CharlieBrown13: Reducing venlafaxine and escitalopram

[CharlieBrown13]

Dear MirandaN,

thank you very much for your lovely message!  
Of course, that's a topic that worries one very much.  I've been on sick leave for a year and a half now and my boss is very nice in that regard.  But soon I won't get any sick pay either, that's difficult.  
And if the ADs would have helped me well (yes, they did, partly I’m doing better) and didn't have so many hideous side effects, I would take them at the suggested dose, at least for a while.  But unfortunately that's not how it is.  

And like you said, it's our life, our health, our body.  And we have to endure the side effects and withdrawal symptoms.  I hope you will find a dose for yourself that will relieve your muscle and joint pain and muscle cramps without too many side effects.  It's such a fine line to walk.  Anyway, I'll keep my fingers crossed for you!  
 

Warm greetings!

[Altostrata]

11 hours ago, CharlieBrown13 said:

Thank you, and I think you’re absolutely right.

Should I start with 2.5 mg venlafaxine in the afternoon tomorrow?

 

 

My guess is that you really need to separate the escitalopram and venlafaxine doses by some hours, as soon as possible.

 

This is difficult. You may feel terrible however you choose to back out of the serotonergics.

 

How are you taking the venlafaxine now? Still 4 XR mini-tablets, for 50mg per day? Rather than attempt a reduction in venlafaxine now, I'd move 1 of those 12.5mg mini-tablets to noon, taking the other 3 at your usual 8 a.m.-ish with the escitalopram.

 

Suggest you take the metoprolol in between the antidepressant doses, not at the same time.

 

I am hoping this relieves some of the symptom intensity you feel in the first part of the day. Please continue to post daily notes.

 

FYI How to talk to a doctor about tapering and withdrawal? What to expect?

 

[CharlieBrown13]

Yes, I still take 4 XR minitablets venlafaxine 50 mg / d in total.  I had now slowly postponed taking escitalopram to 9:00 am because I no longer wanted to take it together at the same time. 
Should I move the venlafaxine in one step to noon or, for example, half an hour later every day?  I've had so many changes now, I'm a little worried that this will be a big step, four hours later.  

I take metoprolol at least 1 hour away from the other medication.

There’s really a lot of fine adjustment necessary ...

Thank you for your advise!

[CharlieBrown13]

Yesterday I took 2.5 mg of the venlafaxine dose at 10:00 am, the rest at 8.00 am.  I didn't notice a big difference because I've been feeling bad in the mornings for the last five days anyway. Last night I didn't sleep at all, about 4 hours the previous nights.  
Today I have had severe nausea, diarrhea, burning skin, drowsiness, tinnitus, sweating and freezing, anxiety and a derailment of my blood pressure all morning. Could it maybe be a wave of venlafaxine dose reduction?  The last reduction was 4 months ago, on June 29th.

I think I've had severe morning withdrawal symptoms for 5 days now, for whatever reason.  Towards the afternoon it gets a little better, if not as it was 2 weeks ago, for example.  
If both drugs work their max at the same time at noon, I get tachycardia again and my blood pressure goes up again, later in the evening is the best time. That’s why we try shifting some of the venlafaxin to a later date. 
Somehow I'm so so tired of the this.  The whole thing has been going on for a year and a half, first the back pain, the surgery, the severe depression and now this crap that just doesn't end, or at least gets a little bit better.  Forgive me for complaining, unfortunately I don't have more strength today.

[MirandaN]

Dear CharlieBrown13,

Poor you, all symptoms always feel much worse when one has not slept. You must be so exhausted! Maybe you can try to rest a bit, even if you cannot fall asleep? For me it has helped somewhat to do guided qigong breathing exercises as well as yoga breathing exercises (check youtube if you would like to try). Breathing exercises can be done while seated so they do not need to be so exhausting. The severe symptoms are still there, of course, but when I keep returning my attention to the guided exercises and my breath it creates a tiny "window of relief". Or maybe there is some other activity that you think can help you create a "tiny window of relief" for just a short time. Take care today! 

