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PortugueseSea: Metoclopramide, Akathisia and Mirtazapine - Introduction and Advice


PortugueseSea

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Hello everyone,

 

I guess I might be an outlier here. My journey into the hellscape of psychiatry started with an anti-emetic, metoclopramide, to which I had a terrible reaction which amounted for what I now know to be akathisia. Now I know that drug mimics or is similar to anti-psychotics.

I took the drug at high doses for 20 days in December (10mg x3 day) for a nausea problem and it nearly destroyed my life. After that I took it as needed and only realized it was causing and keeping my akathisia going at the end of February.

 

My restlessness appeared first with the typical akathisia movements only appearing after discontinuation. I was taken off the drug suddenly and my symptoms got worse after discontinuation. March and April I tried winging it without any medicine but the waves were so violent that I eventually caved and tried propranolol, didn't help. Biperiden, an anti-cholinergic, did help but had nasty side effects.

 

Now it's May and here is the conundrum:

 

I started tandospirone to help with anxiety a month ago. I also started on Mirtazapine recently as the propranolol doesn't help. First, 7.5mg in the evening, that was a month ago. I got a 10 day window, the best until now. Then I had a bad crisis and my psychiatrist upped my dose to 15mg. I got a nice 7 day window, then another crisis, that was a week ago.

 

That crisis has passed. Yesterday I had a good day, today I am worse again. It is a rollercoaster. I don't know how I'm holding my job.

I guess I have two questions.

 

1) Should I stay on the drug or not? This is something I have to decide by next Friday, that's my psych appointment day.

2) Given that I have only been on the drug around 1 month, two weeks on 7.5mg and two weeks on 15mg, would I need to taper if I chose to stop? If yes, how fast or slow would be advised?

Any advice would be greatly appreciated.

 

Taking it one day at the time here. Very rough.

 

PortugueseSea

Early December 2021 - Started Metroclopramide (Anti-Emetic) nausea 30mg (10mg 3x day).

Mid December 2021 - Akathisia symptoms start; Metroclopramide gets changed to PRN, taken 5mg, first every other day, then once every 3 days.

Early March 2022 - Akathisia diagnosed; Metroclopramide stopped; started Propranolol 10mg x twice a day to no effect, Biperiden PRN (0.5mg to 1mg).

Early April 2022 - Started Tandospirone 30mg (10mg 3x day), Quetiapine 25mg (only taken once, it skyrocketed symptoms).

Mid April 2022 - Mirtazapine 7.5mg, 10 day window followed. Discontinued Propranolol.

1st of May 2022 - Akathisia symptoms continue, Mirtazapine upped to 15mg. 7 day window followed. Tandospirone cut to 2x 10mg.

20th of May 2022 - Mirtazapine cut back to 11.75mg (1/4 of a 15mg pill).

Current regimen: Mirtazapine at bedtime for akathisia/sleep/anxiety/depression, 11,75mg; Tandospirone after breakfast and lunch for anxiety, 10mg BID; Biperiden PRN 0.5mg to 1mg.

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  • PortugueseSea changed the title to Metoclopramide, Akathisia and Mirtazapine (Introduction and Advice)
  • ChessieCat changed the title to PortugueseSea: Metoclopramide, Akathisia and Mirtazapine - Introduction and Advice
  • Administrator

Welcome, @PortugueseSea

 

On 5/14/2022 at 8:53 AM, PortugueseSea said:

I started tandospirone to help with anxiety a month ago. I also started on Mirtazapine recently as the propranolol doesn't help. First, 7.5mg in the evening, that was a month ago. I got a 10 day window, the best until now. Then I had a bad crisis and my psychiatrist upped my dose to 15mg. I got a nice 7 day window, then another crisis, that was a week ago.

 

You're taking these drugs for the symptoms resulting from your use of metoclopramide? What did akathisia feel like to you?

 

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

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5 hours ago, Altostrata said:

You're taking these drugs for the symptoms resulting from your use of metoclopramide? What did akathisia feel like to you?

