ClaraC: Needing tapering advice

[ClaraC]

Hello,

 

I have a tapering conundrum that I would love some advice with. I have been on 45 mg of Amitryptilline since 2016 ( this was down from 75mg prescribed in December 2014, was able to self-taper). The reason I was put on it was after suffering from severe life stressors, I completely lost the ability to sleep and had uncontrolled anxiety. I felt like my brain “broke”. After trying everything natural for a year I got desperate for sleep and landed on this tricyclic AD. It helped tremendously and I was like a new person….for a few years. The side effects have caught up with me and I really need to go way down or possible completely off ( my dream). The side effects are a resting high heart rate in the 90’s always ( even when super calm), and it raises norepinephrine so even though it gives a nice sedative effect at night and I do sleep, I always feel a bit wired and “ on” due to a constant high adrenaline level.

So that’s where Klonopin (benzo) comes in. I have taken that (0.25 mg at night) for those days or nights where I was extra stressed and the sedative effects of the AD did not do the job. I used it on and off ( maybe once or twice a week) for years. It got to a point where the adverse effects of the AD were just too much (high HR and anxiety) and last June (2022) I started taking 0.25mg klonopin every night. This helped me sleep a bit deeper and calm me during the day for a few months. Well fast forward all these months and I think the combo of these drugs have just made things worse. I think the AD speeds up the metabolism of the benzo and by morning I have a huge cortisol surge, have to poop, and go eat before my blood sugar drops. Then I have cortisol surges throughout the day, which I really didn’t have before taking it every night. I think I have probably reached tolerance or maybe even interdose withdrawl since I just take it once a night.

 

I am at a point now where both drugs have adverse effects and I need to get off of them. But which to taper first? I read the entire thread on this site about it and I think Amitryptilline ( being a tricyclic) would qualify as both an “accelerator” and a “brake”, and the benzo a “brake”. I have not been on the benzo as long as the AD and I am on a relatively low dose, so does it make sense to taper off that first? My CNS is already in a weakened state and going off the benzo would destabilize it, making it hard to taper the AD. So my thought is to updose the benzo to 0.25mg in the AM too and cover me for 24 hours and then start the AD taper, and focus on benzo taper much later. OR I could just go ahead and taper off the low dose benzo now, rest my CNS for a bit and then tackle the AD taper. 
Something has to go first, so I am in need of help as to which. Thank you in advance for any input.

[Onmyway]

Hi @ClaraC

welcome to SA. Sorry you are dealing with these issues. I am consulting with the other moderators as well to see what the best advice is. 

Have you considered splitting the current dose of 0.25mg clonazepam into half (morning/evening) instead of doubling the dose? Can you give us a symptom diary for a few days so we can advise better i.e. what time you take your medicine, what and what symptoms you experience.

 

Might look something like this. If you already have this just post it but if not, you pls track your symptoms for a few days: 

 

7 am wake up, breakfast, TCA

8 am work, feeling wired

9 am nausea, ruminating, high adrenaline 

.

.

.

11 pm clonazepam 0.25mg, can't sleep 

1 am sleep 

 

OMW

Edited April 10, 2023 by Onmyway

[ClaraC]

Thank you OMW for your reply.

I have not tried splitting the dose yet. Would that be a good idea since during the night my body would expect the bigger amount? I don’t mind trying it if it would work.

 

my day is like this: I eat mostly gluten and dairy free

 

8:00 wake up usually with cortisol surge and need to go poo. Feel better after. Blood sugar begins to drop, eat breakfast of 2 eggs, avocado, fruit. Always feel much better after the eggs and fruit,

10:00: green smoothie of spinach, blueberries, almond butter cherries and apple slice

12:00: lunch of chicken and brown rice or meat and brown rice ( sometimes white)

3:00: snack of nuts/bone broth

6:00: dinner is usually same as lunch

8:30: take 45mg of Amitryptilline ( this will always give me carb cravings within an hour so I need a before bed snack, usually a piece of bread or chips to satisfy. I cannot sleep without a bit of carb)

9:00-9:30 snack of piece of bread, GF crackers and nuts

10:00: 0.25mg klonopin

10:30: usually asleep

 

usually in between meals I might have a cortisol surge mimicking anxiety but not always. If I skip a meal or let my blood sugar drop then I get the cortisol surges for sure. For instance today since I was home all day I kept up on my meals and had very few cortisol surges. But yesterdy I was out and about and less structured with my meals and had several cortisol surges when I did not eat on time.