[CharlieBrown13]

Dear Miranda!

it's so nice of you that you think of me, thank you! I'm doing all sorts of things that could possibly do to me right now, meditation, biofeedback, etc.
The irritating thing for me is that I have no idea what triggered that.  Up until a week ago I was doing relatively well and now I feel like I've stopped taking all my medication suddenly.  Which I didn't do.  All these symptoms (tinnitus, chills, burning of the skin, diarrhea, etc.) weren't there last week.  The nervous system seems extremely overstimulated… 
 

How are you doing with your current dose?  Are you getting on with it just fine?  I very much hope you have a reasonably good day, I wish you all the best!  

Charlie

[MirandaN]

I am also still struggling myself, but hopefully things will get better for us both soon! 

[CharlieBrown13]

Dear @Altostrata

Please excuse that I am only now giving an update, I have not been able to think particularly well the last few days.  
As you recommended, yesterday I started the dose reduction of venlafaxine and took 37 mg venlafaxine at 8:00 am, and 9.37 mg at 12:00 noon (equivalent to 75% of a pellet).  Half an hour after taking the tablets, there was burning of the skin, sweating, then freezing, tinnitus, restlessness and slight diarrhea, as well as headaches and muscle twitching.  Blood pressure and pulse are derailed, it was necessary to take additional blood pressure medication several times.  Afternoon flush.  Today was the same, not nice.  Now my question is - what dose should I take tomorrow?  I think that is really a (beginning) serotonin syndrome every day.  Now I sit here, 6 1/2 hours after the noon-dose with burning skin, diarrhea ,muscle twitching and headache.  
Should I skip the lunch dose altogether?  Or reduce in the morning?
The serum levels of venlafaxine and escitalopram will be determined tomorrow morning, but I won't have the result until Monday, but it is clear that I am overdosed. My psychiatrist still thinks I am underdosed, even though I have described all the symptoms to her.
I have one more question. 5 days before the whole thing started, I drank extremely little one day, I just didn't think about it.  Can this be the cause?  It cumulated?

Thank you so much for your help!!

 

[Altostrata]

I am confused about when and what. When was the last dosage reduction, of what drug? What is your current drug schedule?

 

Please keep daily notes of times o’clock you take your drugs, their dosages, and your symptoms throughout the day. We need to know how you feel before and after taking each drug, and your symptoms in between. Post 24 hours of notes at a time in this topic, in a simple list format with time o’clock on the left and notation (symptom or drug and dosage) on the right.

 

5 hours ago, CharlieBrown13 said:

As you recommended, yesterday I started the dose reduction of venlafaxine and took 37 mg venlafaxine at 8:00 am, and 9.37 mg at 12:00 noon (equivalent to 75% of a pellet).

 

I suggested you reschedule the venlafaxine first, before reducing it. Did you do this? When? What happened to the escitalopram, when are you taking that? When did you move it?

 

5 hours ago, CharlieBrown13 said:

The serum levels of venlafaxine and escitalopram will be determined tomorrow morning

 

It's too bad you have to keep seeing this fool. What will blood levels prove? You have the symptoms of excess serotonergic stimulation.

 

5 hours ago, CharlieBrown13 said:

5 days before the whole thing started, I drank extremely little one day, I just didn't think about it.

 

You need to stay hydrated!

 

[CharlieBrown13]

1 hour ago, Altostrata said:

I am confused about when and what. When was the last dosage reduction, of what drug? What is your current drug schedule?

I reduced Escitalopram on Mo. 18. 10. from 25.5 to 25.0. mg and I splittend venlafaxin at 19.10.21.

My current drug schedule is:

8.00 am 37.5 mg Venlafaxin 

8.45 am 25 mg Escitalopram 

12.00 am 9.375 mg Venlafaxin 

 

 

1 hour ago, Altostrata said:

It's too bad you have to keep seeing this fooblood levels prove? You have the symptoms of excess serotonergic stimulation.

