Managing the Endgame Taper

[brassmonkey]

Managing the Endgame Taper

 

 

Referring to the final part of a taper as the “Endgame” may seem a little misleading as the tapering process is not a game at all, but a rather serious endeavor. The term “Endgame” comes from the sport of chess and refers to the final series of moves to complete a coordinated strategy with a successful outcome. Many chess masters consider it the most important part of a strategy. The same goes for the final phase of tapering psychiatric drugs. We have put a lot of time and effort into our tapers and to lose concentration and rush the final moves could slow the positive outcome.

 

After performing a successful slow tape, the question of “when do I make the jump to “0” comes up. The current wisdom is to go as low as possible in dose strength before making the jump.  Easier said than done as there are physical limitations that become involved.

 

Over the years, it has been determined that the lower the Exit Dose the better.  There have been many targets thrown out, but these numbers are not universal.  Because of the different relative strengths of the various medications we deal with and how each individual reacts to those medications there is no specific Exit Dose that can be used across the board.

 

While doing the main taper three of the things we have emphasized are: Listen to your Body, Keep it Slow, and Take Responsibility for yourself. These three keys are even more important during the Endgame Taper and are quite interrelated. We must Listen to Our Bodies to gauge our reaction to each reduction, take Responsibility to do the correct things required, keeping the taper Slow and Controlled and allowing our bodies to heal and tell us what needs to be done next.

 

Up to this point, following the dictates of our bodies, we have been able to use mathematics and physiology as a basis for our tapers. Some people will have calculated the 10% dosing to get down to low doses with no problems. While others will have needed to listen to their bodies all along and taken periodic breaks from tapering, taper by smaller amounts, or updose. Now we are at the point where the taper changes from science to art as it is important to go from using numbers to allowing our bodies guide us.

 

Paying attention to any symptoms is the key to the Endgame Taper. Depending on what your body tells us we can no longer follow a calendar or set schedule. Rather a person may need to make adjustments on a reduction-by-reduction basis. The amount of each reduction, the hold time, a possible small updose are all potential variables. The object is to have any symptoms fully resolved before continuing with the next reduction. In the end, it is up to the individual to determine what is the right action at any given time.

 

 

 

All the various taper methods that are recommended on SA, the basic 10% every four weeks, the Brassmonkey Slide Method and the micro-tapers are all based on reducing by a percentage of the previous dose. why-taper-by-10-of-my-dosage, the-brassmonkey-slide-method-of-micro-tapering, micro-taper-instead-of-10-or-5-decreases.  This gives a hyperbolic reduction profile that approximates the receptor occupancy (SERT) charts (as described in Horowitz & Taylor, (2019). Tapering of SSRI treatment to mitigate withdrawal symptoms, and Horowitz, et al. (2020). Tapering Antipsychotic Treatment),  https://doi.org/10.1016/S2215-0366(19)30032-X , https://doi.org/10.1093/schbul/sbab017 blood plasma concentrations and several other factors, and is intended to result in the smallest number of symptoms for the shortest amount of time.

 

Because of the exponential mathematics of a hyperbolic taper, each reduction becomes a smaller and smaller amount, but it will never actually reach zero. The taper can proceed until the dose is so small some might dismiss it as homeopathic. Some people find this necessary, but for most such small reductions may not be needed.

 

When a person’s dose becomes too small to reliably measure on their scales or, for a liquid dose, with an oral syringe, they have entered the Endgame Zone and they need to realign their taper accordingly possibly using different techniques.

 

This article is about that Endgame Taper and is divided into several parts for general discussion. Specific information on each subject can be found on the links to that topic and on the link to my Tips and Tricks for Tapering thread. Brassmonkey's Tips and Tricks for Tapering - Tapering - Surviving Antidepressants

 

 

 

1. Introducing the Endgame Taper

2. Determining the Target Exit Dose

3. Using commercial, compounded and liquid preparations for the Endgame Taper

4. Using bead-counting for the Endgame Taper

5. Using dry-cutting for the Endgame Taper

6. Adjusting the Endgame Taper

 

 

1. Introducing the Endgame Taper

Dealing with a long taper is quite a project but, over time it becomes a routine that we don’t have to think about all that much, until one day it becomes obvious that it is coming to an end. Then the question of “when do I make the jump to “0” “comes up.

