Valerie1: Whoops - made a mistake and updosed Mirtazapine - now have akathisia

[Valerie1]

Hi everyone, thanks for letting me join this group.  I was so determined to never take an antidepressant in my life so can’t believe I’m living in this reality.  I had an incident at the start of the pandemic when I had some kind of flu bug ( maybe Covid?) and was taking antibiotics and nausea medicine.  I developed a bad case of acute akathisia and was put on Klonopin and Mirtazapine to combat it, as well as ambien, propranolol and benztropine.  I slowly stabilized and was able to stop the Klonopin at about 6 weeks, the propranolol and benztropine after about 4 months. I started tapering the Mirtazapine in August of 2020 and it has taken me until now to slowly reduce from 7.5 mg to 1.5 mg.  I have my liquid made at a compounding pharmacy and have to shake my bottle vigorously to mix the oil and medicine. Well in March I let my bottle get too close to empty and too concentrated.  When I switched to a new bottle I started having extreme withdrawal symptoms - shaking, facial twitching, numbness and tingling.  I tried switching between the new and old bottles for a few weeks so probably was getting varied dosing .  When I went to the Dr. I was told to updose to 1.7 mg to try to stop the withdrawal symptoms.  I did that about a month ago.  Some problems improved, like the tingling, twitching and tinnitus but I had intense burning in my arms and feet after updosing as well as intense internal Akathisia.  The burning has now improved substantially but the akathisia is still present and some days feels almost unbearable.  I realize it’s the medicine, and isn’t deadly but I get so desperate for some relief from it.  I’ve tried so many herbal things to help but none seems to help much - milk peptides, hops, California poppy,  chamomile.  I’ve had varying success in decreased symptoms with propranolol 10-35 mg but don’t like the insomnia and stomach pain it gives me.  I’ve taken Ativan 0.25 mg twice out of desperation in the last month which did help, but I know isn’t recommended.  About once or twice a week I’ve taken a dose of 0.125 mg Klonopin when I’m shaking uncontrollably or  feel I can’t stand it.  The best relief I get is for an hour or two each night after I take my nightly dose of 2.5 mg Ambien.   I’m really a newbie to psychoactive medicines, except for ambien so I could use everyone’s advice who’ve been on this journey longer than me. I’ve been trying acceptance, massage, walks in nature, prayers, deep breathing and music but when my Akathisia gets too intense I feel I need some relief.  So questions:  Can updosing like I did cause akathisia?  Should I stay at my dose until the akathisia goes away?  When I get desperate what would be the least dangerous option for my cns:  herbal remedies, Cbd oil, homeopathic remedies, propranolol, benztropine, or Small dose of Klonopin 0.125 mg?   Have I totaled screwed my cns  by taking the Klonopin and Ativan a few times?  I have some Cbd gummies here I can try and some skull cap tincture but I’m a bit nervous to try something new.  Also, I bought a whey protein isolate from the Point of Return website before I read your warnings about that group.  Has anyone tried that and know if it helps with akathisia symptoms? Curious to know what others have used when they felt overwhelmed with akathisia.  Sorry to ramble on so long. 

 

[Onmyway]

Dear @Valerie1, 

I am so sorry you have been suffering so badly. Akathisia is horrible. It seems like the liquid suspension is giving too inconsistent dosages and may not be the best way to continue. I looked over the thread on tapering remeron and couldn't find the option of making compounded tablets or measuring using a scale. Do you know if that is an available option? It seems like it would be. Right now your body needs stability and time. This will resolve but may take a while and during that time, the more stable the dosage, the number of drugs/supplements that you take the better it would be. 

 

I know the temptation to take an occasional benzo and some withdrawal specialists recommend it as the lesser of two evils in the case of akathisia. I did it when I had akathisia but discovered that it was actually making me worse (nausea and dark depression the next day). I think of the two propranolol is the lesser evil if it works the same. The risk with the occasional use of all these supplements and drugs is that it is taking the brain out of stability but at times you may consider that risk worth it if things seem unbearable. There is also the risk of having adverse effects from these drugs because your system is so sensitized. 

 

Unfortunately, there isn't a known and sure remedy for akathisia other than time that I know. Would epsom salt baths work? 

At the end of the first post on this thread, this person is writing about a way to relieve symptoms by 'confusing' the CNS. Check it out. I don't know what would work in terms of akathisia.

What is happening in your brain? - Symptoms and self-care - Surviving Antidepressants

 

The Claire Weekes method seems to work for some people and for me acceptance made a huge difference as well. If you haven't yet seen it, check out the thread here:

https://www.survivingantidepressants.org/topic/10964-the-dr-claire-weekes-method-of-recovering-from-a-sensitized-nervous-system/#comment-200597

 

I hope you get a big bright window soon. 

OMW

 

[LostPhil]

1.7mg of mirt is a pretty small dose esp as the increase in your dosage was smaller than that again. It’s possible you are ultra sensitive to it.

 

I got Akathisia bad on 30mg of mirt. Was pacing my flat endlessly - it was horrible. When I got down to 7mg it pretty much stopped. Finally got totally off it and feeling so much better (at least so far!). 

