped ambien and crossed over to valium 17.5 mg. (updosing 2.5 mg. to cover ambien C/T ) tapered valium w/ long holds to 12.74 mg.

2015-present  tapered from 300 mg. trileptal to 113 mg.;  12.74 valium,  4 mg. remeron

 

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ADMIN NOTE This topic is a general discussion about how to decide which drug to taper first. For case-by-case consideration of what YOU should do, please put your questions in an Introductions topic.

I know people who are on cocktails of meds, and not feeling any better. From the knowledge I gained here I really see how dangerous these cocktails are. These doctors will take a patient off of one

I understand all of this but have one question as it relates to gabapentin and ssri’s. If you have a super long taper in front of you off the ssri, would it be wise to get off gabapentin first because being on it will prevent your nerves from healing(and thereby increase your likelihood of akathisia?).

 

1992 Prozac 60 mg - on and off since, currently on 60mg

2000 Gabapentin 600-3600, currently on 1200mg

January, 2014 Oxycodone 10-40mg, currently 30mg

March, 2012  Cortef 15mg

March, 2012 Liothyronine 110mcg

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Please read this topic from the beginning. Gabapentin is a "brake."

 

Your assumption that gabapentin is worse for your nerves than an SSRI is incorrect. It is no better or worse. As gabapentin is a "brake," going off gabapentin first might increase potential for activation or akathisia when you go off the SSRI.

 

If, however, you are having an identifiable adverse reaction to gabapentin, it may make sense to reduce gabapentin first.

 

Please put questions about your own specific situation in your Introductions topic, as discussion about it will take this thread off-topic.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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  • 5 months later...

“Anyway, I think I figured out from "alternative" sources that my AD was interacting with my benzo, so stopping the AD made the benzo metabolize faster. So it was like a dosage cut, even though the dose was the same. I have maybe 80% recovered from that now. So I did a quick goggle on your drugs...even a mainstream source said both those ADs have moderate potential to interact with your benzo. So you probably had a really significant drop in your benzo level once the ADs got out of your system. Just something to think about.”

 

Bubble posted this a year ago and I agree wholeheartedly. In my case my anticonvulsant was inducing my benzo and remeron, almost completely wiping out their sedating effect, which I sorely need. I know this because after reducing oxcarbazepine by 50%, I am sleeping 50% better. These drug cocktails are extremely complex. Trial and error, attention to symptoms and trying to connect your own pattern is very important. Study up on your drugs. Look up interactions, but more specifically induction and inhibition. It is technical and hard to understand at first but once you do it all makes sense.  Now this lop-sided tapering of one drug has its downside, but I will post that in my own thread. The point is, drug interactions/clearance or lack of  matters just as much as whether they are brakes or accelerators. 

 

Grace

Edited by ChessieCat
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amitriptyline from 1980-2002, along wi/ intermittent, infrequent use of benzos over 2 decades

2002-2010 Klonopin 1-2 mg., ambien 10--20, mg, remeron 4 mg. and  trileptal 300 mg

2011 Stopped ambien and crossed over to valium 17.5 mg. (updosing 2.5 mg. to cover ambien C/T ) tapered valium w/ long holds to 12.74 mg.

2015-present  tapered from 300 mg. trileptal to 113 mg.;  12.74 valium,  4 mg. remeron

 

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4 hours ago, savinggrace said:

attention to symptoms and trying to connect your own pattern is very important.

 

Keep Notes on Paper

So close to the end!!!

🏁

Current from 16 October 2021:  Pristiq 0.005mg

ADs since ~1992:  25+ years - 1 unknown, Prozac (muscle weakness), Zoloft; citalopram (pooped out) CTed (very sick for 2.5 wks a few months after); Pristiq:  50mg 2012, 100mg beg 2013 (Serotonin Toxicity)  Tapering Oct 2015 

My full tapering program     My Intro (goes to my tapering graph)    My website

PLEASE NOTE:  I am not a medical professional.  I provide information and make suggestions.