 

Because of the differences in the many drugs we deal with, and how every individual reacts to those drugs, there is no specific Exit Dose that is universal. Over the years we have learned that the lower the dose, before making the jump, the better. Easier said than done as practical limitations of our measuring devices become involved.

 

The human body is an amazing creation with several billion tiny parts all working together to make it function. When things are working correctly this is referred to as homeostasis. It is the natural balance of all the systems of the body working in harmony. When one part of the system gets outside of its normal band of function, the entire body tries to bring things back to center by making adjustments to it and all the other systems. This is what is happening when we feel side effects of psychiatric drugs or withdrawal symptoms while tapering.

 

If psychotropics such as psychiatric drugs are taken on a regular basis, over time the body will adapt to their presence. The drugs will have changed the inter-relationship of all your hormonal systems, the functioning of your digestive system, your sleep pattern, and eventually affected every system in your body. Your body then will require a certain amount of the drug to maintain the new homeostasis built around the drug. As you go down in dosage, your body must adjust to the loss of the drug. If these adjustments can’t keep pace with the decreases Antidepressant Withdrawal Syndrome might occur.

https://www.survivingantidepressants.org/topic/392-one-theory-of-antidepressant-withdrawal-syndrome/?tab=comments#comment-4010

 

While tapering, we have emphasized listening to your body and keeping it slow. A person’s individual reactions to each reduction is quite important, and is, above all else the driving factor for the Endgame Taper. We now must modify our taper according to how our body reacts to each change.

 

How fast the tapers proceed depends on the symptoms a person experiences with each reduction. If there are even mild symptoms after a reduction, then more hold time may be required or possibly a small updose. Flexibility and patience are the keys to the Endgame Taper.

 

Listen to Your Body

 

Throughout the tapering process, we have stressed that it is important to listen to one’s body.  This becomes even more important during the Endgame Taper.

 

The point of tapering is to sneak the dose lower in such a manner as to stay within the body’s comfortable homeostasis bands. Ideally, our bodies will barely notice gradual dosage changes and are not thrown into chaos. This becomes a delicate process when we come to the Endgame Taper because the body is quite sensitive to changes, and the reductions are very tiny but still powerful.

 

By paying attention to any symptoms a person may need to make adjustments on a reduction-by-reduction basis. The amount of each reduction, the hold time, a possible small updose are all potential variables. In the end it is up to the individual to determine what is the right action at any given time.

 

Keep it Slow

 

This is the time to really listen closely to our body and following its dictates and not follow a calendar or a set schedule. It is very important not to rush the process. We all want to get off of the drug as soon as possible but, The Endgame Taper is not the place to speed things up.

 

As we enter the final stages of a taper, it is assumed that a person has performed a slow, smooth taper and is not experiencing heavy waves of symptoms.  If a person is still experiencing withdrawal symptoms, even for just a few days after a tiny reduction, it is an indication that an additional extended hold period may be needed to allow their nervous system to adjust to the tapering that has already been done. It may not yet be time for the Endgame Taper.

 

Before the Endgame Taper is attempted it may be a good idea to take a vacation from tapering. A final extended hold is a good thing to do before starting the Endgame Taper.  This will allow the body to catch up on drug changes, sort things out and consolidate the stabilizations it needs to proceed and make the final reduction to “0”. Just how long this hold lasts, is up to your body but don’t be tempted to rush things just to get it over with.

 

We also recommend before attempting the Endgame Taper that people switch to using some form of liquid medication, either Commercial, Compounded or Homemade. As the Endgame Taper progresses there will be small adjustments that need to be made to the dose strength. Liquids also provide the ability to easily make smaller and smaller reductions in dose strength. Because of the small doses involved a crossover from solid to liquid should not be necessary

 

The Endgame finishes with making the jump to ”0”. Even at this tiny dose the prospects of being drug free can be just as frightening as when one is starting a taper for the first time. If the thought of jumping to “0” causes discomfort, then holding for a while before making the final reduction should not be a problem until you gather the confidence to quit.