Heart rate is always in 90’s resting, low level of adrenaline always noticed, but especially noticed if stressed or busy or ruminating

 

I hope this helps. Let me know if I need to include more.

[Onmyway]

Hi @ClaraC, 

thank you for the detailed symptom report. It would be more helpful if you made it more about the symptoms and less about the food. We are trying to understand whether your symptoms are from interdose withdrawal or from adverse effects of the drug. 

 

Is your only symptom cortisol surges? When did the cortisol surges start? 

I am not sure whether this is interdose withdrawal - clonazepam has a really long half life so it wouldn't be expected, or it is an adverse drug reaction from the clonazepam or possibly tolerance. If you remember the timing - when it started - that may help. 

 

Will non-drug techniques help manage the cortisol surges? We find that having blackout curtains can help lessen or eliminate cortisol surges in the morning. Meditation/deep breathing can help during the day and in your case seems like blood sugar control is helpful. Do you actually measure your blood sugar (this you can do without a prescription I think - you can buy the testing equipment over the counter even if you are not diabetic). Might be worth it to see what is happening because it seems like that is the culprit rather than anything related to clonazepam.

 

When you say low adrenaline, are you measuring this or is this your guess of what is happening? What do your cortisol surges feel like? 

 

I would be very reluctant to recommend doubling your dose of clonazepam because that means double the time of tapering and tapering, even when done slowly, can sometimes lead to difficult symptoms.

 

Other moderators with more experience with benzos will come by to help out soon as well. Hang on! 

OMW

[ClaraC]

Thank you for the reply!

I actually had a bunch of blood tests done yesterday including fasting blood sugar, A1C, thyroid, etc. i am also getting my stool checked for leaky gut and a saliva cortisol test. So when I get those results I will have more info to share.

 

my cortisol surges are most pronounced as I awaken around 7:30-8:00 AM. Those usually makes me need to go poo, which makes me feel better. It feels like my blood sugar also drops too because I feel shaky, nauseous like I really need to eat and feel immediately better after a few bites of food.

 

I generally have cortisol surges or rushes throughout the day, especially when I am out doing something like shopping. Any little extra thing brings them on and in my head I dont feel anxious but my body says otherwise. And I meant to say I feel high adrenaline from the AD before, not low. Sorry. The reason I started the daily Klonopin 9 months ago was because of the side effects of the AD. It gives me a constant high resting heart rate in the 90’s and it being a nor-adrenergic reuptake inhibitor, also keeps my adrenaline high. I feel “on” all the time. It is interesting that most people gain weight on Amitriptylline and yes I have gained some (15 lbs) but with the high adrenaline I hit a plateau and its actually really easy to lose weight (and muscle mass) if I dont eat very regularly. And then possibly hitting tolerance with the Klonopin, I really feel a sped up metabolism. The reason I have stayed on the Ami for so long is that it does give me a good night of sleep, otherwise I would have gone off a long time ago. I wish I would have before I started the daily K.  Its like the mix of these drugs together are giving me bad reactions
 

when I first started the daily klonopin 9 months ago I had some extra life stressors and it seems that after that and especially this year so far, the klonopin has pooped out and I feel like I am in tolerance. So it is hard to know how much of my current symptoms are from the klonopin or the Amitriptilline or the combo of the two. I know it is time to taper and I hear you on not wanting to updose (I would rather not if I can help it), but I also need to feel more stable if I decide to taper.