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  • 4 weeks later...
On 5/4/2012 at 11:34 AM, Altostrata said:

ADMIN NOTE This topic is a general discussion about how to decide which drug to taper first. For case-by-case consideration of what YOU should do, please put your questions in an Introductions topic.
 
Do not put those questions in this topic, because detailed discussion of YOUR particular circumstances will take it off track and make this topic difficult for others to follow. The moderators will move any questions about YOUR particular case to the Introductions forum. Thank you.

 

For tips about tapering individual drugs, see Important topics in the Tapering forum and FAQ


 

Polypharmacy complicates tapering. Which drug to taper first?

Consider discussing the following considerations with your doctor.

 

You are having adverse effects from one or more of the drugs

Any drug causing a serious life-threatening adverse effect should be discontinued as soon as possible. Talk to your doctor about this immediately.

 

"Accelerators" and "brakes"
If no one drug is clearly causing an adverse effect, "discontinue the more activating drugs first," I have been advised by a doctor who studies withdrawal syndromes and iatrogenic damage.

 

Antidepressants and ADHD drugs (most are amphetamine analogs) tend to be activating drugs, causing jitteriness, anxiety, or sleeplessness.

 

Benzodiazepines, the "Z" drugs for sleep, anticonvulsants (such as lamotrigine), Lyrica, gabapentin (Neurontin), and antipsychotics tend to be regulating or sedating drugs, causing drowsiness, sluggishness, or dopiness.

 

The two types of drugs can be thought of as "accelerators" and "brakes."

 

Many people have a sedating drug -- a brake -- added to an activating drug -- an accelerator -- to treat drug-induced anxiety or sleep problems.

 

In those cases, unless you are having clear adverse reactions from a particular drug, taper the antidepressant or stimulant first. Otherwise, you will experience activation from the other drug as you decrease the "brake."

 

"Brakes" may temper withdrawal symptoms

The most common and significant antidepressant withdrawal symptoms are nervous system activations (indicating a too-fast taper): hyper-alerting, sleeplessness, abnormal anxiety, agitation, etc.

Withdrawal sleeplessness is a symptom you want to avoid. It makes tapering much harder and post-withdrawal syndrome more difficult to recover from.

If you reduce the accelerator while taking a sedating drug, the sedating drug may help alleviate the activation of withdrawal. You may plan to taper the sedating drug later.

BUT -- Don't add a "brake" to your cocktail to prepare for withdrawal
Do not increase your risk of neurological damage by increasing your polypharmacy. Adding drugs may conflict with a drug you're already taking.

The sedating drugs also will need tapering, and can incur a withdrawal syndrome of their own.

THE PROPER WAY TO MINIMIZE WITHDRAWAL EFFECTS IS TO TAPER AT A SLOW ENOUGH RATE FOR YOUR NERVOUS SYSTEM.

Benzos are addicting! Why not quit the benzo first?
Yes, benzos are defined as truly addicting drugs. But when it comes to withdrawal, the physical dependency incurred by other psychiatric drugs makes the concept of "addiction" moot.

Psychiatric drugs that are technically non-addicting can be just as hard to go off, and some cause much more physical damage than long-term benzos.

I am not minimizing at all the difficulty of a benzo taper or the seriousness of benzo dependency. We are in the disgusting situation of always having to evaluate the least bad choice. I know many people are anxious to get off benzos once they find they're addicted, but even though ADs are not technically addictive, severe antidepressant withdrawal syndrome is just as bad.

When you are taking an antidepressant and a benzo, if you are not having significant adverse effects from the benzo, consider tapering the antidepressant first for these reasons:

  • Antidepressants are activating while benzos are sedating. The action of the benzo can soften the suffering from antidepressant withdrawal symptoms.
  • Conversely, a concurrent antidepressant will not reduce withdrawal symptoms during a benzo taper. With all due respect, Prof. Heather Ashton's suggestion antidepressants might help is misguided, see http://survivingantidepressants.org/index.php?/topic/1510-ashton-manual-recommendation-of-antidepressants/page__view__findpost__p__14205