 

I think some of us have sensitive constitutions and these drugs really impact us hard where others don’t get as affected. I would be guarded about going on antipsychotics unless it’s a last resort. And do research on them as it’s your body and nervous system on the line not doctors. Good luck - I hope the tide turns for you

[Valerie1]

Attn:  Altostrata, Admin.  I saw a post by you that said that when tapering an updose can be activating .  I’ve tapered 18 months very slowly from 7.5 mg Mirtazapine to 1.42 mg Mirtazapine. I was quite sensitive to tapering and just did microtapering -usually a small amount every few weeks totalling about 7% a month.  I really did well until I got to 1.42 mg and started having tinnitus . Upped back to 1.46 after a few weeks and seemed to stabilize.  Then changed to a new bottle of liquid that was less concentrated than my old compounded bottle and started having WD and some akathisia.  To be honest, the akathisia only started after I was alternating between my old more concentrated bottle and new bottle of compounded liquid. ( I hadn’t been shaking the old almost empty bottle enough so it got concentrated).  So I probably was getting variable dosing,  I went to the Dr a month ago and she has my up my dose to 1.7 mg which I did.  I have been having very uncomfortable akathisia ever since and burning In My arms and legs.   Burning is almost gone but Akathisia persists.  Im taking propranolol daily to cope and once or twice a week a rescue dose of Klonopin 0.125 mg. Twice In the last month I also used 0.25 mg Ativan.    Now after reading this site I will try my hardest not to use the benzos as it sounds like they destabilize things worse in the long run.  My question is, if I don’t seem to be getting over the akathisia at the new higher dose of 1.7 mg do you think I should gradually decrease to a lower dose again to see if the akathisia improves?  I really felt great when I was at this same dose around Christmas time but it’s weird I feel so awful on this dose now but I guess my body got used to the lower dose. Wish I hadn’t updosed like the Dr said to.  So confused whether to taper or hold.  Any advice appreciated.  The only other med I’m on is ambien 2.5 mg nightly.

 

 

[Valerie1]

Has anyone tried clonidine or benztropine for akathisia?  Curious your experience 

[Altostrata]

@Valerie1 please describe your current symptoms in more detail. Are these sensations better or worse at some times of day?

 

17 hours ago, Valerie1 said:

When I went to the Dr. I was told to updose to 1.7 mg to try to stop the withdrawal symptoms.  I did that about a month ago.  Some problems improved, like the tingling, twitching and tinnitus but I had intense burning in my arms and feet after updosing as well as intense internal Akathisia.  The burning has now improved substantially but the akathisia is still present and some days feels almost unbearable.

 

How do you feel before and after taking your mirtazapine dose? How's your sleep?

[Valerie1]

Thanks for responding Altostrata.  I have had such an easy mirtazapine taper until this point feeling pretty normal with relatively little akathisia that I’m in shock this has happened to me. I was started on Mirtazapine 7.5 mg to treat akathisia in March 2020 that I developed after taking nausea meds, so I’m probably prone to getting it.  For the last month since updosing to the 1.7 mg I have had a feeling of inner and outer restlessness. Sometimes I pace , sometimes I can sit still.  I take my dose of ambien 2.5 mg and Mirtazapine 1.7 ( well really 1.68) at 9 pm every night.  My akathisia symptoms pretty much go away for an hour or two before I go to sleep after taking these two..  I sleep about 2 or 3 hours, then wake up and have a hard time sleeping again - kind of 15 minutes or so on and off.  This is especially true in the last couple of weeks that I have been consistently taking propranolol.  Before that I was regularly sleeping 6 hours a night.  I feel kind of jittery but not terrible until around noon.  Then from noon to 7 pm I have a terrible feeling inside that is hard to bear and sometimes a need to pace or move.  Occasionally this becomes unbearable feeling and that’s when I panic and try a small dose of Klonopin.  From 7 to 9 pm the feelings let up quite a bit and I’ve said they improve dramatically after I take the Mirtazapine and especially the ambien.  I see a sleep specialist and have cut my ambien dose from 10 mg to 2.5 mg  over the last few years.  I’ve noticed if I take more than 2.5 mg my akathisia is worse the next day.  My main confusion is whether to hold steady on my updose of mirtazapine or decrease it slightly and see if my akathisia Improves.  It made so much sense what you wrote about updosing sometimes being too stimulating to people when tapering, even if they had previously done fine on that dose.

[Altostrata]

4 minutes ago, Valerie1 said:

My akathisia symptoms pretty much go away for an hour or two before I go to sleep after taking these two..  I sleep about 2 or 3 hours, then wake up and have a hard time sleeping again - kind of 15 minutes or so on and off.

 

I suspect your symptoms the next day are withdrawal from Ambien. It's like a benzo. You have become tolerant to it. @Frogie, can you assist?

[Frogie]

@Valerie1

 

I think by just reading your posts quickly you are having symptoms from the Ambien.

 

Could you try to taper your Ambien to 2 mg and see if that might help?

 

How often do you take the rescue dose of Klonopin? If you take it more that 2 weeks your body will also become dependent on it. 

[Valerie1]

Frogie, I’ve only taken the benzo sporadically in the last 2 months.  Like , literally 