 

Terms and Acronyms

 

I will be using several acronyms for types of measurements in this article. They are ones you will see in many posts throughout the site.  These acronyms and others are defined here:

Brassmonkey's Tips and Tricks for Tapering - Tapering - Surviving Antidepressants

 

 

 

 

2. Determining the Target Exit Dose

How do you know at what dose to make the jump to “0”? Throughout a taper, as part of the Harm Reduction Philosophy, we have strived to keep WD symptoms to a minimum, and the same is true for making the final exit from the drugs. As pointed out elsewhere on the site, our journey doesn’t end at “0”. There is a post taper period that we need to pay attention to also.  https://www.survivingantidepressants.org/topic/23081-are-we-there-yet-how-long-is-withdrawal-going-to-take/?tab=comments#comment-492502 To do so we want to be as symptom free as possible when we make the jump.

 

Because of the different relative strengths of the various drugs, we deal with and how every individual reacts to those drugs, there is no specific Exit Dose that is universal. If a person has been tapering a drug prescribed at 300mgai they will have a larger dose at the end than someone who was tapering a drug that is prescribed at 7mgai.

 

The hyperbolic curve that we base our taper on comes from the SERT Occupancy charts. They show that specific amounts of a drug cause a specific “occupancy” or “down regulation” of the SERT receptors. The nice thing is that these charts are pretty much the same for all the different drugs.  So, following the curve is universal to determine the taper.

 

However, the dose strength associated with each percentage occupancy is not the same across the board. If the dose for 75% occupancy is 300mai for one drug and 7mgai for another, then the doses will be different throughout the curve.

 

As we have learned over the years, the lower the Exit Dose the better. There have been many numbers thrown out to pinpoint it. According to Horowitz & Taylor, 2019 and Horowitz, et al., 2021, tapering should proceed down to 1% receptor occupancy before making the final reduction to “0”.  https://doi.org/10.1016/S2215-0366(19)30032-X , https://doi.org/10.1093/schbul/sbab017

 

Using this idea, Horowitz & Taylor have determined the Target Exit Dose to be about 2.5% of the original prescribed dose, or roughly 1% capacity of the target receptor for each drug. With the caveat that if people are still feeling withdrawal every time they reduce, approaching that point they may need to taper further, and by smaller amounts. By using the methods described later, the dose can be reduced even further. Brassmonkey's Tips and Tricks for Tapering - Tapering - Surviving Antidepressants

 

 

The degree of withdrawal symptoms experienced in the later stages of the taper will determine the timing of the final jumping-off. Giving an exact dose is impossible, but your body will know when it is time. Remember though, if there are any symptoms following a reduction, further holds and reductions are recommended. Then, at some point, your body, not your mind, will say “enough of this already make the jump”.

 

Once we have determined the Target Exit Dose there are several options as to how to proceed with the Endgame Taper.

 

3. Using a Commercial, Compounded, or Homemade liquid for the Endgame Taper

 

Now that we know where we are going, how do we get there? The nice thing about doing a liquid taper is the flexibility it gives us and is why we recommend using liquids for the Endgame Liquid Taper if at all possible. As with all tapering, you will need to listen to your body and if you feel any symptoms after a reduction, stop tapering, and hold until those withdrawal symptoms go away.

 

Using the Endgame Liquid Taper allows us to make very small adjustment so we can creep down in dose while not disturbing our bodies. We can’t tell you what taper rate will be best, as that is now up to the individual to determine. Up to this point the recommended taper has been 10% every four (4) weeks. If this, or whatever taper rate you’ve been using has been working then that is a good place to start.

 

Homemade or Commercial Liquid Endgame Taper Method Overview

 

Using a liquid form of a drug -- homemade, commercial, or compounded -- gives a person the most control over their taper. By varying the dose volume, the dilution ratio or both, very precise measurements and reductions can be achieved. This makes it possible to continue a taper for as long as it is comfortable, with many people jumping to “0” at a fraction of a milligram.

