Hankakston Mirtazapine and Math Illiteracy

[hankakston]

Greetings to each of you!

 

Diagnosed with PTSD at the VA in 1987 (26 months with the Marines in Vietnam). Was immediately put on Xanax. Later switched to Valium. So 28 years with a benzodiazepine, at times as high as 60mg/day Valium. Past two years at 20mg/day. I’d reduced that over the past year down to 2.5mg/day, and then four days early this month without. About that time I noticed not caring much about things. Confusion, heat-sensitivity and a myriad of other unusual physical and mental states. “What is this?” I thought. I leapt at the latest medication prescribed: mirtazapine. Did a search and found it’s incredibly hard and awful to withdraw from. I was prescribed Mirtazapine in January this year (2015). My prescription is 15mg with 30mg tabs I have to cut in half. Now I’m cutting the 30mg tabs in half, and then in quarters. And I just got a new prescription of 7.5mg tabs, telling the doc I need to wean from it. I cut 7.5mg tabs in half. Using a razor blade I cut the half 7.5mgs in quarters, which leaves a tiny chunk and some powder. Last night I took a quarter 15mg=7.5mg plus a half 7.5mg=3.75mg plus the chunk and powder of the quarter 7.5mg=1.875. This equals approximately 13.375mg. I got two hours bad sleep, and felt pretty sick for a few hours after I got up. It’s not bad now. But going from 15mg to 13.375mg must be too fast for me.

 

To compound matters I’m truly math illiterate. It took me a day with a calculator to come up with 13.375mg. And now I see that I should start at 13.5mg. But how, with what I’ve got, to get that?

 

Doing some research here on this forum I find this formula:

 

15 mg starting dosage => 13.5mg => 12.2mg => 11.0mg => 9.9mg => 9.0mg => 8.1mg => 7.3mg => 6.5mg => 5.9mg => 5.4mg => 4.9mg => 4.4mg => 4.0mg => 3.6mg

 

Very good. But still, how in the world to get these doses with what I have?! It looks like I’m going to need a scale.  And perhaps some little capsules to put the powder in?

 

Until I can figure out how to get the first one (13.5mg), I’m not going to start again. But I want to start as soon as possible.

 

If I’m not confusing things, please, if someone knows how to get me started on this let me know.

 

Oh, as for Gabapentin, I will not be weaning from that. I was diagnosed with lung cancer in 2010. The VA removed the upper lobe of the left lung. They gave me another total disability for lung cancer “due to exposure to Agent Orange”. I’ve been cancer free ever since. But the pain has never resolved. For 15 months I was given 30mg long acting morphine and 15mg breakthrough morphine. Over that time I’d never taken the full doses. So, when the VA suddenly cancelled it with no refills, I had enough to wean myself from morphine. The VA today will not prescribe anything stronger than Gabapentin. So I’ll stay on that forever. The dose is 300mg, two capsules four times a day (2400mg/day). And I did take that much for the first year, reducing it over the past year to 300mg four times a day (1200mg/day).

 

I didn’t suffer at all in withdrawing, or reducing from morphine or Valium or Gabapentin. But mirtazapine looks to be a horrific thing.

 

I fear I say too much. In short I’m here to discover how to withdraw from 15mg Mirtazapine. I’m pretty sure most of my questions are answered somewhere in this forum.

 

For that, I thank you very much.

[dalsaan]

Hi hankakston

 

 

Welcome to SA. I think the easiest way to taper off medication is using a liquid.

 

Here is a thread on tapering mirtazapine - http://survivingantidepressants.org/index.php?/topic/5301-tips-for-tapering-off-remeron-mirtazapine/

 

And here is one on using an oral syringe to taper liquid - http://survivingantidepressants.org/index.php?/topic/235-using-an-oral-syringe-and-other-tapering-techniques/

 

These threads have lots of info of value to you. Read through them and done back here to ask follow up questions

 

It's not easy but it can be done

 

Dalsaan

[hankakston]

Thank you, dalsaan.

