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Ollie, Ollie Oxen Free, Managing The Endgame Taper

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brassmonkey
Posted (edited)

I AM IN THE PROCESS OF REWRITING SECTIONS OF THIS POST TO INCREASE THE CLARITY

 

Ollie, Ollie Oxen Free: Managing the Endgame Taper

By Brassmonkey

 

Ollie, Ollie, Oxen Free, the cry that indicated that the game of Hide and Seek was ending and all those who had not been found could return to base without being “caught”. It was a good way to end a game that was far flung and could have a large number of players.  When you heard that cry you knew it was safe to come out of hiding and return to the “normal world”.  Not all Endgames are quite so easy, but by following established patterns the wrap up can go fairly smoothly.

 

Dealing with a long taper is quite a project but over time it becomes routine and we don’t have to think about it all that much.  Until one day it becomes obvious that it is coming to an end.  Then the question of “when do I make the jump to “0” “comes up. The current wisdom is to go as low as possible in dose strength before making the jump.  Easier said than done as there are physical limits that become involved.

 

As we have been learning how to conduct tapers over the years, it has been determined that the lower the dose the better. There have been many targets thrown out with 0.02mgai being a very common one.  However, because of the different relative strengths of the various medication we deal with this does not apply equally across the board. Also, there is the physical ability of the equipment that we use that needs to be taken into consideration.  For the first part of this article I will be talking about using scales to physically weigh out each dose.  People using liquid medications will be following a slightly different procedure, but the Endgame Taper and the Target Exit Dose are still the same.  We will get into the liquid taper later, but the people using liquids still need to read all the information.

 

As we enter the final stages of a taper what we are now dealing with is referred to as the “Endgame Taper”. It is a different beast and needs to be handled in an entirely different manner. It is being assumed that a person has performed a slow, smooth taper and is not experiencing heavy waves of symptoms. If this is not the case, then other considerations will need to be addressed before the jump to “0” can be made and that is not the focus of this article.

 

When we reach the Endgame portion of our taper all the rules get thrown out the window.  It is no longer possible to follow the recommended 10% strategy.  Because of the physical limitations of the tools we are using we are now required to make reduction in the 25% range and more.  If a person has been following the recommended guideline their symptoms load should be reduced to the point that this makes no difference. 

 

The Endgame Taper

 

When a person is stable and not experiencing extreme symptoms by the time they get to 1mgpw it is time to switch to a more aggressive taper. In general that would consist of reductions of 25%, 33%, 50% and 100%.  Holding at each dose for around six weeks.  Using a hold period of six weeks this will give a total taper time of 18 weeks or three and a half months.  It is important to note that the 1mgpw is a reference point only and does not apply to all drugs.  The actual Target Exit Dose is determined by using percentage of the AIC (Active Ingredient Concentration) and working backward from there to determine the start of the Endgame Taper.

 

 

One very important aspect of the endgame taper is that it is time to switch from concentrating on the dose strength and pay more attention to the dose weight. This is to compensate for the differences in the relative strength of the different medications.  For example, someone could be taking paxil with an AIC (Active Ingredient Concentration) of 0.08 while someone else is taking Zyprexa with an AIC of 0.00005. Making the jump at 0.02mgai is a good target for the person on paxil, but it is way too high for the person on Zyprexa. The target for Zyprexa would be more like 0.000025.  Yes, that is a tiny amount but relatively easy to achieve.

 

The AIC (Active Ingredient Concentration) is the ratio of the strength of the medication to its weight reduced to 1. Sounds tricky, but it’s not.  The AIC is calculated by dividing the strength in mgai of a whole tablet by the weight of that tablet. I used 40mgai (Milligrams Active Ingredient) paxil tablets that weighted 500mgpw (Milligrams Pill Weight) for my entire taper. Using the above formula, we get:

 

40mgai / 500mgpw = 0.08

 

So, for each 1mgpw of tablet there is 0.08mgai.  This is just an example; the AIC must be calculated for each different medication and tablet. A 40mgai paxil tablet from one manufacturer may weigh 500mgpw, but from a different manufacturer is could be a different weight, and that would change the AIC. As mentioned above Zyprexa can come in a strength of 2.5mgai and have a tablet weight of 30mgpw.  That would give an entirely different AIC.

