JimCH Use of low dose mirtazapine for sleep aid for 70 year old - and tapering advice

[JimCH]

I was hit with sudden onset/anxiety related sleep issues in October of last year.  Up till that time - other than the typical couple times a night bathroom visits - I did not take any sleep meds.  Occasionally I would use a Benedryl - especially if my sinuses were interfering with my sleep.  My PCP put me some sleep aids - starting with Trazadone and ending with Ambien.  I did not handle them well... though I did get "some" sleep.  I finally saw a neurologist - sleep aid certified - in mid December and he started me on 30 mg of mirtazapine and 10 mg of doxepin to wean me off the Ambien.  That is a lot of stuff - worked well almost immediately and I had minimum side effects - small headache occasionally - increased appetite were the main ones.  I want a plan to taper and he reluctantly gave me one in early January - though he cautioned about moving too fast.  I waited a week and started - Doxepin every other day - when I was down to Doxepin to only a couple a week - then Mirtazapine 15 mg for 2-3 weeks.  So , I ended up taking the Mirtazapine 15 mg for 26 days - then took 7.5 mg for another week.  Once off the Doxepin, I had no side effects with the Mirtazapine. I then stopped everything for 2 weeks it was okay - then it hit me... middle of the night, rapid pulse, can't read or go back to sleep - cold sweats.  So, I finished off my prescription of 7.5 mg pills by taking 7.5mg for a week, then 3.75 mg for a week, then 3.75 mg every other day for a week and finished on Sunday, April 18th.  I slept decently till Friday night - worse Saturday night - 5 hours but early morning same stuff as before - and last night only 4 hours - same stuff in the middle of the night.

 

Okay - sorry for the history - but there appears REALLY good advice here.  Two excellent pharmacists in our Dallas area said if I can get good sleep with a low dose of Mirtazapine, don't worry about get off of it.  On the other hand, perhaps I just need to ride this detox road another day or two or three - I am getting some sleep but when I wake to use the bathroom - usually the second time I can' get back to sleep.  Or restart them and taper much more wisely.

 

I am open for your counsel or questions and thank you in advance.

 

Jim

[Altostrata]

Welcome, @JimCH

 

How are you feeling now?

 

On 4/26/2021 at 11:37 AM, JimCH said:

I waited a week and started - Doxepin every other day - when I was down to Doxepin to only a couple a week - then Mirtazapine 15 mg for 2-3 weeks.  So , I ended up taking the Mirtazapine 15 mg for 26 days - then took 7.5 mg for another week.  Once off the Doxepin, I had no side effects with the Mirtazapine. I then stopped everything for 2 weeks it was okay - then it hit me... middle of the night, rapid pulse, can't read or go back to sleep - cold sweats.  So, I finished off my prescription of 7.5 mg pills by taking 7.5mg for a week, then 3.75 mg for a week, then 3.75 mg every other day for a week and finished on Sunday, April 18th.  I slept decently till Friday night - worse Saturday night - 5 hours but early morning same stuff as before - and last night only 4 hours - same stuff in the middle of the night.

 

We caution people to never skip doses to taper a psychiatric drug. This causes the level of drug in your system to go up and down and may trigger terrible withdrawal symptoms.

 

It was dumb of that doctor to prescribe doxepin and mirtazapine at the same time when a low dose of one alone might have been enough.

 

However, your symptom pattern indicates you have withdrawal from mirtazapine, which would show up a couple of weeks later. Your second attempt at tapering mirtazapine was also irregular. Rebound insomnia is a very common withdrawal symptom.

 

If your symptoms have not gotten better, suggest you reinstate 2mg mirtazapine in liquid form and see how it works over a couple of weeks to quell the withdrawal symptoms. We often see low doses work pretty well. You'd taper off by tiny amounts later, after you stabilize for a while. For background, see Tips for tapering off mirtazapine (Remeron)

 

To help us out, follow these instructions Please put your drug and withdrawal history in your signature You may need to use a computer to do this.

 

Please let us know how you're doing.

[JimCH]

Thank you for your response and advice.  I started back at the 7.5 mg tablets 5 days ago and am working with a local doctor to get it compounded so I can taper more accurately and slowly.  For me, I didn't have any withdrawal symptoms when I tapered before - just by cutting the pills in half... my symptoms only occurred a few days after stopping.  So this confuses me when I am trying to understand how fast to taper.... listen to my own body - etc.  This local holistic doctor said a beta blocker would help with the withdrawal - for the middle of the night "too wired to do anything" that I have experienced now twice.  I have also forwarded him the Tips article.  

 

[Altostrata]

Your withdrawal symptoms from mirtazapine came right on time -- it has a half-life of 20-40 hours, with washout in 4-8 days. Seems you got withdrawal symptoms when the amount of mirtazapine in your bloodstream was quite low.

 

Withdrawal symptoms can sometimes appear weeks after a reduction. We advise people to taper at monthly intervals to allow the bloodstream level to gradually stabilize, before making another reduction. You listen to your body throughout this period. 

 

Your doctor may be interested in 

 

Framer, A. (2021). What I have learnt from helping thousands of people to taper off antidepressants and other psychotropic medications. Therapeutic Advances in Psychopharmacology. https://doi.org/10.1177/2045125321991274

[JimCH]

Thank you again.  I have sent this article to my doctor.  I guess I have two questions:

 

1. Since I have restarted back at the 7.5 mg tablet and did not have withdrawal symptoms during my half and half and half tapering before (only after stopping)... Is it likely that I could taper more quickly by not being on a level for 30 days... but just reducing it by 10% each time... perhaps 2 weeks at a time?  Tapering from 7.5 mg at 10% will take a long time if I drop 10% a month... putting much more of the drug in my system.  

 

2. I had just two days of withdrawal symptoms before starting back on the drug, and didn't try to "ride it out" or use a beta blocker to deal with the rapid heart beat issue.... so, is it possible that I could be one of the 50% or so that might not have lingering withdrawal symptoms?  Is it worth seeing  if this might be the case, then going to the very slow taper if not?

 

No hurry - appreciate VERY MUCH your responses... as I am learning.

 

Jim

 

 

[Altostrata]

On 5/1/2021 at 6:45 AM, JimCH said:

I didn't have any withdrawal symptoms when I tapered before - just by cutting the pills in half... my symptoms only occurred a few days after stopping.

 

You had withdrawal symptoms. They occurred a few days after stopping, which is common. Your subsequent trouble sleeping is a withdrawal symptom sometimes called rebound insomnia.

 

Please don't overthink it. Are you sleeping okay on 7.5mg? Withdrawal symptoms gone? If so, you may want to give your nervous system a rest for a bit before tapering more slowly off the 7.5mg, per Tips for tapering off mirtazapine (Remeron)

 

Follow these instructions: Please put your drug and withdrawal history in your signature 

[JimCH]

I am sleeping well with the 7.5 mg.. withdrawal symptoms went away immediately.  So, I may just following the tapering article (one option) by cutting the 7.5 mg tablets into 4 pieces and just go more slowly... and try to weather the rebound insomnia with beta blockers if needed.  I think this is what my holistic doc wants me to do initially.  Does this make a little sense?