 

 

 

Using an oral syringe

 

Droppers that may come with your liquid drug tend to be inaccurate for our purposes. Oral syringes based on the metric system are available in a variety of sizes with the smaller ones, 0.5mL, 1mL, or 2mL having very fine gradations to 0.01mL.

 

If you have been following a hyperbolic taper at 10% per month https://www.survivingantidepressants.org/topic/1024-why-taper-by-10-of-my-dosage/   a 0.5mL, 1mL, or 2mL oral syringe can enable you to continue a 10% taper or finer by measuring by the tick marks on the syringe, which can be as small as 1/100 milliliter (0.01mL). https://www.survivingantidepressants.org/topic/235-using-an-oral-syringe-and-other-tapering-techniques/?tab=comments#comment-2284  

 

 

Changing the dilution ratio to make the liquid easier to measure

 

Still, as the taper continues, you may find the volume of your dose becomes smaller and smaller until it can become quite difficult to measure even if you use the smallest oral syringe. With the help of a little math and different syringe sizes it is possible to fine-tune a reduction to a very tiny amount using liquids. Altering the Dilution Ratio can give you even finer control to measure out the tiniest doses with an oral syringe.

 

The Dilution Ratio is the strength of the drug in milligrams of active ingredient (mgai) divided by the volume of liquid in milliliters (mL). This works for both suspensions and solutions.

 

Adjustments in the dilution ratio can be made to any liquid, homemade, commercial, or compounded. Why would you want to make a liquid weaker? By adding water or pharmacy base liquid or other dilutant to your drug, you add volume to a dose. If you could not take 0.10mg because your oral syringe could not measure a small enough amount, increasing the volume while keeping the amount of drug the same but a weaker dilution will enable you to measure the tiny dose.

 

 

For example: if a person is using 20mg citalopram tablets and dissolves one tablet in 20mL of water, the resulting liquid is in a 1:1 Dilution Ratio:

 

- 20MGAI per 20mL of liquid is the same as - 1mgai in 1mL of liquid

 

To take 0.50mgai, you would take 0.50mL of the liquid. To take 0.1mgai, you would take 0.1mL of the liquid, or one 1/10 of a 1mL oral syringe.

 

The 1:1 Dilution Ratio liquid is the easiest to work with because any change in volume causes the same change in dose strength. Using 1mL of this liquid gives a dose of 1mgai. Reducing the volume by 10% to 0.9mL also decreases the dose strength by 10% to 0.9mgai.

 

Specific Information of Working with Dilution Ratios can be found here:Brassmonkey's Tips and Tricks for Tapering - Tapering - Surviving Antidepressants 

 

 

4. Using bead-counting for the Endgame Taper

 

Some drugs, for example Effexor XR (venlafaxine XR) and duloxetine (Cymbalta), come in the form of a gelatin capsules full of small beads. People using extended-release drugs in this form frequently will taper using the method referred to as “bead-counting”. Starting with the specific number of beads contained in a capsule they can reduce by a determined percentage by decreasing the number of beads that make up each dose.

 

Because of limitations in the manufacturing process, all the beads in the capsule are not of a uniform size. In the Endgame of a bead-counting taper, it is recommended that people try to graduate their dose by first taking the larger beads, then medium size beads, and finally the smallest beads. This method is not as accurate as we would like and going off one small bead may still be difficult.

 

WARNING NOTE

 

Another drug that comes in bead form is Cymbalta (duloxetine). Beads, tablets, and mini tablets of duloxetine (Cymbalta) cannot be split, crushed, or dissolved. Doing so will cause the drug to be rendered ineffective by stomach acid when it is swallowed. Bead-counting is the best way to taper duloxetine. https://www.survivingantidepressants.org/topic/283-tips-for-tapering-off-duloxetine-cymbalta/?tab=comments#comment-3034  

___________________________

 

For many brands of Effexor XR and Cymbalta, the small beads in a capsule make bead counting workable for the bulk of the taper, but may will cause a dilemma when we reach the Endgame. Some will find making the jump from 1mgai is too high for this drug. This is where using the graduated bead size method mentioned above comes in.