I’ve had one Ativan tablet 0.5 mg and probably 3 Klonopin tablets 0.5 in 2 months.  I’ve skipped weeks with taking nothing and then sometimes once or twice a week taken a small amount from the 0.5 tablet. Usually that has been a fourth of a tablet or even an 1/8 th of a tablet and never more than twice a week. ( well once was 3 times in a week but the doses of Klonopin were 1/8th of a 0.5 mg tablet ) So dosed like 0.125 mg (1/4 tablet) or whatever half of 0.125  mg is.  I realize people can become tolerant after taking it consistently for even a week or two and that is why I have avoided doing so. As for the ambien, I have taken it consistently for a year, more or less.  I was able to sleep without it about 1 or 2 nights a week until I developed tinnitus a few months ago when I was tapering my Mirtazapine.  Then I really couldn’t sleep without it and ended out increasing to 5 mg some nights.  I have reduced to 2.5 mg now for the past month. When I do take a higher dose I feel it makes me more anxious.  The problem is ever since I increased my Mirtazapine dose, my Akathisia has been so uncomfortable.  Propranolol seems to make it more bearable but gives me insomnia.  So not sure how I will sleep without the ambien. Will try reducing it tonight if you think it will help.  I could switch to lunesta if you think that would be better.  Thanks for reading this and for your input.  Was thinking last night of trying 1.25 mg of the ambien and 0.125 of Klonopin and seeing if I felt better today with less ambien,  but after reading so many scary akathisia and benzo stories on here decided against that route.  
I wrote on my calendar the days I took any benzo In the last month : in the month prior to that  I think I took Klonopin twice at a dose of 0.125 mg for tinnitus 
March 21 0.125 mg Klonopin

March 22 0.125 mg Klonopin 

March 25 0.125 mg Klonopin

March 26 0.125 mg Ativan

March 28 0.25 mg Klonopin

no benzos March 28 - April 11

April 11 0.125 mg Klonopin

April 15 Ativan 0.25 mg , Klonopin 0.0625 mg

April 17th Klonopin 0.0625 mg

[Valerie1]

Altostrata, do you have an opinion about holding my Mirtazapine up dose to see if the akathisia stabilizes or if I should go down to see if it improves?   Tomorrow marks the 4 week mark since I updosed from 1.46 mg to 1.7 mg. The main thing that changed in my circumstances was taking the increased dose of Mirtazapine and developing the akathisia.  I think the ambien is probably a contributing factor but a subplot as it is the thing that hasn’t changed that much In the last year.  
 

[Valerie1]

@Altostratasorry wasn’t sure how to tag you in the reply I made to you above

[Valerie1]

@Frogiesorry I’m new to this site so wasn’t sure if I was supposed to tag you in the answer above 

[Valerie1]

Is it safe to take Klonopin occasionally prn without getting addicted?

 

I Have used Klonopin several times over a 2 week period for akathisia, and one dose of 3/4 a pill of 0.5 mg Ativan,  that happened in my Mirtazapine taper.  I used it 4 or 5 times the first week, took a 10 day break and then used about 3 times.   Is it safe for me to use once a week at this point or should I just stop?

 

 

March 21 0.125 mg Klonopin

March 22 0.125 mg Klonopin 

March 25 0.125 mg Klonopin

March 26 0.125 mg Ativan

March 28 0.25 mg Klonopin

no benzos March 28 - April 11

April 11 0.125 mg Klonopin

April 15 Ativan 0.25 mg , Klonopin 0.0625 mg

April 17th Klonopin 0.0625 mg

 

Thanks for your input.  I know it can't be used for more than 2 weeks continuous.  Wasn't sure beyond that if it's safe to occasionally take  a dose when I feel bad akathisia symptoms.

 

 

 

•  
• Quote

March3 2020 Akathisia from taking azithromycin and nausea meds 

May - August 2020 Akathisia treatments:  Klonopin 0.125 mg -0.25 mg x 6 wks

  mirtazapine 7.5 mg , propranolol 10-20 mg,  lunesta 2-3 mg  Benztropine 0.5 

August 2020.  Started tapering Mirtazapine. February 2022:  Mirt down to 1.42  

March 2022.  Updosed to 1.46 mg.  Allowed compounded bottle of mirtazapine to get too concentrated.  Started having akathisia, shaking , tingling when I switched to new less concentrated bottle.  Went to Dr who told me to updose to 1.7 mg.  Updosed  approx. March 23.  Burning in arms and feet, akathisia 
April 2022. Mirtazapine 1.7 mg, Ambien 2.5 mg.  Occasional Propranolol 10-30 mg,  Rescue dose as needed Klonopin 0.125 mg.    Continued Akathisia 

Supplements:  milk peptides, tart cherry, fish oil. Calcium, magnesium and zinc, 

 

 

 

Valerie1

Edited April 20, 2022 by Shep
added title after moving post off the Benzo forum

[ChessieCat]

Your new topic has been moved to an existing topic.  There are many existing topics on SA and SA likes to keep similar information in one place so it is easier to find.  Before creating a new topic, please do a search to see if one already exists.  You can do this by using the site search function, on an internet search engine and add site:survivingantidepressants.org to the search term.

 

whey-protein-isolate-and-protein-powder-shakes

[Shep]

  

4 hours ago, Valerie1 said:

I Have used Klonopin several times over a 2 week period for akathisia, and one dose of 3/4 a pill of 0.5 mg Ativan,  that happened in my Mirtazapine taper.  I used it 4 or 5 times the first week, took a 10 day break and then used about 3 times.   Is it safe for me to use once a week at this point or should I just stop?

 

Valerie, please note I moved your last post from the Benzo Forum to here in your Intro/Update topic so all of your information is in one place. Please continue to post in this thread when asking questions about your taper.

 

If you've only used Klonopin periodically for two weeks, it's safe to stop.

 

On 4/18/2022 at 2:52 PM, Valerie1 said:

I take my dose of ambien 2.5 mg and Mirtazapine 1.7 ( well really 1.68) at 9 pm every night.  My akathisia symptoms pretty much go away for an hour or two before I go to sleep after taking these two.

 

It looks like you're going into interdose withdrawal from the Ambien. Interdose withdrawal means going into withdrawal in between doses, which is common with short-acting Z-drugs like Ambien.