 

(Now I've introduced myself, not sure if this is the place to continue....)

 

Here, somewhere (I'm all over this site, there's so much to see and digest) I found these:
 

"10% reduction per month."

 

"Yes, we recommend a very gradual taper of 10% every 4 weeks, calculated on the last dose -- the amount of decrease keeps getting smaller."

 

I hope against all hope that I can get this done faster. I start with the observation that each person has his own physiology, emotional makeup, and his own mental capacity to overcome obstacles such as this withdrawal I'm [not] looking forward to - if it's correct that it's going to be this bad, this difficult. I'm shooting for a taper of not 10% every 4 weeks - but 10% every 5 days! We'll see....I will report back.

 

I found, again through this forum, an American Weigh Scales GEMINI-20 Portable MilliGram Scale, 20 by 0.001 G. Also, I ordered from Amazon a 1000-pack of size 3 empty gelatin capsules. These are tiny, I know. But in my own work I often do very closeup work. It's getting the weight of the last tiny 1.875mg and the 0.125mg (practically "dust") into the capsules that's going to be my challenge. Even the 7.75mg and 3.75mg things will have to be weighted precisely. However that is, this is how I'm going to proceed. 

 

Your suggestion of using a liquid is something I take to heart. And I thank you for it. I've looked over the system and tools for doing that, and see that I might have to go there in time. But not yet. Let me try the scale and capsules first. I'll report back as to the success of it, and further plans if I find it necessary. Besides the scale and capsules, do you see anything I'm missing? (In order to get the precision necessary, I expect I'll be doing some scraping of the 15mg and 7.5mg tabs onto to scale for precise weight measurement. Jeez, looks like I'm going to have to re-learn the basic math I've lost over the years.)

 

Thank you very much for the kind welcome. 

 

All the best....

[dalsaan]

Sure try the capsules first given you got the scales and capsules

 

How fast you can taper is determined by your nervous system. We recommend starting slow and then going faster if your system allows it. If you destabilise your nervous system it may take longer to cone off than if you'd taken a conservative approach and negotiated the speed with your nervous system. The aim is to come off in good shape and to go as slow as you need to in order to avoid withdrawal symptoms.

 

But, these are your decisions to make and I wish you all the best. Come back to this thread to let us know how you are going/seek support etc

 

Dalsaan

[hankakston]

Sure try the capsules first given you got the scales and capsules

 

 

 

 

Sure try the capsules first given you got the scales and capsules

 

We recommend starting slow and then going faster if your system allows it. The aim is to come off in good shape and to go as slow as you need to in order to avoid withdrawal symptoms.

 

Dalsaan

 

Thank you for your support and encouragement, dalsaan. Certainly, I understand and agree with the slower the better chance of avoiding terrible withdrawal symptoms.

 

But herein lies my problem again: the math. The scale I'm getting says that it "weighs up to 20 grams in 0.001 gram increments". Now this is grams! And we're talking about decreasing by 10%. Starting at my current dose, 15mg, I understand I need to make the first reduction by 0.125mg! This is tiny. I'm afraid this scale cannot measure so tiny a level if it measures only in grams, not mgs. But, to repeat again and again, my math skills are so bad I cannot figure this out. (By the way, starting some four years ago I suddenly forgot most of my multiplication table. Who knows how this happened. Same with my spelling skills....) Can you say to me that this scale will do this work for me? If not, I need to search for a scale that will. 

 

Here's the way I figure it: 

 

I do find it easy to cut the 15mg tablet into one half. This gives me 7.75mg. To that I add half of my other prescription of 7.75mg This is 3.75mg. Then I use my razor blade to cut this little half of a 7.75mg in half again. Now it gets really imprecise as I'm getting a chunk plus powder. Here is where the scale will be a valuable tool - if it can measure a result of 1.875mg! Even so, I'm not there yet. Now I have 13.375mg total to put into the capsule. But I need 13.5mg. True? If so, then I need the scale to measure the tiniest amount of 0.125mg! If this is correct, my question is: "Can this scale do that?!" 