 

True, this is not the best taper, but it can get a person down to one tiniest bead of Cymbalta or Effexor. At that point, it might be a good idea to hold on tapering for 2-3 months, then make the jump to “0” It would be a good idea to have a supply of the tiniest beads on hand to use for rescue doses. This is the only situation where it would be okay to take the drug intermittently as the rescue dose would be taken off and on as needed for a few weeks.

 

More information on tapering by the Bead Counting Method can be found here: Brassmonkey's Tips and Tricks for Tapering - Tapering - Surviving Antidepressants

 

5. Using dry-cutting for the Endgame Taper

Tapering by dry-cutting means you are cutting up or pulverizing tablets and using a scale to weigh your doses. People who are using the Gemini-20 or similar scales to weigh out their dose should be aware that there is a lower limit at which those scales can weigh accurately. For the scales we commonly use, that limit is 4mgpw, or a reading on the display of 0.004g.

 

If it is at all possible to make your drug into a liquid, we recommend doing so in order to continue gradual hyperbolic tapering, rather than to continue dry-cutting.

 

Because of the small amount of active ingredient involved, making the switch to using a liquid preparation should be easier at this time. If a person is getting a noticeable spike in symptoms with each reduction, then it might be a good idea to consider switching from dry-cutting to liquid before attempting the Endgame Taper. This will allow for making more gradual and measured reductions. https://www.survivingantidepressants.org/topic/2693-how-to-make-a-liquid-from-tablets-or-capsules/  

 

People who have found in the past that they cannot tolerate a liquid or are very sensitive to dose changes, should consider having your final doses compounded for you. This will provide more accurate dosing and more control over the dose amount.

 

For those wishing to continue with dry-cutting on their own, we need to understand our scales just can’t do it and it would be hard even with expensive laboratory grade scales. The Endgame Taper for dry cutting will all be done by visually dividing a 4mgpw pile of powder into smaller and smaller parts. Because our measurement of doses will be so approximate, this last part of the taper is likely to be more linear than hyperbolic.

 

It’s important to understand that 4mgpw will not be the same amount of active ingredient across drugs. Normal dosage of sertraline, for example, is far higher than olanzapine, yet the tablets may be of similar weights.

 

Because olanzapine normally dosed at a much lower mgai than many other drugs, it will be harder to taper olanzapine by pulverizing the tablet and dividing the powder into smaller doses because each portion will contain a substantial amount of drug. Reaching the jumping off point may take a lot longer, more pulverizing, and finer visual division of the powder – with higher risk of withdrawal symptoms. Consequently, we do not recommend this method for drugs with prescription doses of 10-15mg or less.

 

More information on tapering by the dry cutting method can be found here: Brassmonkey's Tips and Tricks for Tapering - Tapering - Surviving Antidepressants

 

 

6. Making Adjustments to The Endgame Taper

 

Even in the Endgame, while taking a very tiny dose, it is still possible to feel symptoms with each reduction. Going too fast can cause a backlog of symptoms that can result in destabilization. You may wish to stop tapering and hold at the current dose for a prolonged period. If the symptoms are persistent after a reduction a small updose may be called for.

 

Be patient, the Endgame Taper can be finicky and frustrating. Throughout any taper we have stressed the importance of stabilizing after each dose before drawing any conclusions about that reduction. Many body systems are affected. Changes in the blood plasma concentration alone take a minimum of four (4) days and even longer for some drugs, to stabilize so it is important to allow enough time for each change to settle in before drawing conclusions.

 

It is always better to error on the side of caution and go with smaller reductions or longer hold periods and rounding dose sizes up instead of down. If things have been stabilizing nicely and there is a sudden flair up of symptoms it may be possible to use a slightly higher “rescue dose” to break the cycle and help to stabilize things. This however is not something that should be done on a regular basis, but rather as a “one shot” to get over a bad patch. If it needs to be done more frequently, then an adjustment to the reduction amount may be called for.

 

Information on using a Rescue Dose can be found here: Brassmonkey's Tips and Tricks for Tapering - Tapering - Surviving Antidepressants

 

 

Let the reaction of your body be your guide for how long to hold between cuts in the final phase of tapering off.  Quicker always sounds better, but it is important to be listening to what your body has to say, and not second guessing it, while doing these reductions. Being flexible and adjusting the speed of The Endgame Taper as needed is a key to success.