I dont want either taper to destabilize my already sensitive system, but I really feel like the mix of these drugs are making me sick. 
My heart really wants to start reducing the AD because I need to get those anticholinergic symptoms lower. 45mg is quite a large dose considering I am a pretty petite woman. Its a bit discouraging to read stories of others on here of others on Amitriptilline because many are tapering off of a much smaller dose. I feel like my taper would take forever…like 2-3 years!! Makes me want to cry. 😓

I hope these details help a bit more, thank you for your help and time!

[Shep]

On 4/9/2023 at 6:55 PM, ClaraC said:

The side effects have caught up with me and I really need to go way down or possible completely off ( my dream). The side effects are a resting high heart rate in the 90’s always ( even when super calm), and it raises norepinephrine so even though it gives a nice sedative effect at night and I do sleep, I always feel a bit wired and “ on” due to a constant high adrenaline level.

So that’s where Klonopin (benzo) comes in. I have taken that (0.25 mg at night) for those days or nights where I was extra stressed and the sedative effects of the AD did not do the job. I used it on and off ( maybe once or twice a week) for years. It got to a point where the adverse effects of the AD were just too much (high HR and anxiety) and last June (2022) I started taking 0.25mg klonopin every night.

 

Is the amitriptyline sedating for you? Or are all you're getting from it at this point is that wired feeling?  

[ClaraC]

Yes it sedated me at night about an hour after I take it and I sleep until 6 ot 7 in tge morning.

I feel its both sedating and activating at the same time if that makes sense. I have a constant high hear rate and feeling of too much adrenaline while awake. The mix of these 2 drugs seems to make it worse. I often wonder if the activating part of the Ami is speeding up the metabolism of the benzo?

[Onmyway]

1 hour ago, ClaraC said:

Yes it sedated me at night about an hour after I take it and I sleep until 6 ot 7 in tge morning.

I feel its both sedating and activating at the same time if that makes sense. I have a constant high hear rate and feeling of too much adrenaline while awake. The mix of these 2 drugs seems to make it worse. I often wonder if the activating part of the Ami is speeding up the metabolism of the benzo?

@ClaraC it's unlikely an additional drug speeds up metabolism of the original drug,  it's more likely the opposite if they need the same enzymes. 

 

But drugs can go paradoxical on us. The interaction can be activating even if both drugs are sedating. We know very little about brain chemistry. 

 

It would really help us if you answered the questions above, otherwise it's empty theorising. We are each different with different bodies and a million things could have happened. We are trying to understand what's likely happening in your case. 

 

When did you start feeling this activating feeling? Before/ after clonazepam? How long after you lowered your amytriptiline dose? Were there other stresses around that time - physical (viral illness, menopause, other drugs like antibiotics or asthma/blood pressure/thyroid drugs,  marathon running) or psychological (grief,  new job,  new baby etc. )? How do your symptoms change during the day? Please do a symptom schedule as requested - ignore the food except timing and focus on the symptoms.  It will help us determine which of the likely possible things is at play here.

 

Omw

[ClaraC]

Ok I will try to be as specific as I can: 

 

in December 2014 a psychiatrist gave me Amitryptilline 75mg for anxiety, depression and complete insomnia after some life stressors related to my autistic son. I felt that dose was way too high and at her approval self-tapered down by 2016 to a more comfortable dose. I settled at 45 mg. From the day I started this drug it has always made my resting heart rate high and felt “ energizing” during the day which I have attributed to the nor-adrenergic reuptake inhibition. Since it does sedate me at night and I sleep well I just ignored these other side effects for years and lived life. It also helped my anxiety somewhat, but I have never felt it was a great drug for anxiety due to the high heart rate. I have always had to manage my stress levels to keep my anxiety in check.