    In Dr. Stuart Shipko's e-book Xanax Withdrawal (2012), he addresses the Ashton Manual's apparent recommendation of antidepressants to counter benzo-withdrawal depression, see http://survivingantidepressants.org/index.php?/topic/1510-ashton-manual-recommendation-of-antidepressants/page__view__findpost__p__28759
  • Often, benzos are prescribed to cover up adverse effects, such as anxiety, insomnia, and akathisia, from an antidepressant. When you remove the benzo, the antidepressant's adverse effects come to the forefront. You then may be in such distress, it is difficult to taper the antidepressant slowly enough to forestall severe withdrawal symptoms.
  • Benzo withdrawal before antidepressant withdrawal increases the risk of a difficult antidepressant withdrawal.

    Going into an antidepressant taper with GABA downregulated by prior benzo withdrawal is a very perilous strategy. Your nervous system will need GABA to deal with antidepressant withdrawal symptoms.

    You may more easily control an antidepressant taper. Fast recovery from antidepressant withdrawal will enable you to tackle your benzo taper.

    The people who have the worst withdrawal syndrome are those suffering from both benzo withdrawal and antidepressant withdrawal, because two systems -- serotonin and GABA -- that might help them recover are not functioning due to downregulation.
  • If you have already done the hard work of getting off a benzo and then suffer severe withdrawal syndrome from the antidepressant, you are faced with the decision of whether or not to get on the benzo merry-go-round again.

    Many doctors treat antidepressant withdrawal symptoms with benzos, although that brings in a whole other set of problems, which you know well. Still, many people can't get through withdrawal without an occasional benzo dose. Consider using benzos very, very sparingly.

And then there are antipsychotics...
To make this a little more confusing, if you are taking an antipsychotic, e.g. Seroquel or Risperdal, you may wish to discontinue that first, because of serious adverse health effects from antipsychotics, such as diabetes.

However, if you're taking an antipsychotic to counter an adverse effect of an antidepressant, such as sleeplessness or agitation, you may want to discontinue the antidepressant first.

Conceivably, one might systematically lower the antidepressant part way, then lower the antipsychotic. If sleep doesn't break up, continue to get off the antipsychotic. If it breaks up, stop lowering the antipsychotic, stabilize, and lower the antidepressant, managing the tapers in a way that preserves sleep.

Before tapering, be sure to discuss the above with your knowledgeable medical caregiver.

 

I have found my SSRI taper to be much more severe than my benzo taper. 

I tapered klonopin 1.5 - .25 mg smoothly over many months. I am on 6 mg of Celexa and my discontinuation symptoms have been hellish.  I was put on a mood stabilizer Lamictal or lamotrigene 150 mg. Is Lamictal a brake drug or an activator in this context?

Citalopram 2 mg

Clonazopam .25 mg

Lamotrigine 150 mg

 

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On 4/20/2019 at 1:12 PM, JB1234 said:

I am on 6 mg of Celexa and my discontinuation symptoms have been hellish.  I was put on a mood stabilizer Lamictal or lamotrigene 150 mg. Is Lamictal a brake drug or an activator in this context?

 

Here is information about Lamictal.

So close to the end!!!

🏁

Current from 16 October 2021:  Pristiq 0.005mg

ADs since ~1992:  25+ years - 1 unknown, Prozac (muscle weakness), Zoloft; citalopram (pooped out) CTed (very sick for 2.5 wks a few months after); Pristiq:  50mg 2012, 100mg beg 2013 (Serotonin Toxicity)  Tapering Oct 2015 

My full tapering program     My Intro (goes to my tapering graph)    My website

PLEASE NOTE:  I am not a medical professional.  I provide information and make suggestions.

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My reply is not working through email I tapered off clonazopam first

Citalopram 2 mg

Clonazopam .25 mg

Lamotrigine 150 mg

 

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  • 5 months later...

Anyone knows how to taper biperiden 4mg extended release? 