This is a different doctor, a friend of mine and it was my wish. Then hopefully I'll have that in black and white as proof, because my psychiatrist just doesn't believe me, symptoms or not. We had quite an argument about it on Monday. And then, if possible, I'll find another psychiatrist.

1 hour ago, Altostrata said:

 

Please keep daily notes of times o’clock you take your drugs, their dosages, and your symptoms throughout the day. We need to know how you feel before and after taking each drug, and your symptoms in between. Post 24 hours of notes at a time in this topic, in a simple list format with time o’clock on the left and notation (symptom or drug and dosage) on the

21.10.

3.05 woke up, drowsiness , slight nausea, shaky

4.00 Biofeedback 

4.30- 5.00 Meditation

6.00 went for a short walk

7.00 breakfast 

8.00 Venlafaxin 37.5 mg

8.30 intense skin burning, sweating, dizziness, intense bowel movement, abdominal cramps.

8.45 25 mg Escitalopram 

10.00 seeing my psychotherapist

12.00 Venlafaxin 9.375 mg

12.30 intense skin burning, increase in blood pressure headache, diarrhea, tachycardia, for 15 min severe drowsiness.

13.00-18.00 trying to decrease the blood pressure by taking 16 mg candesartan and 23.5 mg metoprolol additionally.

skin burning remained,  a little shaky

feeling a little better in the evening

22.30 went to bed, meditation 

0.00 woke up again

 

And I'm totally unsure what medication to take tomorrow.  I urgently need your advice, please! There’s literally no one  I can ask here how I should proceed in the next few days. And I am a little bit  afraid that I will get manifest serotonin syndrome.

 

 Thank you very much 🙏!

[Altostrata]

3 minutes ago, CharlieBrown13 said:

12.00 Venlafaxin 9.375 mg

 

Did you move this dose and reduce it at the same time, 2 days ago? It was to be a whole mini-tablet, 12.5mg.

 

I was concerned that if you made a reduction in venlafaxine at the same time, you might get withdrawal symptoms. However, it looks like venlafaxine is causing significant symptoms, so withdrawal may be moot as a risk.

 

Can you hold on another 2 days to see how your daily symptoms settle out with the schedule and dosage changes?

[CharlieBrown13]

6 minutes ago, Altostrata said:

Did you move this dose and reduce it at the same time, 2 days ago? It was to be a whole mini-tablet, 12.5mg.

Yes, I did. I changed the brand too, so now 38 mini globules (retarded) are equivalent to a 12,5 mg mini tablet. I was afraid of the immediate release, if I split them.

 

 

11 minutes ago, Altostrata said:

Can you hold on another 2 days to see how your daily symptoms settle out with the schedule and dosage changes?

I really don’t know. The symptoms get a little more every day and the blood pressure derailment was quite severe and persistent on 20th and even more on 21th.
I just don't want to make anything worse.

[Altostrata]

Since you split the venlafaxine dose, your symptom pattern indicates you are having an adverse reaction to venlafaxine, which appears to be quite a bit more severe than the one you may or may not be having to escitalopram, though it may be facilitated by interaction with escitalopram.

 

Your increase in symptoms may be because your adverse reaction to venlafaxine is now distributed over the day, with something going on in the afternoon (may be related to escitalopram peak plasma at noon). 

 

Since you also reduced escitalopram and venlafaxine (and changed drug brand) at the same time, it is also possible that you have withdrawal symptoms as well.

 

But the adverse reaction to venlafaxine seems so marked, I am tempted to suggest you drop the second 9.375mg venlafaxine dose altogether. It doesn't make any sense to move the adverse reaction back to the morning.

 

This would be a lot of changes in a short amount of time. However, when someone is experiencing serotonin toxicity, fast reduction of the drugs is reasonable.

 

Do you want to do this? It would relieve the blood pressure increase in the afternoon, but may rock the boat in other ways. But going off at least venlafaxine fairly quickly is in your cards.

[CharlieBrown13]

Thank you very much!

 

What would you do?

 

im really not sure. Now it’s three in the morning, im tired and so dizzy , skin is burning heavily.