 

I know you are correct about the very slow taper. I know from a single bad experience. Two nights ago I did get a "rough" amount of 13.375mg. And sleep was terrible. At most I got two hours bad sleep. Then I laid there for four more hours in miserable wakefulness. Finally I gave up, got up and lived through a couple of hours of not being quite in the real world. But that passed and the day went pretty much normally. I haven't tried that again. I'm waiting for the scale and capsules, and hoping....

 

True, I haven't read through the entire article on oral syringes and "How to make a liquid from tablets or capsules". I will do so today. Accuracy and precision seems to be the key. And I'm afraid my first goal of making doses with that scale and capsules is doomed to failure.

 

Thanks again for your replies and encouragement. I'm eager to the point of desperation to get this started with as little side effects as possible. Please let me know if I should take my questions to another thread, the "oral syringes" or "liquid from tablets" areas? I don't want to take up your time here if I'm in the wrong place at this time.

[dalsaan]

This is my understand of your scales capacity. .001 gram = 1 mg. so you can measure a drop from 15 mg to 14 mg but it won't measure a point in the middle eg 14.25.

 

I recommend you read the rest of the liquid thread. It's much easier than what you are trying to do

 

D

[hankakston]

This is my understand of your scales capacity. .001 gram = 1 mg. so you can measure a drop from 15 mg to 14 mg but it won't measure a point in the middle eg 14.25.

 

I recommend you read the rest of the liquid thread. It's much easier than what you are trying to do

 

D

OK, dalsaan. Thanks.   You're leading me in the right direction. I shall return the scale to Amazon, and go from there. [Excuse me. I just read on a tips-for-tapering-off-remeron-mirtazapine topic on this forum: "Rather than switch directly to an all-liquid dose, you may wish to take part of your dose in liquid and part in lower-dose tablets or capsules, gradually converting to all liquid as you get to lower dosages.". So, I will keep the scale. Jeez, this is getting good....] I'm mostly just skimming the liquid thread for now. My god! My poor math. And now chemistry! Well, if I don't find someone here who has done this liquid method specific to Mirtazapine, I'll see if I can enlist my friend who has a degree in Biomedical Engineering Technology. As I show in my signature it was not so difficult for me to reduce both Valium and Gabapentin. I went according to how it felt. As for Gabapentin I simply opened a lot of the capsules and emptied "approximately" half into the sink; put the capsules back together, then into a bottle and reduced by those "halves" as best I felt over some six months. Valium was similarly easy by breaking the 10mg tablets in half for months, and then the halves I broke into fourths just by hand. Nothing so precise as it looks I'll have to do with Mirtazapine using the liquid method. And there were no withdrawal evils as I've experienced with Mirtazapine.

 

I'll be around, report my progress, the method(s) and system(s) I discover in what looks at the moment to be a most difficult pursuit.

[ten0275]

hankakston, hey.

 

the other option is to have someone compound for you. i googled "compounding pharmacy indianapolis" and got a few hits - eagle highland pharmacy being one of them.

 

i have my mirtazapoison compounded at a pharmacy. it costs me about $25 a bottle, which at my dose will last a couple months (until it expires).

 

just something to consider. i too am not particularly agile at math or chemistry and a compound made for you can take the guess work out of the equation. if you have them compound for 1mg = 1ml, it makes it a cakewalk. because what that means is that your current 13.375mg would be a 13.375ml draw in the oral syringe. you know your dose and you take it.

 

glad you are leaning towards a liquid versus crushing and weighing. i had a heck of a time when i tried that method.

 

thank you for your service in vietnam. sorry you are suffering withdrawal, but you can get through this.

 

hang in there.

 

dave

[Altostrata]

Welcome, Hankakston.

 

You might return the gelatin capsules as well. Unless you have the tiny fingers of a pygmy loris, you'll want the larger capsules (at least size 00) if you want to use capsules simply because human fingers are largish.

 

Getting mirtazapine compounded is fine, but you'll still have to calculate doses. You might ask a friendly pharmacist to calculate this at each step.

