eoxb: Hey there

[eoxb]

Hi all,

my name is Bart, I've been on Sertraline (zoloft) only for 3 months or so, including a bout with Alprazolam as well -- and I discovered this place after a pretty harsh day when I stopped abruptly. Being the engineer that I am, I've browsed in deep detail the the tapering-related discussions and specifically the ones about calculating the curve based on the "famous 2019 Lancet Horowitz paper".

 

I'm 80% of the way in building an excel spreadsheet that models their recommended approach, slows it down some, and applies it to Sertraline thanks to other papers' SERT occupancy curves. The Lancet paper suggests a linear decrease of the target occupancy ratio; which I'm adapting so that this decrease would further slown down with each step down the curve (in line with the general reco "go slower when you get lower") -- basically I want to be more prudent than them.

 

In this model, the actual dosage ends up following a power-law that is much slower than "-10% based on initial dose", but quite a bit faster than "-10% based on previous dose", resulting in a 5-to-6-month tapering duration for a starting point (prescription) of 50mg Sertaline.

I still have a few knacks to iron out, and it will be ready for sharing (and can easily be adapted for other molecules and/or other desired tapering speed).

 

Any advice or thoughts are welcome!

[Go2zero]

Hi eoxb,

 

Welcome to this support site. Before we can answer your questions, please give us more information first. 

 

Can you please give us specific information about your drug history for all drugs you are on and have been on, especially for the past 18-24 months?  It would be especially helpful to have the details of your drugs in a concise list (no symptoms), only drug names, specific dates (as best you can say for example early March if you don't recall the day) and dosages of each medication decrease or increase.  Please read the link below for instructions.  This will allow us to give you the best guidance.  

 

https://www.survivingantidepressants.org/topic/18343-please-summarize-your-withdrawal-history-in-your-signature/

 

Interesting to read your ideas about tapering. In my opinion there is not 1 best method how to taper. In the end everybody reacts differently. Some can taper 20% per month based on the last dosage. Others only 2%....

 

We always advise to taper not more than 10% of the last taken dosage. Which might even be too  fast for some.

 

The best compass is always to listen very careful to ones body and mind... 

 

But if you find something worthwhile sharing, please let us know. We are all open for learning more...

 

 

Here is some information  that might be interesting:

 

https://www.survivingantidepressants.org/topic/6036-why-taper-sert-transporter-occupancy-studies-show-importance-of-gradual-change-in-plasma-concentration/

 

https://www.survivingantidepressants.org/topic/1024-why-taper-by-10-of-my-dosage/

 

 

https://www.survivingantidepressants.org/topic/82-the-windows-and-waves-pattern-of-stabilization/

 

 

https://www.survivingantidepressants.org/topic/6632-the-rule-of-3kis-keep-it-simple-keep-it-slow-keep-it-stable/?tab=comments#comment-525233

 

 

Edited August 7, 2021 by Go2zero

[jozeff]

Hi Bart!

 

Welcome. Sound interesting all this. I'm pretty busy trying to figure out the ultimate tapering method myself but don't want to be my own guinea pig...

 

I've been doing 1.5 to 2.5 % per week for 2 years now with some longer holds in between.

 

A 5 to 7 year taper sounds ridiculous.. I am 2.5 years in and have to go a couple of years.

 

Let me know what you come up with, I'm willing to think about it too.

 

Cheers

 

 

Jozeff

 

 

 

 

[eoxb]

Here's where I'm getting at:

 

1. The most discussed tapering methods here are the "10% relative" (= mostly recommended, prudent) and the "10% straight" (= mostly not recommended, fairly aggressive)

Here's how they compare: typically the "10% relative" is 5-6 times longer

(Note- all based on Sertraline 50mg prescription)

 

 

2. Why is the "10% straight" aggressive? The 2019 Lancet paper by Horowitz suggests using SERT Occupancy ratio as a proxy for dose-response, providing evidence (well, proxy evidence) that doses must decrease slower and slower while going down. This rules out the "10% straight" method, for which the implied decrease in Occupancy is very aggressive especially at the bottom of the curve -- while the "10% relative" approach has a much more gentle effect on Occupancy:

On the flip side though, no science backs the very long tail of the "10% relative" curve.

 

 

3. Interestingly, the 2019 Lancet paper by Horowitz suggests an approach whereby Occupancy ratios could be decreased linearly. This produces a very different pattern for reducing doses, but fundamentally, they remain within the mindset of a "10-step program", and they do not provide evidence for the duration of the steps. This results in a fairly fast tapering overall (same duration as the "10% straight" method), while probably being more gentle on the human response.

 

 

4. My hope, fed by careful reading & intuition (but not by scientific proof!!) is that the same level of comfort can be achieved through a faster tapering, calibrated not with a fixed % value, but leveraging what we know of the Occupancy curves. What I decided to explore, was thus: let's use the 2019 Lancet paper as a basis for "occupancy-ratio-based tapering patterns", and let's build a pattern that ticks the following boxes:

-- Occupancy ratio will decrease slower & slower with time, which is more cautious (I've chosen an exponential decrease)

-- Total tapering duration shall be flexible based on personal preferences (and can be refined through trial and error)

-- Final tapering will take place at a pre-defined Occupancy threshold and not a dose threshold (eg 2.5% Occupancy, flexible)

And here's the shape of this proposal -- in the first graph it is calibrated to result in a 200 days tapering (everything else being equal, this is twice longer than the Lancet's, but almost 3 times less than the "10% relative" approach); in the second graph it is calibrated to 260 days:

I call it a "PowerLaw" approach, because the resulting dosage curve ends up following a pretty neat power law.