Abilify from 20 mg to 10 mg-Nov.29,2017 to March.24,2019; Abilify 10 mg March.24,2019 to Sep.26,2020; 9,4ml Sep.27,2020;9,8ml Sep.29,2020;9,6ml Oct.17,2020;9,4ml Oct.30, 2020;9,2ml Nov.15,2020;9ml November 25th,2020;8,8ml December 16th,2020;8,6ml December 30th,2020;8,4ml January 13th,2021;8,2ml February 2nd,2021;8ml February 25th,2021;7,8ml March 17th,2021;7,6ml April 6th,2021;7,4ml April 18th,2021;7,2ml May 4th,2021;7ml  May 26th,2021;6,8ml June 6th,2021;6,6ml July 5th,2021;6,4ml July 21st,2021;6,2ml July 31st,2021;6ml August 13th,2021;5,8ml August 31st,2021;5,6ml September 16th,2021;5,4ml October 1st,2021;5,2ml October 15th,2021

Cymbalta 120 mg Jun.28,2011; 90mg Feb.19,2013 to Jun 5,2014;60 mg Jun.5,2014 to present

Klonopin 1,25 mg Jan.3,2016; 0,25mg Nov.28,2017 to present

biperiden extended release 4mg April.25,2008 to Feb.6,2009;Jun 24.2011 to present

Risperidone 2mg May.4,2017 to Dec 6.2019

Risperdal 1,5mg 12/06/19; 1,75mg 12/08/19; 1,5mg 12/20/19; 1,75mg (0,018g) 12/26/19

Risperidone 1,75ml 1/8/20; 1,70ml 1/18/20; 1,62ml 1/30/20; 1,54ml 2/29/20; 1,44ml 5/6/20; 1,42ml 5/7/20; 1,40ml 5/18/20; 1,30ml 6/1/20; 1,25ml 6/11/20; 1,12ml 7/5/20; 1ml 7/21/20; 0,96ml 8/16/20; 0,875ml 8/18/20; 0,86ml 8/28/20; 0,80ml 3/24/21;0,84ml 3/27/21; 0,86ml 4/4/21

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When deciding whether to taper pregabalin or mirtazapine first - I find that the mirtazapine is by far the more sedating (at 3.75mg). Pregabalin seems to have very subtle effects, and certainly doesn't make me sleepy unlike the mirtazapine. Hence would this be the more activating drug?

Slowly getting better from multiple drug changes. Holding at 20mg fluoxetine, 150mg pregabalin, 3.75mg mirtazapine until I work through some personal issues.

 

 

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@Emphyrio , you have to take your entire set of drugs into account.

 

We don't rank the drugs according to how sedating they are, what's important is the effect they have in YOUR cocktail -- which is extensive. This is the reason we ask people to post such questions in their own Intro topics, where we can see the context of earlier drug changes, interaction reports, etc.

 

Please post questions about what YOU should do in your Intro topic.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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I think she was asking is pregablin an accelerator and mirtazapine a brake?  (Or is that not current thinking any more?) That said, this really is impacted by drug interactions so the question is  almost impossible to answer as interactions are unpredictable, especially from one person to another. It’s anybody’s guess what is going on when there are two or more drugs. 
 

Grace

amitriptyline from 1980-2002, along wi/ intermittent, infrequent use of benzos over 2 decades

2002-2010 Klonopin 1-2 mg., ambien 10--20, mg, remeron 4 mg. and  trileptal 300 mg

2011 Stopped ambien and crossed over to valium 17.5 mg. (updosing 2.5 mg. to cover ambien C/T ) tapered valium w/ long holds to 12.74 mg.

2015-present  tapered from 300 mg. trileptal to 113 mg.;  12.74 valium,  4 mg. remeron

 

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  • 11 months later...

Hi guys, I was hoping someone on here could help me please?

 

I was put on Zyban  300mg ( Bupropion ) in July as I had a breakdown and kinda had no choice but to start a antidepressant.  I had over the years been using Zoplicone for sleep as I am an athlete and need my sleep so I used this off and on for 5 years until last year when I started to feel sick every time I took it then without knowing I ended up creating a reliance on it and we think thats why I ended up having a breakdown as I was most likely experiencing major withdrawls. 