Yes, all my symptoms, including akathisia, anxiety and depression came as a result of my use of metoclopramide. They started within two weeks of me starting the med. At first, I just thought it was all a result of the "stress" of having nausea from an undiagnosed condition.

Akathisia feels well, it depends on how bad it is:

 

A ) If It is really bad it feels like my skull is being crushed from behind or the top, wanting to crawl out of my skin and an unfathomable feeling of despair, my.body.cannot.calm.down. Add to that pacing and fidgeting. I can't function, I just take the Biperiden and it helps. While I wait for it to kick in I just cry. It is a life saver, no matter how much I hate the side effects (making me feel half drunk, slurred speech etc.). Rather than feeling suicidal, I just want to be knocked out.

 

B ) On a "normal" day, it is a sense of discomfort that stops me from focusing on work or daily tasks, I keep crossing and uncrossing my legs and have this feeling of agitation/restlessness at all times. I suffer through my day like that. Can't enjoy anything, anhedonia is pretty bad. This comes with a lot of despair. Suicidal ideation happens at times, mostly morning.

 

Evenings are often 70% free of symptoms.

 

C ) In a window I feel mostly normal, a bit on edge, plenty of anxiety, with a touch of depersonalization. Too bad windows have been partial at best.

 

 

 

Have updated my signature! Thanks!!

Early December 2021 - Started Metroclopramide (Anti-Emetic) nausea 30mg (10mg 3x day).

Mid December 2021 - Akathisia symptoms start; Metroclopramide gets changed to PRN, taken 5mg, first every other day, then once every 3 days.

Early March 2022 - Akathisia diagnosed; Metroclopramide stopped; started Propranolol 10mg x twice a day to no effect, Biperiden PRN (0.5mg to 1mg).

Early April 2022 - Started Tandospirone 30mg (10mg 3x day), Quetiapine 25mg (only taken once, it skyrocketed symptoms).

Mid April 2022 - Mirtazapine 7.5mg, 10 day window followed. Discontinued Propranolol.

1st of May 2022 - Akathisia symptoms continue, Mirtazapine upped to 15mg. 7 day window followed. Tandospirone cut to 2x 10mg.

20th of May 2022 - Mirtazapine cut back to 11.75mg (1/4 of a 15mg pill).

Current regimen: Mirtazapine at bedtime for akathisia/sleep/anxiety/depression, 11,75mg; Tandospirone after breakfast and lunch for anxiety, 10mg BID; Biperiden PRN 0.5mg to 1mg.

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Why did you just reduce mirtazapine? What effect does it have on you? What effect do you feel from tandospirone? What effect from Biperiden?

 

Please put ALL your drugs in the Drug Interactions Checker https://www.drugs.com/drug_interactions.php

and copy and paste the results or a link to them in this topic.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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On 5/21/2022 at 10:43 PM, Altostrata said:

Why did you just reduce mirtazapine?

The reason was that at higher doses Mirtazapine is more stimulating. As I got better right after upping from 7.5mg to 15mg, when the serum concentration was in between 7.5mg and 15mg,  an intermediate dose could be best to stabilize my CNS. Therefore the 11.75mg, 3/4 of the smallest pill available in Japan.

 

On 5/21/2022 at 10:43 PM, Altostrata said:

What effect does it have on you?

Mirtazapine helps me sleep, which the akathisia symptoms prevented. It also stimulates my appetite and calms my breathing. Akathisia-wise, it does not seem to do much beyond that. I did experience suicidal ideation and restlessness the next day when I first upped to 15mg but, as previously mentioned, that could have been the akathisia. I was hoping it would stabilize my nervous system given it is considered first line therapy. I have not noticed considerable side effects except mild sedation and sugar cravings. 

 

On 5/21/2022 at 10:43 PM, Altostrata said:

What effect do you feel from tandospirone?

Tandospirone has helped control crying spells, I noticed that after starting it they have become less common. These normally happened when akathisia symptoms are at their worst, morning and lunch time. I am thinking about discontinuing this last. Side-effects wise, for the first two weeks I did feel mild sedation for a couple of weeks of starting. 