 

If you want to save money, you could simply make a mirtazapine liquid with water yourself. We can give you the initial formula for that.

 

Reducing by 10% every 5 days is a rather fast taper. Give the initial 10% decrease a couple of weeks, at least, and see how you do. If you feel withdrawal symptoms, they will only get worse if you accelerate your taper. But everyone is different, and it could be you can taper faster.

[hankakston]

hankakston, hey.

 

the other option is to have someone compound for you. i googled "compounding pharmacy indianapolis" and got a few hits - eagle highland pharmacy being one of them.

 

i have my mirtazapoison compounded at a pharmacy. it costs me about $25 a bottle, which at my dose will last a couple months (until it expires).

 

just something to consider. i too am not particularly agile at math or chemistry and a compound made for you can take the guess work out of the equation. if you have them compound for 1mg = 1ml, it makes it a cakewalk. because what that means is that your current 13.375mg would be a 13.375ml draw in the oral syringe. you know your dose and you take it.

 

glad you are leaning towards a liquid versus crushing and weighing. i had a heck of a time when i tried that method.

 

thank you for your service in vietnam. sorry you are suffering withdrawal, but you can get through this.

 

hang in there.

 

dave

 

This is very good. Simply Google "compounding pharmacy". Now why didn't I think of that!? So I did that, and sure enough there's one right here where I actually live (Lafayette, IN). It's Custom Plus Pharmacy. This is really wonderful! 

 

I've not yet started withdrawal. Only one try, going from 15mg Mirtazapine to 13.375mg That was two nights ago, and the withdrawal symptoms, although bad, lasted only about 8 hours. It was enough, though, that I went searching and found this great forum. There's almost too much here, so much I need to study and absorb. Some of which I cannot do - the math and actually anything science. Your lead is a welcome thing. I do appreciated it, Dave.

 

I'll get there. Actually 13.375mg from 15mg is too big a step. I'm heading for 13.5mg when I start. Hoping this pharmacy can tell me more about how they can help with that.

 

Vietnam. Well, it was an adventure. I was scared out of my wits most of the time. And yet that experience has given me motivation in many of my life's issues. This Mirtazapine. It was a capital error on my part not to have looked it up when it was prescribed in January or early February. I put my trust in the neurologist, a private doctor outside of the VA, loving the great sleep mirtazapine provides. But never suspecting the awful other effects until I realized I was practically a zombie - the lethargy is what alerted me to this evil drug. So here I am. Needing desperately to get this thing out of my life, and get back to work. I'm glad I've found individuals like you to be with me on this new, rather scary adventure.

 

Looks like you've gone a long way from Remeron 30mg almost two years ago, down to 1.9mg. Congratulations!  

 

All the best,

 

Bob

[brassmonkey]

Hi Hank-- looking through your numbers and they aren't working.  It appears that you are assuming that a 15mg tablet weighs 15mg.  When in fact they don't.  15mg is the weight of the active ingredient in the tablet.  Because it is such a small amount the drug companies add fillers and buffering agents to make the pill up to a handle able size.  First thing you need to do is figure the average pill weight.  Weigh ten pills, add the weight together and divide the total by 10.  That is your average pill weight.  To make a 10% reduction multiply the average pill weight by 0.9. If you weigh out this much of a pill you will have the proper dose.  If you divide the pill weight by the milligram weight (pw/15mg) you will get how much pill weight you need for 1mg or active ingredient.

 

I have been using 40mg paxil tablets for my entire taper. 

 

40mg paxil = 500mgpw

1mg paxil  = 12.5mgpw

0.08 mg paxil = 1mgpw

 

so by measuring things by 1mgpw I can get a very small amount of active ingredient.

 

One drawback to a compounding pharmacy is that you need a prescription for each separate dose you want to have made up.  So unless your doctor is onboard with your taper that could be a problem.  Another drawback is that you loose the flexibility of staying on a dose a couple of weeks longer than planned.