 

 

Edited May 10, 2022 by ChessieCat
corrected spelling error

[bubbles]

Hello Brassmonkey,

 

I wonder if I could ask a clarifying question? Is the idea that the Target Exit Dose (2.5% of high/original dose) is the dose immediately prior to the jump to zero, or rather a point at which you might start to go in "blunter"/bigger increments?

[brassmonkey]

The Target Exit Dose is the strength of the last dose you take before jumping to "0".

[bubbles]

Thank you brassmonkey. Much appreciated

[sarahw]

I calculated the accuracy of 0.001g scales in measuring dosages, based on a 10mg tablet weighing 78.5mg (which is what my citalopram tablets seem to be). Shown below.

 

If reductions of more than 10% are problematic, then surely day-to-day fluctuations (due to limited measurement precision) of 10% are also problematic. And the dosage at which this level of error is reached is about 0.6-0.7mg.

 

I can’t imagine creating a liquid suspension would improve that very much either.

[Faure]

When I create a liquid suspension I make up 4 or 5 days at a time so am weighing relatively large amounts (just now I did 0.098g*, I think - that’s for 4 days). I’ve been making a liquid since around February and have not had any destabilising effects so I think the accuracy is good enough; actually I feel better and better with every dose drop ☺️

 

* 0.098g pill weight, divided by 5 equals 2mg active ingredient of mirtazepine for me. 

 

I have written about my method on my thread but copied it below so you don’t have to go looking for it:

 

Quote

 

Method

 

 

I already have a spreadsheet of my BrassMonkey slide doses.

 

On Mondays I weigh 4 days worth of powder that I ground up myself and I will make 3 days worth of liquid. 

I measure 20ml of water using a 5ml syringe that a friend picked up at his local chemist.

I tip the powder into the 20ml of water and give it a good, gentle stir.

While the water is still swirling I draw up 5ml of water and dispense into a mini jam jar.

I repeat 2 more times (stirring is key to ensure even distribution of the powder across the water)

I keep the jars in the fridge
I dispose of the remaining liquid (I believe it is important to have more liquid than you need to account for losing it on the way and also so that there is enough liquid to keep the mixture swirling around for the final extract.) I am very suspicious of dregs where the particles settle so make sure when I draw up liquid I draw from the middle of the suspension (not at the bottom). 
This gives me 3 doses to use Mon - Wed 

 

On Thursdays I repeat but because this will do 4 days (thurs - sun) I use 25ml of water and weigh 5 days worth of powder.

 

The general opinion on SA is that homemade liquids last no longer than 4 days and it’s better to be safe than sorry. 

 

This is *really* easy to do and will work for quite some time as I’m weighing 3-4 days worth of powder at a time which means I’m weighing quite a large amount and the scales are accurate at these high amounts. At some point it will be necessary to change my method and when I get there I can share how I do that

 

•  

 

 

,

[LanaCoFireBird]

Hi, I have a clarifying question: 

I was originally prescribed 250 mg of lamictal. 
In 2017  I made a (too fast) taper down to 150 and have been on that for years until I started mg slow taper in 2023. 
 

would your reccomend 2.5% of 250 or 150 as a general goal? (I know it’s an art and not a science when we get to those really low dosages. 
 

I’m on 30 mgs now so my end game is pretty distant but I’m just thinking and planning ahead. 

[brassmonkey]

Are you trying to establish an endpoint for making the jump, or just a target point to start the Endgame Taper?

 

I would go with the lower dose of 150. 

[Daniel1269]

On 5/10/2022 at 8:47 PM, brassmonkey said:

Because of the small amount of active ingredient involved, making the switch to using a liquid preparation should be easier at this time.

Hi @brassmonkey,

 

When we get to 4mgpw if dry cutting,  is there any cross over period required from tablet to commercial/DIY liquid?

Or can we just go to the same AI dose with the liquid straight away given its a low amount with no cross over period?