 

To help they said with the bupropion side effects I was told to use Diazepam & this would also help me with the benzo problem I had with Zoplicone. After 4 weeks of using 6mg of Diazepam I started tapering and of course have gone way to fast. I have had on & off withdrawls about 5 times now over 4 months and I am currently at 1.15mg and struggling big time.

 

The main problem I have now is sleep. I can't sleep anymore with the lower doses of Diazepam and taking the full 300mg of Bupropion. I have major dry mouth at night that keeps waking me up. I may get at best 1-2hrs a night now. I also am having major headaches at the end of the day & stomach problems as side effects.

 

After reading more on here the consensus seems to be to taper the AD as its an upper first and leave the benzo ( The brake they called it ) to last. I am starting to agree as my sleep has got worse the lower I reduce the Diazepam.

 

Question 1 -

 

Problem I have in NZ is they gave me Zyban SR 150 twice a day which I understand is more used for smoking. This is the only product we have in our country. I need clear advice as to weather Zyban SR & Wellbutrin SR are exactly the same drugs & release etc as the links on here are mainly talking about Wellbutrin for taper.

 

Question 2 - Can you cut Zyban 150mg to use for tapers & does it stay as SR or change to IR ? Meaning once cut it becomes instant release to be taken 3 times a day?

 

Question 3 - Can someone confirm that its best advised to hold the benzo for now & taper the Zyban first & does the side effects such as sleeplessness improve once lowered?

 

Thanks for the help so far too. Your a gem guys

 

2015 - Started Zoplicone for sleeping off & on for 5 years ( No more than a week to 10 days at time )

2016 - Stared Thyroxine as I have Hasimotos Hypothyroid ( Still taking today 25mg )

2019 - Problems with Zoplicone started, Tried Temazepham with same problems

2020 - June - Had massive problems with trying different medications and had a breakdown

2020 -  July - Started 6mg Diazepam to help with side effects of Zyban ( Bupropion ) 300mg  

2020 - August - Started Diazepam taper as I have a dependence to Benzo's ( Funny that after they said zoplicone was not a benzo...)

2020 - Oct - 1.2mg diazepam ( Have had 5 major withdrawls since Aug )

 

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@johnnyj

@savinggrace

 

Your discussion (16 posts) have been moved to Johnnyj's Introduction topic.

 

Please see my post here.

So close to the end!!!

🏁

Current from 16 October 2021:  Pristiq 0.005mg

ADs since ~1992:  25+ years - 1 unknown, Prozac (muscle weakness), Zoloft; citalopram (pooped out) CTed (very sick for 2.5 wks a few months after); Pristiq:  50mg 2012, 100mg beg 2013 (Serotonin Toxicity)  Tapering Oct 2015 

My full tapering program     My Intro (goes to my tapering graph)    My website

PLEASE NOTE:  I am not a medical professional.  I provide information and make suggestions.

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  • 4 months later...
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getofflex

What if someone is on two activating drugs, for example, Prozac and Wellbutrin?  Assuming they have no adverse effects from either of the drugs? 

***Please note this is not medical advice.  Discuss any decisions about your medical care with a doctor who understands psych meds and how to withdraw from them, if you can find one.

Lexapro   Started Apr 15 '02 - 10 mg;  Apr 2 '20  0.18 mg; Jul 16  0.17 mg, Aug 23  0.16 mg, Oct 7  0.15 mg, Nov 8 - 0.14, Jan 16 '21 - 0.13, Feb 7 - 0.12, Feb 22 - 0.11, Mar 26 - 0.10, May 21 - 0.09, June 15 - 0.08 Aug 16 - 0.07, Oct 6 - 0.06 

Ibuprofen 800 mg, or Tylenol 1000 mg as needed

other meds: Levothyroxine 75 mg

Trazodone nightly, stopped in late 2019

Xanax on occasion, stopped in late 2019

magnesium in small amounts at breakfast, 3 PM 

suppl AM: fish oil, flax oil, vit C, vit E, calcium

suppl PM: magnesium 350 mg, GABA 750 mg, Estroven, melatonin 2.5 mg

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ChessieCat

Just some of my thoughts.