 

 

 

[Altostrata]

I would take a breath and drop the second 9.375mg venlafaxine dose. You are getting an overdose as it is.

[CharlieBrown13]

Ok, than I’ll do that. I Keep you updated!

 

Thank you!

 

[Memphisto]

Hi Charlie,

just wanted to check in. I really hope you get better quickly. I think you are in good hands here. It will get better!!! 

I send you a lot of healing to the Isar. 

[CharlieBrown13]

Hi Memphisto, 

thanks for stopping by and asking!  I also believe that I am in very good hands here.  Now I'll wait what happens in the next few days (and longer), I just had some minor and major changes (venlafaxine from 50 mg to 37.5 😬).  I would so love to sink the medication deep into the Isar and never have to see it again (and my psychiatrist too). 
How are you?  Is it getting better? In any case, I am very happy about your words and appreciate them very much!  

Best wishes back!

 

Charlie

 

[CharlieBrown13]

22.10.

1.00 woke up, nausea, dizziness, headache, feeling of fear in stomach 

In and out of sleep till 4.00

5.00 Biofeedback, Mediation, feeling very drowsy 

7.00 breakfast 

8.00 doctors appointment for blood drawing

8.00 37,5 mg Venlafaxin 

8.30 burning skin, extrem drowsiness (had to stop the car for 15 min), felt not like myself (slight DP), shaky, stomach and bowel cramps. Burning skin lasted till late afternoon 

8.45 25 mg Escitalopram, felt very exhausted 

-12.00 reading, watching TV etc, felt really ill

12.30 lunch

14.00 shop grocery, still felt ill, burning skin, stomach cramps, shaky, brain doesn’t work very well, tinnitus,  feeling very sad 

17.30 went to family, my brothers birthday 

19.00 with family in restaurant, felt relatively good

22.15 going to bed

 

first day venlafaxin dose reduction

 

 

 

[Altostrata]

10 hours ago, CharlieBrown13 said:

19.00 with family in restaurant, felt relatively good

22.15 going to bed

 

first day venlafaxin dose reduction

 

Looks like it took about 12 hours for drug blood level of venlafaxine to drop slightly from the steady state established by the 50mg dose, and you got some relief. This is a good sign.

 

It will take at least 3 days for the decrease in venlafaxine to fully register neurobiologically.

[CharlieBrown13]

I slept a few hours more, albeit very restlessly. The morning is unfortunately terrible now, fear, nausea, my brain no longer obeys me and I feel a depersonalization.  
I'm lying here in bed right now and don't know what to do. Just wait and see, right?  The venlafaxine withdrawal symptoms will also appear in the next few days, I assume.  My psychologist (not the psychiatrist) calls me every day and asks how I am doing.  She said I should think about my admission to a hospital again, but I think with that, to put it bluntly, I am signing my final verdict.  
Can depersonalization come from serotonin toxicity?

I feel like as if I were poisoning myself with venlafaxine every day anew.

What if I can no longer tolerate venlafaxine?  I still can't just take it off ?!

Thank you so much for your help, @Altostrata, you don’t know how much I appreciate that!

[CharlieBrown13]

@Altostrata, sorry, one more post.

It is now almost seven hours after the last venlafaxine intake.  My blood pressure is now very high (160/106), I have slight chills and itching on my head (I know that from Tramal).  I suppose I have developed an intolerance (or allergy) to venlafaxine (or have always had it in a mild form).  

How should I proceed?

 

Thank you again!

[Memphisto]

@ Alto

 

Would it be possible to change the venlafaxine from retard to unretarded? I think then the plasma level could decrease faster. Or would it be too many changes now? 

 

Does the venlafaxine generally have an activating effect, so that it is better not to take it in the afternoon or later in order not to endanger sleep?