 

Many Thanks.

[brassmonkey]

4mgpw can still have a fairly potent dose of Ai. Some people have very little tolerance for liquids and react poorly to the change. Which is why we recommend doing a crossover. With the small amounts required it would be fiddly, but it only takes a few weeks, and it is better to do that than to risk destabilization. In the end it is all up to the individual and how they feel, but I really recommend doing it.

[Daniel1269]

@brassmonkey

 

i.e 1/4 4mgpw visually 3/7 days? Then 1/2 4mgpw visually, 3/4 4mgpw etc. then full liquid from there on in?

 

Many Thanks.

[brassmonkey]

That's the ticket.

 

[Daniel1269]

 

 

On 5/10/2022 at 8:47 PM, brassmonkey said:

People who are using the Gemini-20 or similar scales to weigh out their dose should be aware that there is a lower limit at which those scales can weigh accurately. For the scales we commonly use, that limit is 4mgpw, or a reading on the display of 0.004g.

 

@brassmonkey
 
 

To bypass this issue could we not just place the calibration weight that weighs 10g alongside the tablet on the scale? 

 

So as opposed to just the tablet weighing 0.004g, it would weigh 10.004g paired with the weight?

 

This way a liquid transition would not be necessary, as we can get down to say 10.001g (1mgpw) by dry cutting?

 

Or even just alongside an uncut pill where the uncut pill weight is known?

 

(I.e 0.155g uncut pw, so the paired weight would be 0.159g pw if the desired mgpw was 0.004 g?) 

 

Let me know your thoughts?

You could possibly be referring to the fact that these scales cannot detect anything below 0.004g PW, in which case this question would be invalid, but just in case you aren’t referring to that.

 

Many Thanks.

[brassmonkey]

It is common practice to use the calibration weight, or any weight, in that manner. It does help, but there are lower limits to which the scales just won't go. Eventually the decreases will be so small that they are within the scales margin of error, so it will be impossible to get an accurate reading. I wrote about it here: Brassmonkey's Tips and Tricks for Tapering - Tapering - Surviving Antidepressants

 

[Daniel1269]

@brassmonkey,

 

I see, should I be using the 10g calibration weight even at the high mgpw like 0.155g to equal 10.155g or can I just use the pill by itself at this stage and use it when I get lower (if so, how low?).

 

Also, Dr Josef Witt Doering conducted an experiment with the GEM scale and an analytical balance and concluded that the GEM scale was only 2/3mg out from the Analytical Balance , and he recommended to potentially switch to liquid form below 80mgpw because of this, can i disregard this and carry on doen to 4mgpw with the GEM scale? He also said if it’s working for you just carry on until it doesn’t.

 

One final thing, can you explain why the AIC is relevant, I understand the calculation, however as both the MGAI and MGPW are proprtional, as long as you are consistently applying the same reduction percentages each time to the PW, this will correspond to the same percentage reductions in AI?

 

Is the AIC just something to be aware of or does it have any practicality?

 

Thank you so much again for all your continued advice/support.

[brassmonkey]

It's nice to see that someone has really checked out the scales and validated them. For the money they are a really good scale. The use of the extra weight is to throw the scale into the midrange of its sensitivity, where it is the most accurate. At the higher dose levels, it is already there so the extra weight is not needed. Where it really starts to get noticed is below the 10mgpw range.

 

The really important factor in measuring doses is not the actual weight of the dose, but rather consistency in how the dose is measured. With out advanced analytics it is impossible to actually know the actual mgai amount in each dose. So, the number we use becomes a reference point to aim for with each dose. By using the same equipment and process we try to make the mgpw as accurate as possible and as repeatable as possible. This will give a mgai that is very close to repeatable. The minor variations will average out over time, absorption rates and bioavailability. We are trying to maintain a constant blood plasm concentration range and the mgai controlls that.

 

The AIC is not commonly used, just a good thing to know. It is usually used to determine dosing if there is only one known variable. If you know either the mgpw or mgai you use it to calculate the other. It comes in quite handy when people are guessing at their dose or switching between pill and liquid.