On 5/21/2022 at 10:43 PM, Altostrata said:

What effect from Biperiden?

Biperiden reduces head pressure and restlessness during an akathisia crisis. Normally, a 0.5mg dose is sufficient. If it is particularly excruciating I take 1mg and cry until the worse has passed.

Side-effect wise it is a myriad. I feel like I am drunk, have slurred speech, hampered thought process, and derealization.

Early December 2021 - Started Metroclopramide (Anti-Emetic) nausea 30mg (10mg 3x day).

Mid December 2021 - Akathisia symptoms start; Metroclopramide gets changed to PRN, taken 5mg, first every other day, then once every 3 days.

Early March 2022 - Akathisia diagnosed; Metroclopramide stopped; started Propranolol 10mg x twice a day to no effect, Biperiden PRN (0.5mg to 1mg).

Early April 2022 - Started Tandospirone 30mg (10mg 3x day), Quetiapine 25mg (only taken once, it skyrocketed symptoms).

Mid April 2022 - Mirtazapine 7.5mg, 10 day window followed. Discontinued Propranolol.

1st of May 2022 - Akathisia symptoms continue, Mirtazapine upped to 15mg. 7 day window followed. Tandospirone cut to 2x 10mg.

20th of May 2022 - Mirtazapine cut back to 11.75mg (1/4 of a 15mg pill).

Current regimen: Mirtazapine at bedtime for akathisia/sleep/anxiety/depression, 11,75mg; Tandospirone after breakfast and lunch for anxiety, 10mg BID; Biperiden PRN 0.5mg to 1mg.

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DRUG INTERACTIONS:

https://www.drugs.com/interactions-check.php?drug_list=1640-0,384-0
Mirtazapine and Biperiden;

 

Please not that Tandospirone was not included due to now showing up in the search engine; it being generally only used in East Asia might be the reason. 

Early December 2021 - Started Metroclopramide (Anti-Emetic) nausea 30mg (10mg 3x day).

Mid December 2021 - Akathisia symptoms start; Metroclopramide gets changed to PRN, taken 5mg, first every other day, then once every 3 days.

Early March 2022 - Akathisia diagnosed; Metroclopramide stopped; started Propranolol 10mg x twice a day to no effect, Biperiden PRN (0.5mg to 1mg).

Early April 2022 - Started Tandospirone 30mg (10mg 3x day), Quetiapine 25mg (only taken once, it skyrocketed symptoms).

Mid April 2022 - Mirtazapine 7.5mg, 10 day window followed. Discontinued Propranolol.

1st of May 2022 - Akathisia symptoms continue, Mirtazapine upped to 15mg. 7 day window followed. Tandospirone cut to 2x 10mg.

20th of May 2022 - Mirtazapine cut back to 11.75mg (1/4 of a 15mg pill).

Current regimen: Mirtazapine at bedtime for akathisia/sleep/anxiety/depression, 11,75mg; Tandospirone after breakfast and lunch for anxiety, 10mg BID; Biperiden PRN 0.5mg to 1mg.

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23 minutes ago, PortugueseSea said:

Please not that Tandospirone was not included due to now showing up in the search engine; it being generally only used in East Asia might be the reason. 

 

Here is a page where you can check for individual drug interactions.  Under the heading Interactions there is a list of drugs.  At the top right of the list you can Search for a drug.

 

https://go.drugbank.com/drugs/DB12833

 

According to this from Wikipedia it is closely related to buspirone:

 

"Tandospirone is an anxiolytic and antidepressant drug used in China and Japan, where it is marketed by Dainippon Sumitomo Pharma. It is a member of the azapirone class of drugs and is closely related to other azapirones like buspirone and gepirone."

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Thank you very much!
 

Mirtazapine and Tandospirone:

 

Tandospirone may increase the serotonergic activities of Mirtazapine.

 

Mirtazapine and Biperiden:

 

Tandospirone may increase the central nervous system depressant (CNS depressant) activities of Biperiden.

 

 

Early December 2021 - Started Metroclopramide (Anti-Emetic) nausea 30mg (10mg 3x day).