 

You can tell it's interdose withdrawal because your symptoms resolve when you take the drug. You take both drugs at the same time, but mirtazapine has a half-life of 20 - 40 hours, meaning you still have quite a bit of it in your system in the evening, but Ambien's half-life is only about 2 hours. From this information, we know that it's the Ambien causing the interdose withdrawal.

 

On 4/18/2022 at 2:52 PM, Valerie1 said:

 I see a sleep specialist and have cut my ambien dose from 10 mg to 2.5 mg  over the last few years.  

 

What month and year did you start taking Ambien? Your signature has it listed on the line for April 2022.

 

Please update your signature to list the month / year you started taking Ambien. A direct link to your signature is here:

 

 

Account Settings - Create or Update Your Signature. 

 

 

On 4/18/2022 at 2:52 PM, Valerie1 said:

I sleep about 2 or 3 hours, then wake up and have a hard time sleeping again - kind of 15 minutes or so on and off.  This is especially true in the last couple of weeks that I have been consistently taking propranolol.

 

If your sleep is getting worse when you consistently take propranolol, it may be due to a paradoxical reaction - the more you dampen down the brain and nervous system with sedating drugs and supplements, the more it fights to stay alert. This creates a paradoxical alerting reaction. You wake up instead of calm down.

 

Also, there's a "moderate" drug interaction between these drugs. Here is the drug interaction report (NOTE: you may need to register with the site in order to view it, but it's free to do so).

 

Drug Interaction Report - propronolol, mirtazapine, and ambien

 

How often have you taken Propranolol over the last month?

 

The best path forward is going to be to stop randomly adding in sedating drugs. This is confusing your nervous system and may lead to kindling, which is damage to the nervous system caused by abrupt changes.

 

You may also want to cut your Ambien in half and slowly move half the dose to earlier in the day. To do this, take 1/2 your dose one hour earlier each day until you've moved it back to noon. This will help with the interdose withdrawal.

 

I would avoid Klonopin or any other benzo and see if simply spacing out the Ambien does the trick. Also, let us know more about your propranolol use (the number of times taken over the past month) because we need to see if you've developed a dependency.

 

 

 

[Valerie1]

Hi Shep, thanks so much for responding.  I have taken ambien intermittently since 2010.   I have taken it almost nightly for the last year normally at 2.5 mg.   A month ago I took bad advice from a Dr. and updosed my Mirtazapine from 1.46 to 1.68 mg. I think I had inadvertently been taking alternating doses a few weeks prior to that as I was switching between two bottles of varied concentration of my compounded Mirtazapine.   I have had very distressing akathisia since then and have taken propanolol 10-35 mg nearly every day since then. I have also had burning sensations in my arms and legs and the most annoying thing is the internal restlessness and unease that I feel.   I am shaking so much or in so much distress if I don't take any propanolol.   I have been trying a few herbs like skull cap or lemon balm as well for the akathisia to avoid the temptation of taking more benzos.   I know i'ts best not to take anything but I just get desperate for some relief.   I saw my  sleep specialist today and he doesn't think I have inter dose dependency from the ambien. Not sure if he's right or not.  Your explanation sounded logical too.   I guess I wasn't really accurate when I said that all my symptoms disappear when I take ambien, but some of my symptoms do abate.  I just figured its because ambien hits the same receptors as benzos so it makes sense it would abate some of the akathisia.   

 

I'm assuming you are including sedating herbs when you say not to randomly add sedating drugs?   It's better just to take the same thing every day right?  The last thing I want to do is kindling.  So if I find an herb that helps, best to take it every day in the same amount?    I'm thinking for the next week or two of holding steady with the following regimen:  Let me know your thoughts:  Mirtazapine 1.68 mg , Ambien 2.5 mg, Propanolol 10-15 mg twice a day, milk peptides, tart cherry, vit b6, vit D. Magnesium and skull cap and lemon balm.  (Can't decide if I should take the denatured whey protein powder or not).

 

My hat is off to everyone who handles the akathisia without taking anything.  It is brutal. Wish I was braver.

 

Also since upping my dose a month ago seems to only have led to misery and more akathisia, I'm curious your opinion if you think I should hold my dose until the akathisia goes away or try cutting and see if my akathisia improves?

I hadn't realized that upping your dose is not advised.

 

Thanks again for responding Shep.

[Onmyway]

8 minutes ago, Valerie1 said:

Hi Shep, thanks so much for responding.  I have taken ambien intermittently since 2010.   I have taken it almost nightly for the last year normally at 2.5 mg.   A month ago I took bad advice from a Dr. and updosed my Mirtazapine from 1.46 to 1.68 mg. I think I had inadvertently been taking alternating doses a few weeks prior to that as I was switching between two bottles of varied concentration of my compounded Mirtazapine.   I have had very distressing akathisia since then and have taken propanolol 10-35 mg nearly every day since then. I have also had burning sensations in my arms and legs and the most annoying thing is the internal restlessness and unease that I feel.   I am shaking so much or in so much distress if I don't take any propanolol.   I have been trying a few herbs like skull cap or lemon balm as well for the akathisia to avoid the temptation of taking more benzos.   I know i'ts best not to take anything but I just get desperate for some relief.   I saw my  sleep specialist today and he doesn't think I have inter dose dependency from the ambien. Not sure if he's right or not.  Your explanation sounded logical too.   I guess I wasn't really accurate when I said that all my symptoms disappear when I take ambien, but some of my symptoms do abate.  I just figured its because ambien hits the same receptors as benzos so it makes sense it would abate some of the akathisia.   