 

Hope this doesn't confuse things even more.

[ten0275]

One drawback to a compounding pharmacy is that you need a prescription for each separate dose you want to have made up.  So unless your doctor is onboard with your taper that could be a problem.  Another drawback is that you loose the flexibility of staying on a dose a couple of weeks longer than planned.

 

hey bob,

 

i see what brassmonkey is saying above, but that isn't necessarily correct. if your doctor supports your taper, no problem. if your doctor does not support your taper, no problem. as long as he will write for it to be compounded, he can just keep on cranking out the prescriptions for 15mg and you can just be tapering without him knowing the difference.

 

also, i don't think you lose any flexibility at all for staying on a dose a couple of weeks longer than planned. particularly if the doc keeps writing for 15 mg.

 

here is precisely what i did. i went to my doc when i was at 7.5mg (i didn't get wise to liquid until that point) and said please write this so i can have it compounded into liquid form. please write that it be compounded 1mg=1ml. the doctor did this. and still does this. and i never have him lower the prescribed dose. he still writes for 7.5mg daily and i only take 1.9! i have to dispose of some mirt at the end of the bottle when it expires and that is all.

 

i really think it is a good bet for you. if the doc writes for 1mg=1ml, then all you need to figure out is what each 10% cut is. and as alto pointed out, the pharmacist can assist with that if need be. or you can use this handy dandy percent calculator:

 

http://www.onlineconversion.com/percentcalc.htm

 

re: vietnam and "I was scared out of my wits most of the time." i don't think i have talked to a single vietnam vet who wasn't scared out of their wits most of the time. and even if they got out without ptsd, the whole experience echoed for them in most areas of their lives.

 

hang in there and let us know how else we can advise.

 

dave

[dalsaan]

Just like Dave, I get mine compounded as well 1mg - 1ml and because I'm on a low dose I ask the compounding pharmacy to make up half a batch at time so I don't run out.

 

It is very simple

 

Dalsaan

[brassmonkey]

That's fine if you're getting the liquid form made for you, but compounding also refers to making up specific dosage capsules from dry ingredients and for those you need a specific prescription for each dosage you want made.

[Altostrata]

Correct, a compounding pharmacy can make up capsules with custom dosages. As brassmonkey said, you will need a separate prescription for each dosage.

 

The drawback to this is that the compounded prescription can be quite expensive. You will need to ask the pharmacy for a quote. Also, you need to check your insurance coverage for this.

 

brassmonkey, you sound like an expert with a digital scale.

[brassmonkey]

I use them frequently at work.  Back at Prior Place they weren't big on making your own liquid so I ended up explaining the weighing process quite a few times.  Being discalculaic myself I've had to think through the steps and equations very carefully and have worked them down to the bare essentials.

[hankakston]

That's fine if you're getting the liquid form made for you, but compounding also refers to making up specific dosage capsules from dry ingredients and for those you need a specific prescription for each dosage you want made.

 

This is what I'm facing and not understanding. Just returned from the pharmacy and didn't understand. He wrote down for me what to show my doctor:

 

"Mirtazapine to be compounded into a liquid form equal to a concentration of 1mg/mL

"Use an oral syringe to measure doses."

 

I don't know how to ask my doctor for this. I'll be starting from my 15mg/day mirtazapine to 13.5mg (BTW, that seems like a big reduction. I wonder what kind of withdrawal symptoms to expect the first days. And toward the end of the month do these symptoms ever end?). What exactly do I tell my doctor I need? When I told him last week I wanted to withdraw, he gave me 7.5mg tablets to take once a day! Of course I did not even try that. I'm afraid he won't understand this any more than I do.

 

Help on this ASAP will be much appreciated.