 

People who are using scales to weigh out their dose should be aware that there is a lower limit that those scales can weigh accurately. That limit is 4mg, or a reading on the display of 0.004g. When this range is being approached it is time to start making the switch from dose strength to dose weight for measuring things.

 

Because of this limitation in the equipment, it now becomes necessary to start to visually divide the dose. This is done by initially weighing out 4mgpw of the tablet and using a sharp object, like a razor blade or craft knife, carefully dividing the pile of powder into four (4) equal parts. This gives 4 piles of approximately 1mgpw each. If you take 3 of those piles you get a 25% reduction in the dose strength from the original 4mgpw.  After several weeks at this level a second reduction  of the original dose is taken by using  two (2) of the piles.  Finally, a third reduction is taken by using just one (1) of the piles. Because this is now a linear taper the percentages increase drastically with each reduction making the second reduction 33% and the third reduction would be 50%.  With the final one being 100% when the jump to "0" is actually made. 

 

This third reduction will give a dose weight of 1mgpw, which corresponds to the weight of the AIC. In doing so the person is now taking a dose strength that is equal to the AIC ratio number.  In my case that was 0.08mgai. But we can go even further, which is a good idea.

 

That 1mgpw can be further visually divided in the same manner.  However, the amount of powder is very small, so it becomes harder to make equal divisions.  From here on each reduction is decreased by 50%.  Again, it shouldn’t be a problem symptom wise as the amounts of the dose are so small. The first reduction would be to cut the pile in half and the second reduction is to cut that pile in half again.  By now the pile is so small it will be almost impossible to make the divisions. It also makes the dose strength so small it’s time to make the jump to “0”.

 

Doing the visual divisions in this manner will yield an Target Exit Dose of ¼ of the AIC. If you skip the final visual division, you would be getting ½ of the AIC as an Target Exit Dose.  Either of these would be an acceptable place to make the jump to “0”.

 

People who are using liquid medications have it a bit better.  Because of their “dilution ratio” it is quite easy to make very small reductions.  This makes it easier to stay with the recommended 10% reduction plan, or what ever percentage that person is using.

 

By making changes to the “dilution ratio” it is easy to make a very small dose volume into something more manageable. For homemade solutions, by doubling the amount of liquid used to make the solution you effectively double the volume of the dose you take, while keeping the dose strength the same. So if you have been making your liquid by dissolving a 10mgai tablet in 10mL of liquid and taking a dose of 1mL you would now dissolve the same tablet in 20mL of liquid and take 2mL to get the same amount of active ingredient.  By having the extra volume to work with it is easier to make very small changes in dose strength or very small doses.

 

The same thing can be done with commercial liquids.  Almost all of them can be diluted with water in the same manner. There will be instructions on making dilutions on the bottle. If you are using a suspension media, such as Oraplus, adding more of the media has the same affect. However, altering a commercial liquid by adding water will decrease the time that the liquid is good for.  Once the water has been added the liquid must be kept in a refrigerator and only can be used for four or five days before it should be discarded.

 

When using a homemade liquid, it is important to pay attention to the AIC ration of the original tablets. This ratio gives you the Target Exit Dose strength you are looking for as your jump off point. In general, ½ to ¼ of the AIC number is a good target to aim for. In any case the smaller the dose the better.

 

The problem comes for the people using commercially prepared liquids, as there is no way to calculate the AIC for them. The numbers required just are not available.  All you can determine is the dilution ratio and that will not translate into a Target Exit Dose. However, buy using the known AIC of tablets it is possible to calculate a good approximation of what the Target Exit Dose should be.

 

For general purposes these calculations come up with 1/35,000 of the original dose. This is not a hard and fast number but will get you a lot closer than just aiming at 0.02mgai across the board. The Target Exit Dose would be calculated by dividing a person’s original full-strength dose by 35,000. So, if a person started to taper while taking 600mgai of a specific drug they would get:

 

600 / 35,000 = 0.017mgai

 

Using this number as a target they can manipulate their dose volume and dilution ratio accordingly to achieve this strength of dose.  Because of the dilution rations and ability to vary the volume of the dose it is possible for them to continue with the 10% recommended schedule or whatever schedule they reduce by until the very end of the taper.