 

I'm assuming you are including sedating herbs when you say not to randomly add sedating drugs?   It's better just to take the same thing every day right?  The last thing I want to do is kindling.  So if I find an herb that helps, best to take it every day in the same amount?    I'm thinking for the next week or two of holding steady with the following regimen:  Let me know your thoughts:  Mirtazapine 1.68 mg , Ambien 2.5 mg, Propanolol 10-15 mg twice a day, milk peptides, tart cherry, vit b6, vit D. Magnesium and skull cap and lemon balm.  (Can't decide if I should take the denatured whey protein powder or not).

 

My hat is off to everyone who handles the akathisia without taking anything.  It is brutal. Wish I was braver.

 

Also since upping my dose a month ago seems to only have led to misery and more akathisia, I'm curious your opinion if you think I should hold my dose until the akathisia goes away or try cutting and see if my akathisia improves?

I hadn't realized that upping your dose is not advised.

 

Thanks again for responding Shep.

Hi @Valerie,Shep is more knowledgeable about the sedating drugs so I'll let her handle that but can you stop taking vitamin D and B6. They're probably adding to the akathisia

 

Small change, might have some impact.

[Valerie1]

Sure thanks Onmyway.  I can stop them.  The pharmacist told me that Vitamin B6 is a treatment for akathisia but it doesn't seem to be helping so maybe that's not right.   If you think the Vitamin D is activating I can stop for now too.   Do you have an opinion about Fish oil? I was taking that but was worried it might be activating.

 

[ChessieCat]

1 hour ago, Valerie1 said:

The pharmacist told me that Vitamin B6 is a treatment for akathisia but it doesn't seem to be helping so maybe that's not right.  

 

Many members find the B vitamins activating, B6 especially.

[Valerie1]

Thanks Chessie Cat!

 

[Onmyway]

I think vitamin D is universally activating esp in withdrawal. Fish oil could be for some people - you can stop all and add fish oil at a low dose to observe. Can you list the herbs as well in your signature? It will help us help you.

Edited April 21, 2022 by Onmyway

[Shep]

@Valerie1 You're getting lots of great information regarding the problems with the supplements and the drugs you're taking. Before making any changes, let's please see how what you're taking now is actually affecting you within the context of when you take your drugs. After a few days of doing a daily journal, we can then set up a game plan for going forward. 

 

Please see the below quote box for instructions on writing a daily drug and symptoms journal. Please also include any supplements you're taking and the number of hours you're sleeping at night. 

 

 

On 9/27/2016 at 2:49 PM, Altostrata said:

In the course of discussion in your Introductions forum topic, you may be asked to keep notes on paper of your daily symptom pattern, including when you take your drugs, their dosages, and any symptoms. We ask this because there may be something we can do to reduce the symptoms.

 

What we need to see for every single day over several days is what symptoms you get before and after you take your drugs. If you're not taking any drugs and have withdrawal symptoms, we still need to see your symptom pattern throughout the day:

 

The time of day, dosage, and severity of symptoms are essential information. Include

 

- Time and dosage for all drugs taken throughout the day, psychiatric and non-psychiatric.

- Following each dose, note any symptoms. If you are having a reaction to the drug, it may take hours for a symptom to show up -- that's why we ask you to keep notes all day long.

- If you're not taking any drugs, your symptoms throughout the day.

- Your sleep pattern. Since so many drugs disturb sleep, if you find you're waking in the middle of the night, it could be from a drug you took earlier in the evening. If you're not taking any drugs, there may be ways you can improve your sleep.

And so forth. A diary, in chronological order, looking something like this:
 

Example:

DATE:

 

6 a.m. Woke with anxiety
8 a.m. Took 2.5mg Lexapro
10 a.m. Stomach is upset
10:30 a.m. Ate breakfast
11:35 a.m. Got a headache, lasted one hour
12:35 p.m. Ate lunch
4 p.m. Feel a bit better
5 p.m. Took 2.5mg Lexapro
6 p.m. Ate dinner
9:20 p.m. Headache
10:00 p.m. Took 50mg Seroquel
10:20 p.m. Feeling dizzy
10:30 p.m. Fell asleep
2:30 a.m. Woke, took 3mg Ambien (NOT "took 1/2 tablet Ambien")
2:45 a.m. Fell asleep
4:30 a.m. Woke but got back to sleep

 

[Valerie1]

Ok Shep - will do.  Today is Thursday 4-21-22.  I worked a 12 hour nursing shift and this is how it went:

 

3 am. Woke up after sleeping 4 hours.  Felt jittery and akathisia.  Took 1.25 mg ambien.  Slept 2 more hours and felt better.   
 

6 am.               Took 10 mg propranolol, ate lucky charms and went to work

 

7 am -  1 pm.  Ate  rice cakes with sunflower butter and rasp, jam ,and an apple, string cheese and potato chips Felt some shakiness and internal and external akathisia but it was bearable,  I was able to  distract myself and not focus on my symptoms too much because I was working in labor and delivery and babies were coming out fast and furious 😀. I thought “ I should sign up to work every day because I’m not home naval gazing,

 

1 pm.            Took 10 mg propranolol 

 

3 pm - 6 pm.   The worse time of the day when my akathisia is at its worst.  Legs burning,  inner restlessness.  Can’t let anyone know what I’m going through.  Have to stay professional but boy this is hard.

 

7 pm.     Symptoms relieved a bit.  I made it 12 hours

 

8 pm.  Back home.  Take a few drops lemon balm in some water.  Take 1.25 mg ambien .  