 

I would say since about 2021 due to life stressors, the symptoms mentioned above have gotten harder to keep under control. In 2021 we were contemplating a huge move across the country which made my anxiety skyrocket. I actually went back up to 50 mg of Amitryptilline during that time to ease the anxiety. That seemed to make things worse since I felt it made my heart rate even higher, so I soon ( within about six months) went back down to 45 mg. We ended up not doing the move because of my health. Then in 2022 we had a big remodel because since we didn’t move we needed more space in our current house. That brought on more stress. Up to this point I had been taking klonopin only as needed for the nights I could not sleep just with the AD. So I decided by June 2022 to add the 0.25mg klonopin every night. This seemed to help for a while but since we still had decisions to make regarding the remodel, I still had stress in my life.

 

As of December of 2022 til now I have been working really hard to focus on my health and lower stress levels. But I have yet to get to the place where I feel good or stable again. I sure didn’t help my medicines work by adding extra stress to my body, especially when the AD causes a high heart rate in the first place.  I feel like I am at a place now where the drugs are doing more harm than good and I really need the AD lower to get the heart rate and nor-adrenaline down. And I don’t think the klonopin is helping keep me calm anymore. Tolerance has developed and may even be giving me withdrawals, but between the 2 drugs it’s hard to know. So if I taper I am unsure which should go first and would having a little more klonopin in my system make the taper of the AD easier?

 

here is a daily symptom timeline:

8:00 am wake up, immediately feel cortisol dump or surge, usually have to poop but not always. This is the biggest cortisol surge of the day

8:30- by this time I know I need to eat since it feels like my blood sugar drops…feel a little nausea, shaky. I eat 2 eggs and some oatmeal and feel instantly better

10:00- feel more slight cortisol surges, mimicking anxiety, feel the need to eat a snack, like nuts

12:00-again more slight cortisol surges. Drink green smoothie with protein in it.

4:00- feel slight cortisol surges, anxiety, have another snack

5:30-6:30- again feel slight cortisol surges, feel anxious eat dinner. Always have some good protein

8:30-9:00 take my 45 mg Ami usually get intense carb cravings around this time and have a carb of brown rice or GF crackers

10:00-take 0.25 mg klonopin

10:30- usually asleep

 

i will add to this that I always feel better after eating. The anxiety lessens and cortisol surges stop. When I need to eat they get worse. And I feel the need to eat every 2-3 hours, if I go too much longer the cortisol and anxiety get worse. It feels like my metabolism has sped up and I burn through food very fast. As I said even though Ami causes weight gain I have had trouble keeping it on, especially since adding in the klonopin. It feels like the klonopin just made the situation worse not better and as you say, almost feels like they went paradoxical on me. I just don’t feel well almost all the time and am working with an integrative doctor to see if anything else could be causing these symptoms. My gut says it is the drugs and I need to come off but I want to go about it in a way that will cause the least disruption in my already sensitive nervous system. I feel like as soon as I can get my heart rate and adrenaline down I will feel better but that means starting a taper of the AD now before the klonopin and I am not sure if I can handle that. That is why I had considered going up in the klonopin to taper off the AD and then tackle the benzo later, but I know that brings in the whole favor of a long benzo taper later. Ugh, I really dont know what to do.

 

i hope this gives you the info you need. I tried to be as thorough as possible. thank younfor taling the time to read all this!

 

 

 

[Onmyway]

Hi @ClaraC, 

this is really helpful. Thank you for the detailed description. 

 

There are a few possibilities here: 

 

1) amitriptyline activation and blood sugar sensitivity 

 

2) clonazepam tolerance 

 

3) paradoxical reactions from two sedating drugs or the interaction of the two

 

To me seems like 1) is the most likely issue as your main complaint is about the effects of amitriptyline.

I would suggest a slow taper of this drug. Note that a 10% drop to 40.5mg and then to 36.6 and then to 33  will lower your drug burden significantly and may give you some respite in a few months. 