(NB- each step is 11-day long in these graphs, which is 9-10x the half-life of Sertraline. This is customizable)

 

 

5. ==> As a conclusion, here is the illustrative dosage curve for the PowerLaw approach (in the first graph: calibrated at ~200 days; in the second graph: calibrated at 260 days), compared with the other 3 main approaches.

 

 

Other comments:

- The slope of the targeted decrease in Occupancy Ratio is customizable, so as to choose a more cautious or more aggressive tapering duration; always respecting a "slower as you go lower" principle.

- Usual caveat: I am not a doctor, and I have not yet tested this approach. It is for now purely theoretical, based on a/ the practical wisdom gathered throughout this website, b/ the key notion that SERT Occupancy ration is the best available proxy for dose-response, c/ some basic math modeling to expand on the Lancet's approach and making it customizable.

 

Next step:

- Making a somewhat user-friendly spreadsheet combining all this!

[Go2zero]

Interesting theory @eoxb . Always good and interesting if we can find better tapering methods.

 

The fact is that we all react differently. In theory you may be right, when you take SERT as a basis to calculate the amounts of tapering. In my personal case your theory may work (partly). For example I have tapered Lexapro down from 10mg to 7,5mg and from7,5mg to 5mg both in 1 step. Also going down further to 2,5 mg went easily and fast. When I went further down it was still going quit OK until I came at 0,7mg. 

From there on tapering became nearly impossible due to extreme heavy WD symptoms. This whole process from 10mg to 0,7 went over years and with longer holds (especially at 2,5 and 0,7mg). But unless these hold tapering under 0,7 mg became a hell!

 

We see much other examples here where members already experience extreme WD in the high SERT regions. For example when they go down from 20 mg Lexapro (SERT 82%) to 10mg (SERT 78%). 

 

As said we all react different. And therefor everybody should listen to his body very carefully. This is eventually our best compass in my opinion.

 

Maybe @brassmonkey can add something to this. He is very experienced in these things.

[brassmonkey]

We actually work quite closely with Mark Horowitz frequently discussing his work and comparing notes on our ideas. 

 

The charts you provide are quite interesting and bear some looking into. My big concern is that SERT Occupancy is only a part of the ADWD experience. It is a useful gage for how much drug is involved and the percentage to reduce it by. The 10% hyperbolic taper we recommend fits the reduction amounts very closely to the SERT curve. So the actual reductions don't cause that much of a shock to the system.

 

There are many other factors involved that require attention during the taper. These drugs affect every system in the body and all their interactions. That is where the timing of a taper comes into play. As we reduce the amount of the drug and the SERT receptors upregulate and start to function again the entire homeostasis of the body is thrown off. It is the realignment of that homeostasis that causes the WD symptoms that we experience.  The body wants to get back to it's natural balance, but there are so many things to adjust it can't do it all at once. Make one small adjustment in this system and it throws another one off, so it needs to be adjusted and so on in a cascade of changes. Only to be repeated again and again as the drug is reduced.  These adjustments take an unpredictable amount of time and need to be accomplished before the next reduction is made. If the reductions come too quickly the body loses control of the changes and chaos prevails. That chaos manifests as a major crash and takes many months to resolve. Once resolved the body is still sensitized to changes requiring even smaller changes and longer time periods for reductions.

 

There are many protocols for reducing these drugs. The one we follow is "Harm Reduction". We try to reduce the drug as quickly as possible while causing the least discomfort to the member. The drugs may be tapered more aggressively, but a price will be paid in the form of increased symptoms. Many people can reduce at a much quicker rate and have no problems. We never see those people.

[jozeff]

Thank you for sharing your thoughts Bart, very interesting.

 

Your powerlaw approach could probably be achieved by tapering 5% per week instead of 2.5 %. You will take the sert Occupancy in consideration and taper much faster. You will still have a long tail off course but I'd rather take let's say 0.5 mg of citalopram  (in my case) and go down from there in a year than rushing and have regrets later.

 

What go2zero says is very important  I think. I crashed big time going from 25 to 18 mg citalopram. Considering the sert Occupancy I should have barely noticed this reduction.

 

My wife tapered sertraline very fast,  30% jump two times, and she never complained about anything. We have to understand our brain and metabolism better to create the perfect tapering method.

 

Also I believe in strong placebo effects. My wife asked me to taper her meds and don't tell her the exact dosage change. If I told her she jumped quite a bit she started feeling off and miserable a couple of days later and blaming her symptoms on the taper.

 

The 30% jump she insisted on doing herself and that time she felt perfectly fine.

 

I appreciate your ideas and look forward to new thoughts Bart.

 

Cheers..

 

Jozeff