 

9 pm.   Akathisia symptoms seem more bearable even though my legs are burning,  

9 pm.   Take milk peptides, tart cherry capsules and 1/2 dose of undenatured whey. Protein powder

 

 

 

 

 

 

 

[Shep]

@Valerie1Thanks for the drug and symptoms journal. You're doing really well handling 12 hour nursing shifts. 

 

What time of the day did you take the mirtazapine?

 

It looks like you went ahead and split your Ambien from one dose to two. Let us know if you find that helpful. We usually recommend slowly moving the dose one hour a day until you get it to the time you want (the gradual move is easiest on the nervous system), however, if it's giving you more sleep in the wee hours of the morning, you may be fine with this abrupt transition. 

 

6 hours ago, Valerie1 said:

6 am.               Took 10 mg propranolol, ate lucky charms and went to work

 

Try swapping out the sweet breakfast for some protein, such as a plate of scrambled eggs, and see how you feel. Starting the day off with sugar can cause blood sugar crashes that may be mistaken for withdrawal symptoms. The cleaner you can keep your diet, the better you'll feel. This is especially true for folks working all day. Also make sure you're drinking plenty of water throughout the day. 

 

Please do a couple more days of notes. 

[Valerie1]

Attn:  Shep, Altostrata, Onmyway, Frogie or anyone else very experienced with tapering Mirtazapine or with akathisia.  I really need your advice whether to hold my dose of Mirtazapine or reduce it.  It’s been about 5 weeks since I raised my dose from 1.46 mg to 1.68 mg,  I had some mild akathisia before raising the dose and the Dr thought raising the dose to 1.7 would make the akathisia better.  Instead it made it much worse.  Especially every afternoon for about 4 or 5 hours it tends to be excruciating.  I feel I’m close to the limit of what I can endure without going to Urgent Care or ER, but I stop myself because I figure they’ll just give me benzos which I’m trying to avoid. Propranolol was helping me at first but seems to be losing its effectiveness.  I remember Altostrata said raising the dose when tapering can be very activating like taking a larger dose than someone has ever had.  So wondering how to best help my battered cns - stay at this higher dose or slowly start tapering again and see if I get relief from the akathisia.  Thanks in advance for your advise.

[Shep]

On 4/22/2022 at 7:03 AM, Shep said:

Please do a couple more days of notes. 

 

@Valerie1It will really help to have these notes. 

 

Please also include the time you take the mirtazapine and the dose (it was left out of your first set of notes). We need to see your symptoms within the context of when you take your drugs. 

[Valerie1]

text.txt

Friday April 22

 

5 am: woke up for work .Felt mild inner and outter akathisia 

 

6 am: breakfast. 10 mg propranolol 

7 am- 12 noon Mild Akathisia at work.  Felt uncomfortable but able to concentrate well and do my job.

12 noon Took 5 mg propranolol with lunch

1 pm to 4 pm Akathisia stronger harder to concentrate 

4 pm  work done

5:30 pm:eat dinner at restaurant with friends . Feel just miserable with internal restlessness .  Hard to endure. Take 5 mg propanolol 

7 to 9:30 pm : watch a play Anne of Green Gables. Felt horrible in the 1st half but aka let up some in the 2 nd half and I was able to enjoy the play

10:30 pm: Home. Took 2.5 mg Ambien and 1. 68 mg Mirtazapine.   No supplements today 

11:30 pm Fell asleep until 5 :30 am. Only woke up once 

 

Edited April 24, 2022 by Shep
reduced font

[Valerie1]

Saturday April 23

6:30. Woke up.  Felt jittery but not terrible

8:30. Started shaking  Ate breakfast   Took 5 mg propranolol 

9:30. Walked dog at college.  Mild akathisia 

10:30. Went to Farmers market. Able to enjoy despite mild akathisia 

1 pm. Ate lunch. Akathisia start getting to get worse . Took 5 mg propranolol 

2 pm. Tried milk peptides, 2 drops homeopathic vervain and magnesium 

3 pm.  Felt worse akathisia. Panicky. Shaking and jerky movements when I walk. Took epsom bath. Took 5 mg propranolol 

4 pm. Took sliver ambien (1 mg)

5 pm. Feeling much improved. Went to surprise birthday party

8 pm. Akathisia still uncomfortable but bearable.  Legs burning 

8 :20 arms burning now.  Aka getting stronger 

8:30  Took tart cherry capsules, calcium, magnesium and zinc capsule and NAC 600 mg

           1.5 mg ambien

9 pm  Took 1.68 mg Mirtazapine. 

9 pm went in jacuzzi with son and his girlfriend.  Felt mod. Inner aka. Able to enjoy the conversation anyway.

10. Still feeling moderate akathisia. Not sleepy. Probably took propranolol too late in the day.  It gives me insomnia.  Took another 1.5 mg ambien.

10:30 pm started watching Netflix in bed. Only lasted about 5 minutes and fell asleep

12:30 woke up with Netflix show still playing on my iPad . Turned it off and went back to sleep. Feel a little jittery 

3am woke abruptly. Feel quite jittery . Able to sleep again

5 am woke again. More jittery but able to sleep again 

6:30 woke for real with mild tinnitus this morning . Feel mild internal akathisia and I’m shaky and trembling . Arms are burning .muscle twitching in legs.  

Edited April 24, 2022 by Shep
reduced font

[Shep]

@Valerie1Thank you, Valerie. Your notes are very helpful.