 

23 hours ago, CharlieBrown13 said:

Hi Memphisto, 

thanks for stopping by and asking!  I also believe that I am in very good hands here.  Now I'll wait what happens in the next few days (and longer), I just had some minor and major changes (venlafaxine from 50 mg to 37.5 😬).  I would so love to sink the medication deep into the Isar and never have to see it again (and my psychiatrist too). 
How are you?  Is it getting better? In any case, I am very happy about your words and appreciate them very much!  

Best wishes back!

 

Charlie

 

 

I am really sorry to see how you are doing right now. I really think of you often. 

 

I had trouble sleeping last night, but no comparison to you. Anxiety is at a low level right now with a few spikes coming through every now and then. Overall it is bearable though. Still living in the back of my mind though is the fear that it could get worse again at any time. The withdrawal is just unpredictable. 

 

[CharlieBrown13]

@Altostrata

It took me six hours and enormous amounts of additional antihypertensive agents to bring the RR (today max 170/112, normal 110/80) back to a reasonably normal value.  I am still very shaky and restless, and my pupils are noticeably dilated.  
I'm actually a bit afraid of taking my medication tomorrow, I'm already worried about the blood pressure and the morning drowsiness, the confusion and all the other symptoms.

My question now is whether it would be justifiable to pause venlafaxine for a day, or is that a bad idea?  

Please excuse the many posts and questions!!  I’m simply afraid.

I had already called the hospital today, but they couldn't say anything more than to reduce one of the two medications a bit.  Or does it bring something, e.g. to postpone venlafaxine in the afternoon (which would probably mean a completely sleepless night ...)

 

I'm very grateful for every idea !!

[Altostrata]

9 hours ago, CharlieBrown13 said:

Can depersonalization come from serotonin toxicity?

 

Yes.

 

9 hours ago, CharlieBrown13 said:

The morning is unfortunately terrible now, fear, nausea, my brain no longer obeys me and I feel a depersonalization.  

 

Is this before or after you take 37.5mg venlafaxine and 25mg escitalopram?

 

About the high blood pressure event -- I think you are experiencing withdrawal from dropping 1/4 of the venlafaxine. As I said earlier, I don't think there's going to be an easy way for you to back out of this drug combination, which is also causing serious adverse effects. Cross fingers, your withdrawal reaction will settle or at least diminish in a few days, you still have plenty of serotonergic in you. Hang in there. 

 

It would be more helpful to me if you put these symptom events into a chronology, like you did here 

 

6 hours ago, CharlieBrown13 said:

I have slight chills and itching on my head (I know that from Tramal).

 

What is Tramal? When did these chills and itching appear?

[CharlieBrown13]

48 minutes ago, Altostrata said:

 

Is this before or after you take 37.5mg venlafaxine and 25mg escitalopram

After, although I wake up very dizzy. Provided I did sleep.

 

48 minutes ago, Altostrata said:

 

About the high blood pressure event -- I think you are experiencing withdrawal from dropping 1/4 of the venlafaxine. As I said earlier, I don't think there's going to be an easy way for you to back out of this drug combination, which is also causing serious adverse effects.

The high blood pressure started last weekend every afternoon 5-6 hours after taking medication, a few days before I dropped the Venlafaxin to 37.5. 
And yes, you said it and I completely believe you. Unfortunately.

 

48 minutes ago, Altostrata said:

What is Tramal? When did these chills and itching appear?

Tramadol is an opiod (I had it 20 years ago , had a herniated disc), structurally closely related to venlafaxine, also releases serotonin.
The chills and itching began a week ago and increase in intensity every day.
 

When i'm healthy (enough) again, i will somehow return the favor for your help!!!

[CharlieBrown13]

49 minutes ago, Altostrata said:

It would be more helpful to me if you put these symptom events into a chronology, like you did here

Yes, I’m sorry, I’m a bit confused today. Won’t happen again!

[Altostrata]

5 minutes ago, CharlieBrown13 said:

The high blood pressure started last weekend every afternoon 5-6 hours after taking medication, a few days before I dropped the Venlafaxin to 37.5. 

 

So, before reduction of venlafaxine. That was not good. I need to know what's happened after the reduction to 37.5mg venlafaxine.