 

This makes it look very favorable to try and switch to using a liquid for the final part of one’s taper.  On the surface it seems like a good idea, but there are always the uncertainties of switching between tablets and liquid that suggest against this.  Having almost completed a smooth, slow, effective taper it is not a good idea to “rock the boat” and try to change things up. Many people can change between the two with no problems, but it requires a careful cross taper that can take many weeks and there is no guarantee that the cross over will be successful.  If not successful this would cause a major setback requiring a second cross taper, months of stabilization and then restarting the original taper.  All in all, it would be quicker to just stick with the original method than to risk destabilizing everything and having to cope with a major delay.

 

We frequently get questions on how to handle the Endgame Taper and I hope this article has answered most of them.  The Endgame is a different time in a taper, and we haven’t paid much attention to it.  By switching from strength-based dosing to weight based dosing it will be easier to make the tiny adjustment required to bring a smooth taper to a successful conclusion.

Edited by brassmonkey
Rewrite in Progress 04/22/2020
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Terry
5 hours ago, brassmonkey said:

The problem comes for the people using commercially prepared liquids, as there is no way to calculate the AIC for them. The numbers required just are not available.  All you can determine is the dilution ratio and that will not translate into a Target Exit Dose. However, buy using the known AIC of tablets it is possible to calculate a good approximation of what the Target Exit Dose should be.

I'm using a commercially prepared sertraline solution, 20 mg/ml.  So I guess I'm mistaken in believing that 20 mg is the AIC?  I have no idea how else to calculate it. 😬

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mdwstrx

@brassmonkey

 

Wow.  Thanks for your time and effort to clarify  the endgame taper. I learned several things tonight after reading the above. 

The fun thing is that it prompted me to look up the phrase Ollie, Ollie, Oxen Free.  I learned that it most likely came from the

German phrase 'Alles, alles auch sind frei' (All,all are also free)! :)

 

Like @Terry above, I'm tapering using a commercially prepared liquid - escitalopram 5 mg/5ml.

 

Assuming I was using a 5 mgai tablet - it seems, according to the above, I should take 5 / 35,000 = 1.42?  Say yes pls.... 🙏

I know that's way off but not sure how else to calculate either... 

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Terry
7 minutes ago, mdwstrx said:

Assuming I was using a 5 mgai tablet - it seems, according to the above, I should take 5 / 35,000 = 1.42? 

The answer I got was 0.00142.  That's a really tiny amount!  😲

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mdwstrx
1 hour ago, Terry said:

The answer I got was 0.00142.  That's a really tiny amount!  😲

 🤭 I much prefer the 1.42. 

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mdwstrx
1 hour ago, Terry said:

The answer I got was 0.00142.  That's a really tiny amount!  😲

I know. Either way seems off. 

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bubbles

I will have to reread this more carefully. I can't weigh a pill, has anyone done this with a 50mg sertraline tablet? (Of any brand, just to give a bit of an idea.)

 

Looking at the proprietary liquid option, which I can't get here, but anyway... I see that starting from my highest point of 100mg and dividing by 35,000 (which is what I think it says) the exit dose is 0.0028. That is very much smaller than I'd intended to go to. From today, at 2.9mg (which is 2.9% of my highest dose of 100mg) it will take 32 months of 10% reductions to get to 0.1mg. When I tell people that I have 2 years to go to taper from my tiny dose, they think I'm nuts. If I continue to go down at 10% per month, making greater and greater dilutions, it will take 5.5 years to get to 0.0028, which seems wrong.

 

Have I read that exit dose calculation correctly?

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brassmonkey

Your close md, but still off by a power of 10. My calculator says 1.42 -4  so it would be 0.000142.  This would round easily to 0.0002 which is 0.2mgai. That is right where you want to be for a Target Exit Dose. Yes, it's an extremely tiny amount.

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brassmonkey

Terry-- the definition of AIC is dose strength divided by dose weight. It only applies to tablets.  In a way what you calculated is an AIC but AIC does not translate between pills and liquids when being calculated. I am starting to compile a database of AICs and Target Exit Doses for various medications and will be adding it to my original post. Once I find someone who has the information for sertraline tablets I can do the calculations.

 

Using the formula I mentioned I am betting a Target Exit Dose of 0.0007g or 0.7mgai.  This is a little high so I would aim for half or a quarter of that 0.375mgai or 0.1875mgai. Those numbers can be rounded up to 0.4 and 0.2.