[dalsaan]

When you say you don't know how to ask him for the liquid, I assume you mean how do you broach the topic of the compounded liquid. I would say to him that you want to come off your mirtazapine in a way that avoids any disruption to your nervous system and that a liquid gives you the most control over that. Then say, you've researched it and you'd like a prescription for a 1 to 1 concentrate and give him word for word what the pharmacist said

 

I wouldn't worry to much about withdrawal. I think anticipating a significant reaction increases the likelihood of that happening. We recommend the 10 percent rule because most people can tolerate this. If you find you can't you can try other things. Cross that bridge if you come to it

 

D

[hankakston]

When you say you don't know how to ask him for the liquid, I assume you mean how do you broach the topic of the compounded liquid. I would say to him that you want to come off your mirtazapine in a way that avoids any disruption to your nervous system and that a liquid gives you the most control over that. Then say, you've researched it and you'd like a prescription for a 1 to 1 concentrate and give him word for word what the pharmacist said

 

I wouldn't worry to much about withdrawal. I think anticipating a significant reaction increases the likelihood of that happening. We recommend the 10 percent rule because most people can tolerate this. If you find you can't you can try other things. Cross that bridge if you come to it

 

D

 

OK. Called his nurse, left a message. I know he won't be in till Tuesday. I think I need to call again. If he sends his last prescription of 7.5mg to be compounded that's not going to work. I should tell him I'm starting at 15mg, reducing to 13.5mg. Right? Or does it make a difference? And will this prescription go for one month? Or is it only for one day? The pharmacist said it would cost $35. Doesn't seem very much if it's good for a month. 

 

Meanwhile I've got Vitamin E 400 IU D-Alpha Tocopherol and Omega 3 Fish Oil with 800mg EPA, 600mg DHA. And I've been taking 400mg Magnesium Citrate for a couple of years.

[hankakston]

Finally. I've got a prescription for Mirtazapine that the local pharmacist compounded into liquid form at 1mg/ml

 

I still don't understand the math. How to convert mG to mL ? Is there a convenient easy-to-work conversion tool somewhere? What I find on the web doesn't make sense. I put in 6.5mg and it converts to mL as 0.0065

 

Don't see a way to measure so tiny an amount.

 

My neurologist wants me to start from where I'm at (15mg), and start the weaning at 14mg He's given me a prescription for 7.5mg tabs. So, I'm to measure into the syringe 6.5mg and take that with the tablet. But the syringe shows only mL

 

I'm ready to go. But I'm right back to where I started this topic with: "Math Illiteracy". No amount of reading will get me literate in math or chemistry or any kind of science. I just cannot grasp numbers beyond simple addition. Seriously, I can't. Math scares me more now, since I've forgotten even my multiplication table. 

 

Is it so simple that the pharmacist and the doctor have done the work for me? I can read the syringe. I see on the big syringe a 6mL Is that all? Just fill it up to between the 6 and 7mL level? I bet that's so.

 

My best friend is a PhD in Math (Princeton, 1972). I haven't asked him about this medical matter yet. But I read in his book "Mathematics is About the World", chapter one "Euclid's Method", under a sub chapter "The Paradox for a Proper Realism" the following:

 

"The mathematical issue arises from the fact that all measurements of continuous quantities is approximate...one never achieves infinite precision. There is always a limit to the subdivisions that one makes and to the accuracy with which one can apply them. All precision is finite." I did not know what a "continuous quantity" is. He answered, "A continuous quantity is, essentially, a quantity such as length or weight that can be indefinitely subdivided." And then "Regarding precision, any measurement of a specific magnitude stops after some finite number of decimal places." 

 

Now this seems to speak to something I read here on the forum about precision being more important than accuracy. But I'm betting I can get pretty close to 14mg with the 7.5mg tab plus 6.5mL of the compound. 

 

What do you think?

[Altostrata]

hank, your calculations are correct!

 

If you have a 1mg/1mL liquid, to take 6.5mg, you take 6.5mL. There is a one-to-one correspondence between milligrams and milliliters in your liquid.

[hankakston]

Thanks, Altostrata. I'm going to try the neurologist's directions. Tonight I reduce from 14mg (my starting point was a 15mg prescription) since Monday (today is Friday) to ----- excuse me....I just looked again at the doctor's page. I should have started with my 7.5mg tablet plus 7mL liquid. This equals 14.5mg. Jeez, I went all the way down these four days to 14mg! I'm thinking now that I ought to stay at 14mg for four more days. And then reduce for four days (according to his schedule) to 13.5mg. Etc.