 

5 minutes ago, CharlieBrown13 said:

The chills and itching began a week ago and increase in intensity every day.

 

The itching is on you head? I need to know what times o'clock this occurs. I hope it diminishes with diminished venlafaxine.

 

8 minutes ago, CharlieBrown13 said:

When i'm healthy (enough) again, i will somehow return the favor for your help!!!

 

Thank you. As you're a prescriber, I hope to enlist you in the art of deprescribing. As you can see, it's a medical puzzle!

[CharlieBrown13]

12 minutes ago, Altostrata said:

 

So, before reduction of venlafaxine. That was not good. I need to know what's happened after the reduction to 37.5mg venlafaxine.

It happened not very much, less stomach cramps and less skin burning. Otherwise the days after reducing and before we’re the same. But it’s only been yesterday I took 37.5 mg for the first time.

Yes, it’s on my head. And it starts approximately at 2 pm (6 hours after venlafaxine, you can set the clock accordingly),  together with the chills and the increasing blood pressure , and then I’m very shaky. So I’m really a little afraid of tomorrow, because today the symptoms were a few hours longer than yesterday.

 

You can count on me, I’m now a deprescriber 😊

 

And sorry, I messed up the quotes again. Apparently not my day today.

 

16 minutes ago, Altostrata said:

Thank you. As you're a prescriber, I hope to enlist you in the art of deprescribing. As you can see, it's a medical puzzle!

12 minutes ago, Altostrata said:

 

The itching is on you head? I need to know what times o'clock this occurs. I hope it diminishes with diminished venlafaxine.

[CharlieBrown13]

I slept for barely two hours, and I’m still tachycard (HF 94) and shaky. I’m afraid that by taking the medication tomorrow morning, things will get worse, because I think, this is more due to being overdosed than withdrawal. I’m a little afraid for my heart, because of the daily high blood pressure and the ongoing tachycardia. 
It is no possibility to skip the venlafaxine dose for a day, I assume?

[Altostrata]

I don't know. You could be having withdrawal symptoms. Or, it could be a culminating adverse reaction.

 

However, excessive dosage of antidepressants does justify abrupt discontinuation. If you quit venlafaxine, can your doctor help with a benzodiazepine prescription?

[CharlieBrown13]

Yes, I’ve something at home. But I think, I go to the hospital later. They should have the plasma level determined there and then advise me.  I'm really feeling worse and worse. If it’s withdrawal, then ok, I have to go through. But if it’s overdosed, then we have to change something.

[Altostrata]

Either way, you should not be taking those two drugs together.

[CharlieBrown13]

Yes, that’s right, it hasn't done me any good the whole time and now it's really bad.

 

 Thank you for your help!

[Altostrata]

How are you? If your symptoms are still severe, please consider going to the hospital, tell them you have serotonin syndrome and difficulty stopping the drugs.

[CharlieBrown13]

Dear @Altostrata, I was just about to write to you anyway.  

I went to the hospital this morning, I was just really really miserable and I had dilated pupils and increased reflexes new to all other symptoms. 
I was admitted to the hospital, the medication is paused. It is a serotoninsyndrom.
Something that my psychiatrist has never seen in 25 years of professional activity and therefore does not exist. I told her every single symptom I had, and what did she say - depression. Of course. 

I think maybe I will really file a complaint, I’m so so angry. 
I’m doing better since noon today, my head is still not completely clear and my muscles are still twitching, the tinnitus is better, my blood pressure and pulse are normal again.  I will certainly no longer take both drugs together, I have to discuss how to proceed with the doctors here.  
I wanted to thank you very much again!  I was somehow still with the withdrawal thought and only when you said that it was serotonine toxicity, it dawned on me.  
But when things are so bad for you, your thoughts are no longer clear. 

So thank you very much again, you really really saved me!! 
I will keep you updated what happens next (provided you want to know), withdrawal will come for sure…

Do you have any suggestions? Continue escitalopram in a in a lower dose? And no venlafaxine. Have you ever had a case like this?