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brassmonkey

Bubbles-- that looks about right. My numbers come up a little different but, using that approach will take over five years starting at 2.9mgai.  Which is why we are advocating switching to a weight based taper instead of a percentage based taper when a person reaches 1mgai. This number depends on  which medication is being tapered, as I pointed out in the article zyprexa would be much lower, making working with the AIC so important.

 

It appears that your question is hypothetical though, as you are actually using 50mgai tablets for your taper. Is this correct?

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Terry
20 hours ago, brassmonkey said:

Using the formula I mentioned I am betting a Target Exit Dose of 0.0007g or 0.7mgai. 

@mdwstrx @bubbles This would take me another 5+ years of tapering.  Then I'd have the alprazolam (xanax) taper, another 4 years (?) or more.  I'll be well into my 80s by then! 

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brassmonkey

Terry-- that would be true if you continue to use the 10% every four weeks that we recommend for a baseline taper. It will take seven dose half life cycles to get to a reasonable Target Exit Dose.  Which, if all goes well, will be about four or more years.  As I mentioned to bubbles above, this is why we are now advocating switch to a different strategy for the Endgame. 

 

If a person is stable and not experiencing extreme symptoms by the time they get to 1mgai it is time to switch to a more aggressive taper. That would consist of reductions of 25%, 33%, 50% and 100%.  Holding at each dose for around six weeks. This will give doses of 0.75mgai, 0.5mgai 0.25mgai and finally the jump to "0". Using a hold period of six weeks that will give a total taper time of 18 weeks or three and a half months.

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mdwstrx
1 hour ago, brassmonkey said:

If a person is stable and not experiencing extreme symptoms by the time they get to 1mgai it is time to switch to a more aggressive taper. That would consist of reductions of 25%, 33%, 50% and 100%.  Holding at each dose for around six weeks. This will give doses of 0.75mgai, 0.5mgai 0.25mgai and finally the jump to "0". Using a hold period of six weeks that will give a total taper time of 18 weeks or three and a half months.

 

@brassmonkey

 

Withdrawing my question.  :) I just noticed the new heading indicating

that you're rewriting sections of the original post for clarity.

Thank you.

Md🌷

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Jmizz

@brassmonkey

 

so I take my doses mixed in water off of a 25mgai tablet of lamotrigene. So based off what you’re saying, once I got to around 1mgai I would need to switch to weighing for the accelerated taper at the end? I guess I’m confused as to what makes the 25/33/50/100 different with weight as opposed to just jumping by those percentages off the water solution?

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brassmonkey

Jmiss-- that's part of what I'm in the middle of rewriting.  The directions for handling the taper were inadequate so I'm in the process of reworking them, it will take a couple of days.

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Jmizz

@brassmonkey

thank you man.

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bubbles
On 4/22/2020 at 3:34 AM, brassmonkey said:

It appears that your question is hypothetical though, as you are actually using 50mgai tablets for your taper. Is this correct?

 

Yes and no. :) I'm currently using compounded capsules. The pharmacy, I believe, grind up tablets and put them in capsules in the correct amount. I was preparing to switch over to tablets in a suspension fluid. I've got everything I need (the fluid had to come from the US which took a while). My plan had been to do a trial run while I had plenty of capsules left but I was rather stressed by all the virus stuff so I shelved the idea for a few weeks.

 

I'm just trying to get a feeling for how long this will take. It will take a year to get to 1mg. I'm not sure how to work out the mgpw without an appropriate scale but I imagine 1mgpw is going to be less than that. Perhaps 0.1mg, which will take 33 months to reach. Then another 3 months, if I read all that correctly. So that's another three years. I'd assumed maybe another two years.

 

I have no way to weigh the tablets so I was indeed doing a hypothetical calculation.  However, I've found a possible glitch. In an attempt to find a weight I looked on the regulator's website. I couldn't find a tablet weight, but I found that apparently 50mg tablets actually have 56mg of sertraline hydrochloride listed as the active ingredient. I looked up Zoloft and it looks like that is 55.95mg for a 50mg tablet. I'm going to have to contact the compounding pharmacy an ask them about it.