 

[*Below I show his schedule. It's kind of weird to me, the numbers] I'm on day five and feeling mentally funny. Some physical issues, but not too bad yet. His idea is much faster than what I read here, so I'll take it as far as I can. If unsuccessful, I'll try the full 10% or 5% per month as recommended on this forum. It's awful, and amazing how fast this medication has taken over. I've been taking Mirtazapine now only since late January or early February (I don't even know when it started). It's cost me my memory, my spelling and grammar, and what little I did have in mathematical ability. If nothing else, this withdrawal experience shows me what I've already accepted philosophically: I.e., there is no mind/body dichotomy. This withdrawal is a strange integration of effects on the mind and the body. How'd I not notice early on the mind/body damage as it was taking place? I look at my daily journal, and can actually see the exact date I should have seen. It was on March 13, 2015. Just about two months into taking mirtazapine. I've seen this drug called an "evil" drug. I'll say!

 

*[Here's the neurologist's schedule] I do not understand the numbers "48", etc. after the amount of liquid. I wonder if it's important. Can someone explain? In every case, I appreciate the replies I've received on my post. And the thorough directions on the forum as to pharmacy compounding (I'd never have known!), crushing or mixing one's own liquid. And so on. I'm going to try making my own liquid next week. If I'm successful with the neurologist's directions, that will be one new person's experience to share. With full grasp of the individuality involved in tapering, I offer the following. Will keep you all posted:

 

7.5mg pill                                                                                            Liquid

 

7                                                                                                          7          48        X 4 days

6                                                                                                          6          42

5                                                                                                          5          35

4                                                                                                          4          28

3                                                                                                          3          21

2                                                                                                          2          14

1                                                                                                          1          7

                                                                                                            0

 

 

 

No pill                                                                                                  7

                                                                                                            6

                                                                                                            5

                                                                                                            4

                                                                                                            3

                                                                                                            2

                                                                                                            1

                                                                                                            0

[Altostrata]

....

 

Reducing by 10% every 5 days is a rather fast taper. Give the initial 10% decrease a couple of weeks, at least, and see how you do. If you feel withdrawal symptoms, they will only get worse if you accelerate your taper. But everyone is different, and it could be you can taper faster.

 

Please do NOT reduce every 4 or 5 days. It can take that long for withdrawal symptoms to show up. If you've done another decrease in the meantime, you've compounded your problems.

 

Do not count on being able to go up in dosage to compensate for withdrawal symptoms. Sometimes it doesn't work.

 

Please do NOT decrease any faster than 2 weeks so you can assess the withdrawal symptom pattern. With luck, you won't have any.

[hankakston]

You are right, Altostrata. Thank you. I'm not chancing reducing after only 4 or 5 days. I've done a reduction now from 15mg/mirtazapine to 13.5mg for only four days so far. Will stay there for at least two weeks. You mention assessing the withdrawal symptoms. So far not bad. First night slept 10 hours! (My normal sleep pattern before Mirtazapine was 4 - 6 hours/night. I've just never needed much sleep. Same pattern on Mirtazapine) Second night, slept 9 hours! Mentally (both days) after waking, a bit of confusion for about 5 hours. Physically, an odd sort of mild "hay-fever". Day 3 after five hours sleep, no confusion. Same sort of very very mild "hay-fever". Last night again 5 hours sleep. Today no confusion. Physically, that little bit of sinus-like thing. Very little, but noticeable. So I'm watching for withdrawal symptoms. If it stays this way without confusion and just a bit of "hay-fever" I'm tempted to try the next reduction to 12.2mg after 2 weeks. Do you still caution against such a move? How to know? What should I look for mentally and physically before the next reduction? You seem to warn against dropping too soon and then going back up to where I left off. You all are the experts, and it seems that one month is the tried and true time span. And yet, you do account for variations according to how an individual can handle it. Obviously I'm eager to hasten the process, but don't want to do something stupid.