 

The first thing you're going to want to do is to set up a very strict schedule for taking your drugs and supplements. Although you're struggling, you're still doing very well coping with a high-stress and lengthy workday and still making time for friends and family.  You already have a strong baseline to work with. But now let's set yourself up for success with a taper. 

 

Please pick one dose and whatever time(s) of day you want to take each of your drugs and your supplements and then stick to that dose and time schedule every day. If you decide to take the full dose of Ambien at 10 PM, then you'll take it at that timeframe, regardless of early-hour wakening. If you decide you want take 10 mg Propranolol at 10 AM and 3 PM, then stick to that schedule and that dose.  It's very important to do this. Otherwise, you're going to slip and slide your way through this and the damage to your nervous system from abrupt changes may lead to kindling your nervous system. You don't want this to happen. As a nurse, you probably understand this concept more than most of us. This kind of damage can affect cognitive functioning, which is the last thing anyone working needs to happen. 

 

Please find a few minutes of quiet time and sit down with a piece of paper and decide which times of day are best for each of your drugs and supplements. Also write down the dose. This will be your schedule to follow until you stabilize. Pick the supplements you think are most helpful, set the same dose and times of day to take each of them. The simpler you can make this (with the fewest supplements), the better. Try not to complicate your taper. You can't outwit or outrun withdrawal with on and off supplement and drug use. This thread may help:

 

The rule of 3KIS: Keep it simple. Keep it slow. Keep it stable.

 

We don't recommend a lot of supplements, as many members report their nervous systems are simply too fragile to handle them. However, magnesium and fish oil tend to be calming to the nervous system and many people report they do help. Please only add in one supplement at a time and at a small dose to see if your nervous system can tolerate it. For more, please see:

 

 King of supplements: Omega-3 fatty acids (fish oil)

 

Magnesium, nature's calcium channel blocker

 

 

Please post your schedule once it's complete. And keep on with the daily notes. 

[Valerie1]

Shep,

 

Thanks so much for your prompt and thoughtful response and for caring.   I know it sounds like I'm coping well but I don't really feel that I am.  What I'm experiencing with the akathisia feels like I"m at the point often where it is almost unbearable, especially in the afternoons. My schedule on the 2 days I work is so different from my days off that is hard to have the exact same schedule every day.  Maybe I can take my vitamins to work and take with dinner there.  Or maybe there can be a range of times that I take something like 6 to 8 am propanolol and 6-8 pm vitamins.  I'll try to be more consistent though and cut down on my supplements.  I'm just so desperate for anything to give me some relief.  Looking to start taking clonidine or benztropine next week if things don't improve.   Before I take that drastic move though, I really would like your and the other moderators opinion about whether I should start slowly tapering again.   I've had a great taper for 18 months up to this point without much akathisia at all from 7.5mg down to 1.46 mg.  Since playing around with my dosing a little bit in February and March, it's been pretty bad.  Its especially  bad since I updosed from 1.46 to 1.7 mg.     I don't seem to be stabilizing at 1.7 mg so I keep thinking it would make sense to slowly taper back down again to see if akathisia gets better (I saw Altostrata post that it can be very activating to your nervous system to updose when you're tapering).    I really would like some feedback about the possibility of tapering down some.     Thanks so much!   You and the other moderators are much appreciated.

 

 

 

[Shep]

16 hours ago, Valerie1 said:

Or maybe there can be a range of times that I take something like 6 to 8 am propanolol and 6-8 pm vitamins.

 

Yes, if you're dealing with a difficult work schedule, you may need to work some flexibility into the schedule, but try to keep it within as narrow a range as possible. You may need to set a timer on your phone or watch to remind you. You really don't need to take these drugs more than 3 or 4 times a day, so you'd only need to schedule one or two times during the workday to take a drug and the other doses would be before work and after work. Once you stop trying to fix withdrawal by taking something right away, you'll find your schedule is much simpler. 

 

16 hours ago, Valerie1 said:

Looking to start taking clonidine or benztropine next week if things don't improve.  

 

Please note we're not medical professionals here and cannot help you set up a new drug cocktail. All we can do is give you harm-reduction tapering advice. If you're going the route of adding in helper drugs, you'll need to work exclusively with your doctor, not an online forum. We can't handle the complexity of this type of taper strategy. We don't know of any magic fixes for withdrawal and we see adding in drugs to cause more harm than good. 

 

16 hours ago, Valerie1 said:

Looking to start taking clonidine or benztropine next week if things don't improve.   Before I take that drastic move though, I really would like your and the other moderators opinion about whether I should start slowly tapering again.   I've had a great taper for 18 months up to this point without much akathisia at all from 7.5mg down to 1.46 mg. Since playing around with my dosing a little bit in February and March, it's been pretty bad.  Its especially  bad since I updosed from 1.46 to 1.7 mg.     I don't seem to be stabilizing at 1.7 mg so I keep thinking it would make sense to slowly taper back down again to see if akathisia gets better (I saw Altostrata post that it can be very activating to your nervous system to updose when you're tapering). 

 

You may be okay reducing the mirtazapine a bit to see if that helps. However, looking at your notes, it seems that the akathisia is worse during the day before you take the mirtazapine at night. Also, I noticed this:

 

On 4/17/2022 at 9:11 PM, Valerie1 said:

 I’ve had varying success in decreased symptoms with propranolol 10-35 mg but don’t like the insomnia and stomach pain it gives me.