Mid December 2021 - Akathisia symptoms start; Metroclopramide gets changed to PRN, taken 5mg, first every other day, then once every 3 days.

Early March 2022 - Akathisia diagnosed; Metroclopramide stopped; started Propranolol 10mg x twice a day to no effect, Biperiden PRN (0.5mg to 1mg).

Early April 2022 - Started Tandospirone 30mg (10mg 3x day), Quetiapine 25mg (only taken once, it skyrocketed symptoms).

Mid April 2022 - Mirtazapine 7.5mg, 10 day window followed. Discontinued Propranolol.

1st of May 2022 - Akathisia symptoms continue, Mirtazapine upped to 15mg. 7 day window followed. Tandospirone cut to 2x 10mg.

20th of May 2022 - Mirtazapine cut back to 11.75mg (1/4 of a 15mg pill).

Current regimen: Mirtazapine at bedtime for akathisia/sleep/anxiety/depression, 11,75mg; Tandospirone after breakfast and lunch for anxiety, 10mg BID; Biperiden PRN 0.5mg to 1mg.

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10 hours ago, PortugueseSea said:

The reason was that at higher doses Mirtazapine is more stimulating.

 

15mg mirtazapine is not a high dose of mirtazapine. How has the reduction to 11.75mg affected your sleep?

 

If your symptoms increased after reducing mirtazapine, I would restore 15mg mirtazapine. It's posslble you are taking the other 2 drugs unnecessarily, and the sleep induced by mirtazapine will enable very slow recovery, as we see from psychiatric drugs. You can taper off mirtazapine later.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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13 hours ago, Altostrata said:

 

15mg mirtazapine is not a high dose of mirtazapine. How has the reduction to 11.75mg affected your sleep?


My sleep as been unaffected or even improved. I really think sleep is crucial, it gives me a break from akathisia and allows my brain to heal.

 

13 hours ago, Altostrata said:

If your symptoms increased after reducing mirtazapine, I would restore 15mg mirtazapine.

Noted, they haven’t though. I had a smaller crisis yesterday but nothing compared to last week or 10 days ago.

 

13 hours ago, Altostrata said:

It's posslble you are taking the other 2 drugs unnecessarily

The Tandospirone definitely. I have often wondered about that.


 

13 hours ago, Altostrata said:
13 hours ago, Altostrata said:

It's posslble you are taking the other 2 drugs unnecessarily, and the sleep induced by mirtazapine will enable very slow recovery, as we see from psychiatric drugs

 

The Biperiden I take as little as possible, only in a full blown crisis. PRN, I figured it’s better than taking an emergency benzodiazepine. It calms my system down.

 

I am definitely willing to consider alternatives though!

 

Could you elaborate on the Mirtazapine sleep helping? I definitely feel well rested. I was just worried that at 15mg it could be contributing to the akathisia as the time I felt best was in the 7.5mg to 15mg transition.

Early December 2021 - Started Metroclopramide (Anti-Emetic) nausea 30mg (10mg 3x day).

Mid December 2021 - Akathisia symptoms start; Metroclopramide gets changed to PRN, taken 5mg, first every other day, then once every 3 days.

Early March 2022 - Akathisia diagnosed; Metroclopramide stopped; started Propranolol 10mg x twice a day to no effect, Biperiden PRN (0.5mg to 1mg).

Early April 2022 - Started Tandospirone 30mg (10mg 3x day), Quetiapine 25mg (only taken once, it skyrocketed symptoms).

Mid April 2022 - Mirtazapine 7.5mg, 10 day window followed. Discontinued Propranolol.

1st of May 2022 - Akathisia symptoms continue, Mirtazapine upped to 15mg. 7 day window followed. Tandospirone cut to 2x 10mg.

20th of May 2022 - Mirtazapine cut back to 11.75mg (1/4 of a 15mg pill).

Current regimen: Mirtazapine at bedtime for akathisia/sleep/anxiety/depression, 11,75mg; Tandospirone after breakfast and lunch for anxiety, 10mg BID; Biperiden PRN 0.5mg to 1mg.