 

You check for side effects and drug interaction.  If the person had taken one of the drugs by itself and knows how it affects them then they might reduce the one that was started afterwards especially if they know that their sleep was okay on the single drug.

 

From https://www.drugs.com/:

 

Common Wellbutrin side effects may include:

  • dry mouth, sore throat, stuffy nose;

  • ringing in the ears;

  • blurred vision;

  • nausea, vomiting, stomach pain, loss of appetite, constipation;

  • sleep problems (insomnia);

  • tremors, sweating, feeling anxious or nervous;

  • fast heartbeats;

  • confusion, agitation, hostility;

  • rash;

  • weight loss;

  • increased urination;

  • headache, dizziness; or

  • muscle or joint pain.

 

Common Prozac side effects may include:

  • sleep problems (insomnia), strange dreams;

  • headache, dizziness, drowsiness, vision changes;

  • tremors or shaking, feeling anxious or nervous;

  • pain, weakness, yawning, tired feeling;

  • upset stomach, loss of appetite, nausea, vomiting, diarrhea;

  • dry mouth, sweating, hot flashes;

  • changes in weight or appetite;

  • stuffy nose, sinus pain, sore throat, flu symptoms; or

  • decreased sex drive, impotence, or difficulty having an orgasm.

 

In the case of Prozac and Wellbutrin because of the interaction is might be worth considering reducing one for a while and then reducing the other for a while.

 

When the Wellbutrin is reduced whilst taking fluoxetine then because it increases the effect of fluoxetine it might need to be reduced by less than 10%.

 

As with reducing any drug/s symptoms would need to be monitored.

 

From https://reference.medscape.com/drug-interactionchecker

Serious - Use Alternative

  • fluoxetine + bupropion

    fluoxetine increases toxicity of bupropion by unspecified interaction mechanism. Avoid or Use Alternate Drug. May lower seizure threshold; keep bupropion dose as low as possible.

Monitor Closely

  • bupropion + fluoxetine

    bupropion will increase the level or effect of fluoxetine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor.

So close to the end!!!

🏁

Current from 16 October 2021:  Pristiq 0.005mg

ADs since ~1992:  25+ years - 1 unknown, Prozac (muscle weakness), Zoloft; citalopram (pooped out) CTed (very sick for 2.5 wks a few months after); Pristiq:  50mg 2012, 100mg beg 2013 (Serotonin Toxicity)  Tapering Oct 2015 

My full tapering program     My Intro (goes to my tapering graph)    My website

PLEASE NOTE:  I am not a medical professional.  I provide information and make suggestions.

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getofflex

@ChessieCatthanks for the info. I'm going to copy and paste it to Babs65 for her perusal, and recommend she taper the Wellbutrin first per your PM.  Thanks for the help! :)

***Please note this is not medical advice.  Discuss any decisions about your medical care with a doctor who understands psych meds and how to withdraw from them, if you can find one.

Lexapro   Started Apr 15 '02 - 10 mg;  Apr 2 '20  0.18 mg; Jul 16  0.17 mg, Aug 23  0.16 mg, Oct 7  0.15 mg, Nov 8 - 0.14, Jan 16 '21 - 0.13, Feb 7 - 0.12, Feb 22 - 0.11, Mar 26 - 0.10, May 21 - 0.09, June 15 - 0.08 Aug 16 - 0.07, Oct 6 - 0.06 

Ibuprofen 800 mg, or Tylenol 1000 mg as needed

other meds: Levothyroxine 75 mg

Trazodone nightly, stopped in late 2019

Xanax on occasion, stopped in late 2019

magnesium in small amounts at breakfast, 3 PM 

suppl AM: fish oil, flax oil, vit C, vit E, calcium

suppl PM: magnesium 350 mg, GABA 750 mg, Estroven, melatonin 2.5 mg

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