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Taking multiple psych drugs? Which drug to taper first?

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savinggrace

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

 

 

 

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GracieAnn

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?).

 

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Altostrata

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.

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savinggrace

“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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ChessieCat
4 hours ago, savinggrace said:

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

 

Keep Notes on Paper

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JB1234
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?

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ChessieCat
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.

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JB1234

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

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Manny78

Anyone knows how to taper biperiden 4mg extended release? 

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