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Just came from the doctor. The last few days I have been more stable and akathisia symptoms have been mild, if that is even possible.

 

I have decided to stay where I am, 11.25mg Mirtazapine and 10mgx2 a day Tandospirone. My psychiatrist suggested staying on this regimen for at least a year. Thing is, I would like to start tapering way sooner than that.

My doctor mentioned that the compound pharmacies would not allow me to go very very slow so I guess I am stuck making powder for my taper (?). Don't trust myself to handle the liquid.

 

Thank you so much for all the suggestions!

 



 

Early December 2021 - Started Metroclopramide (Anti-Emetic) nausea 30mg (10mg 3x day).

Mid December 2021 - Akathisia symptoms start; Metroclopramide gets changed to PRN, taken 5mg, first every other day, then once every 3 days.

Early March 2022 - Akathisia diagnosed; Metroclopramide stopped; started Propranolol 10mg x twice a day to no effect, Biperiden PRN (0.5mg to 1mg).

Early April 2022 - Started Tandospirone 30mg (10mg 3x day), Quetiapine 25mg (only taken once, it skyrocketed symptoms).

Mid April 2022 - Mirtazapine 7.5mg, 10 day window followed. Discontinued Propranolol.

1st of May 2022 - Akathisia symptoms continue, Mirtazapine upped to 15mg. 7 day window followed. Tandospirone cut to 2x 10mg.

20th of May 2022 - Mirtazapine cut back to 11.75mg (1/4 of a 15mg pill).

Current regimen: Mirtazapine at bedtime for akathisia/sleep/anxiety/depression, 11,75mg; Tandospirone after breakfast and lunch for anxiety, 10mg BID; Biperiden PRN 0.5mg to 1mg.

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On 5/24/2022 at 3:15 AM, PortugueseSea said:

The Biperiden I take as little as possible, only in a full blown crisis. PRN, I figured it’s better than taking an emergency benzodiazepine. It calms my system down.

 

Do you find biperiden helpful PRN? It's not usually dosed like that.

 

If you find 11.25mg mirtazapine helps you sleep, it if works, it works.

 

On 5/27/2022 at 9:11 AM, PortugueseSea said:

My doctor mentioned that the compound pharmacies would not allow me to go very very slow

 

In other countries, compound pharmacies make up doses according to the doctor's order. So your doctor probably is wrong.

 

As your situation really involves adverse effects from a drug that is not a psychiatric drug -- not withdrawal -- and you are under the care of a psychiatrist, it's outside the purview of this site. Please let us know when you want to taper a psychiatric drug.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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2 hours ago, Altostrata said:

Do you find biperiden helpful PRN? It's not usually dosed like that.


Yes, one hour after taking it it provides some relief of the akathetic movements and mental akathisia, more the former than the latter. Yeah, the dosing is unusual, I was originally on it twice daily but my doctor changed it to PRN. I sometimes wonder if I that was wise...

 

2 hours ago, Altostrata said:

In other countries, compound pharmacies make up doses according to the doctor's order. So your doctor probably is wrong.

Thank you so much for this info, I am confident I can push for those small reductions now!

 

2 hours ago, Altostrata said:

As your situation really involves adverse effects from a drug that is not a psychiatric drug -- not withdrawal -- and you are under the care of a psychiatrist, it's outside the purview of this site. Please let us know when you want to taper a psychiatric drug.

Well, as far as I am aware, being a dopamine antagonist Metroclopramide is psychotropic, no matter what the label says. It can definitely damage the CNS.
https://www.ema.europa.eu/en/news/european-medicines-agency-recommends-changes-use-metoclopramide

As for not being a withdrawal... well, I am not sure. My symptoms escalated after discontinuing a psychotropic drug that can cause withdrawal (refer to the article below for an example), so I do not see any other way to interpret what has been happening to me. My doctor surely thinks my escalation of symptoms was due to the discontinuation of the med.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1002885/pdf/westjmed00106-0072.pdf

I very much want to start tapering the Tandospirone and or the Mirtazapine as soon as I feel stable enough!

Thank you so much for the help and advice!