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bubbles

Ah, @brassmonkey I think I misread and got tangled up in pill weight. Your response above to Terry talks about 1mgai, so a year to get to 1mg and then start the more aggressive taper?  If that's the case, I'm much happier. :)

 

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brassmonkey

Trying to keep all the different measurements straight can be a real trick a times Bubbles.  The part I am rewriting is to help clarify when a liquid taper should switch to the larger reductions and a schedule of what those reductions should be. the whole idea of the Endgame Taper is to tie things up in a fairly rapid manner because the standard way of doing it would take so long and really isn't necessary. A rough guess is that starting from the 2.8mgai you are currently taking you should be totally off in nicely under two years.

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bubbles
4 hours ago, brassmonkey said:

A rough guess is that starting from the 2.8mgai you are currently taking you should be totally off in nicely under two years.

 

That's a huge relief, thank you for clarifying. 

 

I'm hoping to finish my taper with regular tablets and managing it myself. My earlier intention had been to go down in 0.1mg stops below 1mg but given that Sertraline is a 'weaker' med (50mg as a standard dose vs 10mg for escitalopram), perhaps it isn't necessary.

 

All that said, I need to contact the pharmacy and find out what dose I'm really on (that 50/56mg thing). 

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hayduke

@brassmonkey Thanks for writing up this guide.  I'll refer back later once you've got your edits in.

 

It's timely for me, I can feel the gate opening at these lower dosages lately and have been starting to think about a smooth landing.

Handy that I've been doing liquid titration the whole time.

Cheers

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Gertie

@bubbles @brassmonkey Here's some sertraline data.  My daughter is on 50mg Cipla brand of sertraline. Each tablet weighs approx 160mg. 

So the AIC would be 50/160 = .3125mg.

Jump-off targets vary depending on method used:

1/2 AIC = .156mg

1/4 AIC = .08mg

1/35000 start dosage = 50/35000 = .00142.

 

Brass Monkey, in your example you showed that a starting dose of 600mg would have a target jump-off of 600/35000 = .017mg.  Also with Bubbles you converted 100/35000 = .00285mg.  Yet in some of your answers to people above, you are saying the answer is in grams, and then you are converting it to mg (example: md 5/35000 = .000142g, converted to .0142mg.  Or Terry .0007g, converted to .07mg (althoughI think you put .7mg).  How do we know when the answer is supposed to be in grams and then converted, and when it is supposed to be in mg?

 

I know you are re-writing, so if this will be addressed then please disregard.  I still wanted to give you the sertraline info, so figured I'd ask while I'm here.

Thanks!!

 

ps: Just realized we also have 25mg Zoloft brand tablets.  Each weighs right about 80mg.  So the AIC seems pretty consistent between those two brands.

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brassmonkey

Gertie-- thank you for the information it's a real help.  Yes I am working on rewriting those sections, there are so many numbers in a lot of different combinations that it was getting too confusing.

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Tattycorum
Posted (edited)
On 4/26/2020 at 1:31 AM, Gertie said:

@bubbles @brassmonkey Here's some sertraline data.  My daughter is on 50mg Cipla brand of sertraline. Each tablet weighs approx 160mg. 

...we also have 25mg Zoloft brand tablets.  Each weighs right about 80mg.  So the AIC seems pretty consistent between those two brands.

My sertraline tablets measured out as 

25 mg pills: average weight 0.077 g = 77mg

100 mg pills: average weight 0.311 g = 311 mg

 

Hope this help!

 

Edited by Tattycorum
error

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brassmonkey

Thanks Tatty-- that is helpful information, I'll be using it in the rewrite that is coming soon.

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hayduke

@brassmonkey

 

For your records:  I weighed a 2.5mg tablet of generic olanzapine from Alphapharm branded Zypine at 0.103 grammes.  IIRC other pills in the same class vary from 0.95 or so up to 0.104g or so.  I'd hope the active ingredient remains consistent at least.  If it's useful to you I'll update later with more info as I get through them.  There is another brand of generics here as well but I'll wait till this brand has run out before opening those.

 

My most accurate scales measure grammes to three decimal places, so around 2% dosing precision is the most I could expect with these pills weighing them dry.  Making a liquid suspension gives me another order of magnitude or so more precision. 

 

Cheers

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brassmonkey

Thanks Hayduke that's very helpful.  Yes, as you get more information please pass it along.

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hayduke
On 5/17/2020 at 2:47 PM, brassmonkey said:

Thanks Hayduke that's very helpful.  Yes, as you get more information please pass it along.

 

I've weighed another three or four of that same Alphapharm generic since and they're all 0.103 or 0.102 once they settle.

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