 

On 4/18/2022 at 3:24 PM, Valerie1 said:

The problem is ever since I increased my Mirtazapine dose, my Akathisia has been so uncomfortable.  Propranolol seems to make it more bearable but gives me insomnia.  So not sure how I will sleep without the ambien.

 

Any drug that causes insomnia can cause akathisia. It's possible the propranolol is creating problems. The timing of the akathisia is more consistent with the propranolol. 

 

Also, I noticed this: 

 

21 hours ago, Valerie1 said:

4 pm. Took sliver ambien (1 mg)

5 pm. Feeling much improved. Went to surprise birthday party

8 pm. Akathisia still uncomfortable but bearable.  Legs burning 

 

Taking a bit of Ambien and then feeling better speaks to the fact you may be getting interdose withdrawal. 

 

Right now, I really don't know what to tell you. With your drugs and supplements all over the place and a history of using helper drugs such as a benzo, z-drug, and blood pressure med, and countless supplements to mask withdrawal symptoms, you're likely dealing with quite a number of issues.  Withdrawal symptoms are your body's way of telling you "too much! stop!" and encouraging you to hold for sometimes weeks or even months. 

 

16 hours ago, Valerie1 said:

(I saw Altostrata post that it can be very activating to your nervous system to updose when you're tapering).  

 

It can for some people at certain times, but the mirtazapine updose is only one part of a much bigger drug cocktail equation. 

 

16 hours ago, Valerie1 said:

I know it sounds like I'm coping well but I don't really feel that I am.  What I'm experiencing with the akathisia feels like I"m at the point often where it is almost unbearable, especially in the afternoons.

 

Are you able to schedule some time off? Say a week or so of vacation or sick leave to really work on getting on a viable schedule? You're heading toward a complete nervous system crash if you're not able to slow things down and get your drugs and supplements in order. 

[Valerie1]

Thanks again Shep for your thoughtful response.  Yes I can take a week off if needed.  I could try stopping the propranolol for a few days and see if my symptoms improve.  Just wasn’t sure if I needed to taper it after taking it for a month? I tried skipping it one day last week and my pulse got really fast so I took a dose again.  Maybe I can try tapering it off over this week. I have used propanolol the days I work for BP control for about 6 months and it never caused me akathisia.  Really I was feeling great until I took variable dosing of my Mirtazapine a few months ago.  That’s why I feel fairly confident it is the Mirtazapine that triggered the akathisia.    There was a direct correlation, especially after I updosed.  Just seems to me that cutting down a bit to see if akathisia improves is a better option than throwing more meds or supplements into the mix.  Do you agree?  Thanks again for all the time you are taking to try to help me. I am taking note of what you say and have stopped trying any new supplements or herbs.  Going to try to keep it simple per your advise so as not to confuse my nervous system too much.   You asked me to make a schedule and stick to it and let you know what it is.  Here is what I came up with.  Let me know what you think if I try this for a week.  I know you advised splitting up the ambien dose and slowly moving it up.  However I have tried it at 3 pm the last few days which is when I usually struggle the most with akathisia and am tempted to try some rescue herb or medicine. It seemed to calm things down and help me not seek a quick rescue.
 

9 am Propranolol 5 mg,  fish oil, 

3 pm. Propranolol 5 mg , 1 mg ambien

7 pm. Calcium, magnesium and zinc capsule, milk peptides, tart cherry, 1/2 tsp whey protein powder

9 pm 1.68 mg Mirtazapine, 1.5 mg ambien 

 

 

 

 

[Shep]

8 hours ago, Valerie1 said:

 I could try stopping the propranolol for a few days and see if my symptoms improve.  Just wasn’t sure if I needed to taper it after taking it for a month? I tried skipping it one day last week and my pulse got really fast so I took a dose again.

 

You can become dependent on these drugs in a month, and it does sounds like you may be. So let's keep this one in the mix for now. 

 

8 hours ago, Valerie1 said:

9 am Propranolol 5 mg,  fish oil, 

3 pm. Propranolol 5 mg , 1 mg ambien

7 pm. Calcium, magnesium and zinc capsule, milk peptides, tart cherry, 1/2 tsp whey protein powder

9 pm 1.68 mg Mirtazapine, 1.5 mg ambien 

 

This looks good (as long as the Ambien isn't sedating for you at the 1 mg dose if you have to drive home from work). 

 

8 hours ago, Valerie1 said:

Really I was feeling great until I took variable dosing of my Mirtazapine a few months ago.  That’s why I feel fairly confident it is the Mirtazapine that triggered the akathisia.    There was a direct correlation, especially after I updosed.  Just seems to me that cutting down a bit to see if akathisia improves is a better option than throwing more meds or supplements into the mix.  Do you agree?

 

Why don't you reduce the mirtazapine down to 1.55 mg and see if that helps. You probably shouldn't go too low because you've been on the higher dose for a few weeks and may have adapted to it, even if it may be causing some side effects. 

 

And then keep the schedule you set up for your drugs and supplements. 

 

Thanks for setting up the schedule. I really think once you stop moving things around and experimenting with doses you're going to feel a lot better.

 

Please keep posting your daily notes. This is important, especially as you're setting up a schedule and reducing the mirtazapine. 

[Valerie1]

Thanks again Shep for your help.  I'll probably wait to make a dose decrease until after my husbands surgery appointment this Thursday, just in case it makes me less functional.   Was also wondering if you think my taking fish oil may be activating to the akathisia?   Wondering if I should hold that until akathisia improves.

 

All the best

[Valerie1]

I tried my fish oil without much food on my stomach this morning and had crazy intense akathisia a few hours later.  Too stimulating?