 

Seems like an amitriptyline taper first would be the right way to start, as you lower the dose, the activating symptoms from amitriptyline would lessen. Amitriptyline does impact blood sugar and may be what causes your sensitivity to blood sugar changes. As you lower your dose your symptoms may get better. 

https://www.mayoclinic.org/drugs-supplements/amitriptyline-oral-route/precautions/drg-20072061

 

I don't hear anything that may indicate clonazepam tolerance at this point so would advise against increasing the dose (hopefully save you trouble later). In the meantime, as you lower your ami burden do what you are doing - keep a tight control over your blood sugar levels by always carrying a snack etc. Non-drug ways of keeping your nervous system on track are always better - drugs cost more later than the benefit that they provide. 

 

If your sleep gets disrupted you can slow your taper but at 10% it may not. I will come back later to get you some links on how to implement this

 

OMW

 

 

[Onmyway]

 

 

 

An alternative, even more gentle way of tapering: 

 

 

[ClaraC]

Thank you OnMyWay for your input and help. I have read these threads before but I will look at them again. I think a 10% or slower taper of the AD is a great idea. I am not sure my anxiety ( constant cortisol surges) can handle going down without upping my klonopin dose, so this is my dilemma. If I can manage it, then your suggestions would be the way to go. Thanks again!

[Onmyway]

Hi @ClaraC, 

 

it didn't seem to me that your cortisol surges need klonopin - they will likely lessen as the ami lessens. If eating a power bar fixes them why mess with klonopin. But you know yourself better so your call. You are the ultimate decision maker for your own body so it is up to you what you choose to do. You will bear the consequences of your decisions, we are here to advise based on our experience in general. 

 

We don't recommend treating withdrawal symptoms with benzos except in extreme circumstances and definitely not preventatively. Each subsequent taper has the potential to be worse. At this rate, you will be on tapering off of ami for about 3 years (depending on when you decide to jump off - lower gets harder) and then you are in for benzo tapering. As long as you are aware of the tradeoffs - it's your call. 

 

At the same time, I want to warn you that tapering can come with a lot of tough emotions and feelings/symptoms so you need to be prepared to just bear some of them rather than rely on pharma solutions to treat them. I am saying this because I was completely unprepared for that myself and my instinct was to rush to xanax and klonopin at the beginning. It was the wrong call for me (I did it for less than a month and before I found SA). 

 

Hope your taper goes easily. Please take care of yourself. 
I highly recommend non-drug techniques for treating emotional symptoms - I like Claire Weekes, Kristin Neff etc. 

We also recommend magnesium and Omega-3 but try them one at a time and at low doses. Magnesium was better than a benzo for me. Omega-3 did not do much for me personally but others love it. 

 

https://survivingantidepressants.org/index.php?/topic/36-king-of-supplements-omega-3-fatty-acids-fish-oil/

https://survivingantidepressants.org/topic/15483-magnesium-natures-calcium-channel-blocker/

 

Be sure to not take other psychoactive substances during withdrawal - prescribed or not, they can set you back. This includes alcohol, pot, some vitamin supplements (B and D, especially if your nervous system has already been sensitized), other supplements, some antibiotics tend to create issues for people as well [you can check on the Symptoms forum to see what worked and what didn't for others]. 

 

 

 

Good luck, 

OMW

Edited April 12, 2023 by Onmyway

[ClaraC]

Thank you again for all your input. Would it really be 3 years til I am off Ami?? That makes me want to cry. I imagine it goes faster at first and slows down once you get to a lower dose. That just seems like a long time for the body to continue to be in withdrawl. But I guess if it goes  smooth and slow enough the withdrawl isnt too bad. I was hoping it would be more like 2 years or less. 

[Onmyway]

If you do it properly enough from the beginning likelihood of bad withdrawal is less likely but there may still be difficult episodes where you may need to hold. 

 

It occurred to be last night that if you think the combination of clonazepam and Ami  is making you more agitated now it may be even worse if you increase the clonazepam dose.  

 

You might start without increasing it and see where you go. 

 

Again,  up to you.