 

As long as you are using the same pills the mgpw and mgai are in direct proportion and change the same way. If you change pills, either by strength or manufacturer the numbers can be different.

[Daniel1269]

1 hour ago, brassmonkey said:

The really important factor in measuring doses is not the actual weight of the dose, but rather consistency in how the dose is measured.

@brassmonkey,

 

Could an example of this be a full 50mg Sertraline tablet? We know that a full tablet is 50mgai, therefore we can use that as a baseline and calculate the desired mgpws and mgais accordingly?

 

1 hour ago, brassmonkey said:

If you change pills, either by strength or manufacturer the numbers can be different.

I agree, what I’m about to say is with reference the differing manufacturers, not strengths, but one way to manage this issue would be to simply weigh each pill individually regardless of manufacturer, and depending on the reduction number you are on ( for example, you are on the 3rd reduction of your taper) you can multiply the full pw that you’ve just recorded by 0.9^3 (if you are reducing the MGAI 10% each time) and this will output the desired pw needed for that reduction, do you agree?

 

Finally just for clarity, can i still go down to 4mgpw with the Gemini and add in the extra weight around 10mgpw?

 

Many Thanks.

[brassmonkey]

Yes, your Sertraline example is workable.

 

Yes, going down to 4mgpw and using the weight will work nicely. Thats how I did it.

 

Weighing each tablet each time is a workable way to get around the problem. But it brings in a lot of calculations and extra weighing that increases the possibility of making an error. Most people don't face the problem of changing manufacturers more than once or twice during their taper. So, it could lead to a lot of extra work for nothing. Also, very many of our members are mathematically challenged making anything more than a very basic calculation a problem.

[Daniel1269]

@brassmonkey,

 

Firstly, thank you so much for your response above.

 

If my GEM scale has a maximum capacity of 50g and comes with two 20g calibration weights, shall I use both of these weights to bring the scale into its midrange, or just use one of the two weights, I assume the latter?

 

Also, is it preferable to start using the calibration weight/s even at the higher pill weights and not just below 10mgpw for a chance at better accuracy? If so I will start using the weight when I next carry out my dry cuts.

 

Many Thanks.

[OffPills]

Hi @brassmonkey,

 

I’m preparing my next step in tapering.

My citalopram liquid doesn’t contain water, but it does contain ethanol (96%). So I bought ethanol (96%) to dilute my liquid. I would rather dilute my liquid with something less strong, because of my issues with acid reflux and inflamed esophagus. What are your thoughts about this and can you confirm using ethanol is the right way forward?

 

 

[brassmonkey]

@OffPills I would go with regular vodka if you want to go with alcohol. By diluting the liquid, you will be increasing the volume of the dose. This could lead to unwanted side effects from the larger volume of alcohol.

 

Water and alcohol work very well together in solution, so, you shouldn't have a problem using it to dilute your meds.

[brassmonkey]

@Daniel1269 only one weight is needed. It shouldn't make a difference when you start using it, it is all up to how difficult it is to work with.

[Daniel1269]

Thank you🙏

[OffPills]

19 minutes ago, brassmonkey said:

@OffPills I would go with regular vodka if you want to go with alcohol. By diluting the liquid, you will be increasing the volume of the dose. This could lead to unwanted side effects from the larger volume of alcohol.

 

Water and alcohol work very well together in solution, so, you shouldn't have a problem using it to dilute your meds.

Thank your for your quick response,

 

Because you mentioned the following in your ‘tips and tricks’ thread:

 

Before diluting a commercial liquid check the packaging for instructions. Many can be diluted with water, but some can’t, so it is best to check. If water is listed on the ingredients, then it is okay to add.

 

So I bought the ethanol (96%) and was not going to dilute with water, because the label says it doesn’t contain water. So just to make sure, your advise is to use alcohol, being vodka or ethanol?

[Terry]

As BrassMonkey said "Water and alcohol work very well together in solution."  So you should be able to use water to make your dilutions of citalopram liquid.  Best of luck with your taper!

 

Terry

[brassmonkey]

Using the alcohol would be fine, either one. Just be careful with the size of your dose so you are not affected by the alcohol.