Early December 2021 - Started Metroclopramide (Anti-Emetic) nausea 30mg (10mg 3x day).

Mid December 2021 - Akathisia symptoms start; Metroclopramide gets changed to PRN, taken 5mg, first every other day, then once every 3 days.

Early March 2022 - Akathisia diagnosed; Metroclopramide stopped; started Propranolol 10mg x twice a day to no effect, Biperiden PRN (0.5mg to 1mg).

Early April 2022 - Started Tandospirone 30mg (10mg 3x day), Quetiapine 25mg (only taken once, it skyrocketed symptoms).

Mid April 2022 - Mirtazapine 7.5mg, 10 day window followed. Discontinued Propranolol.

1st of May 2022 - Akathisia symptoms continue, Mirtazapine upped to 15mg. 7 day window followed. Tandospirone cut to 2x 10mg.

20th of May 2022 - Mirtazapine cut back to 11.75mg (1/4 of a 15mg pill).

Current regimen: Mirtazapine at bedtime for akathisia/sleep/anxiety/depression, 11,75mg; Tandospirone after breakfast and lunch for anxiety, 10mg BID; Biperiden PRN 0.5mg to 1mg.

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It's possible you do have withdrawal effects from metroclopramide, but we do not address every psychotropic. Akathisia is a known adverse effect of the drug, see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2993902/

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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  • 3 weeks later...

Thank you so much for the replies!

 

I have taken your advice to heart and talked with my doctor. We have decided to stop both the Tandospirone and the PRN Biperiden. We have also reinstated the Mirtazapine at 15mg. Very low dose Valproate (Depakote, 100mg) was added because it helps increase GABA levels.

 

I am also to take Clonazepam PRN (0.5mg) if things get desperate. Fortunately they have not and I have started to slowly stabilize. My doctor and I are very happy and she has accepted to taper the Mirtazapine very slowly in the future.

 

Thank you so so much. Will update my signature.

Early December 2021 - Started Metroclopramide (Anti-Emetic) nausea 30mg (10mg 3x day).

Mid December 2021 - Akathisia symptoms start; Metroclopramide gets changed to PRN, taken 5mg, first every other day, then once every 3 days.

Early March 2022 - Akathisia diagnosed; Metroclopramide stopped; started Propranolol 10mg x twice a day to no effect, Biperiden PRN (0.5mg to 1mg).

Early April 2022 - Started Tandospirone 30mg (10mg 3x day), Quetiapine 25mg (only taken once, it skyrocketed symptoms).

Mid April 2022 - Mirtazapine 7.5mg, 10 day window followed. Discontinued Propranolol.

1st of May 2022 - Akathisia symptoms continue, Mirtazapine upped to 15mg. 7 day window followed. Tandospirone cut to 2x 10mg.

20th of May 2022 - Mirtazapine cut back to 11.75mg (1/4 of a 15mg pill).

Current regimen: Mirtazapine at bedtime for akathisia/sleep/anxiety/depression, 11,75mg; Tandospirone after breakfast and lunch for anxiety, 10mg BID; Biperiden PRN 0.5mg to 1mg.

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This topic contains links to other informative topics:

 

Important topics in the Tapering forum and FAQ

 * * * * * *   PLEASE WATCH THIS VIDEO   * * * * * *

Antidepressant Withdrawal Syndrome and its Management

 

MISSION ACCOMPLISHED:    (6 year taper)      0mg Pristiq      on 13th November 2021

Woohoo!!!  Finally off Pristiq    Post 0 updates start here

ADs since ~1992:  25+ years - 1 unknown, Prozac (muscle weakness), Zoloft; citalopram (pooped out) CTed (very sick for 2.5 wks a few months after); Pristiq:  50mg 2012, 100mg beg 2013 (Serotonin Toxicity)  Tapering from Oct 2015 - 13 Nov 2021   LAST DOSE 0.0025mg

My full tapering program     My Intro (goes to my tapering graph)    My website

PLEASE NOTE:  I am not a medical professional.  I provide information and make suggestions. 

Please DO NOT TAG me - thank you.

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