 

I found the quote below on the topic "Pharmaceutical liquids to make suspensions" If I do understand the math, then here's my variation on that recipe transposed from Alprazolam to Mirtazapine:
 

I’ve got Ora-Plus and

a 120mL orange bottle (from the pharmacy) plus

a 10mL and a 20mL syringe (from the pharmacy).

 

I’ve tested dissolving a 30mg Mirtazapine tablet in water. It takes some 10 minutes to dissolve completely. Now to test a single pill in Ora-Plus. If it dissolves completely as it does in water, then I do the following. Let me know if it’s harder than I think. And especially if I’ve got the math wrong, which I suspect I do. But keep in mind I won't be needing this for a couple of weeks at the earliest. So I have time to get it right:

 

Here would be my recipe:

MIRTAZAPINE 1 mg/mL, 120 mL

 

Mirtazapine 30 mg/tablet 4 tablets

Ora-Plus 120mL

I'd measure out 30mL of Ora-Plus into the 120mL orange bottle. Drop 4 30mg tablets in the liquid. When they dissolve, I measure out another 30mL of Ora-Plus to fill to the top of the 120mL orange bottle.

Shake. And refrigerate. Then shake each time I use it.

 

Say I'm down to 12.2mg/day of Mirtazapine. Then I use the 10mL syringe to get 4.7mL liquid. This, plus a 7.5mg tablet of Mirtazapine. 

 

Fixed the link.
 

Check this out:

http://www.paddocklabs.com/html/products/pdf/Ora-Sweet%20SF%20Sell%20Sheet.pdf


It gives an example for how to make a xanax suspension!! WOOT!!!

Quite the find! (Note: You don't need the sweetener to make the suspension; use the Ora-Plus to fill out the 120mL.)

Here's the recipe:
ALPRAZOLAM 1 mg/mL, 120 mL

Alprazolam 2 mg/tablet 60 tablets
Ora-Plus 60mL
Ora-Sweet SF* q.s. 120 mL ("q.s." means "as much as you need")
• Expiration 60 days
• Protect from light
• Shake well before using

*Ora-Sweet SF may be substituted with Ora-Sweet.

 

[Altostrata]

That sounds like a recipe for 1mg/1mL mirtazapine liquid to me.

 

Why did you choose to use Ora-Plus rather than just using water?

 

You may wish to get a 5mL oral syringe for those small measurements.

[hankakston]

That sounds like a recipe for 1mg/1mL mirtazapine liquid to me.

 

Why did you choose to use Ora-Plus rather than just using water?

 

You may wish to get a 5mL oral syringe for those small measurements.

 

So then, my calculation is correct?  

 

I'm choosing Ora-Plus in the hope that it'll last longer than water? Or last longer? Here's where I got the idea for Ora-Plus, just less than half way down the page Posted 07 October 2012 - 03:12 PM. It's you who post the above recipe with Ora-Plus. In the body of the post is this:

 

Here's the recipe:

ALPRAZOLAM 1 mg/mL, 120 mL

 

You write: (Note: You don't need the sweetener to make the suspension; use the Ora-Plus to fill out the 120mL.)

 

That is where I got the idea to use Ora-Plus. Is there a good reason I should be using water instead?

 

You are very precise, and I'm not. I say:

 

Here would be my recipe:

MIRTAZAPINE 1 mg/mL, 120 mL

 

Mirtazapine 30 mg/tablet 4 tablets

Ora-Plus 120mL

 

And then I go on with my recipe.

 

You say:

 

That sounds like a recipe for 1mg/1mL mirtazapine liquid to me.

 

Should I have put a 1 in mine? Thus:

 

MIRTAZAPINE 1 mg/1mL, 120 mL

 

What made me wonder "...if I’ve got the math wrong, which I suspect I do" 

 

It seems too easy. All I do here is multiply 30 by 4 (30mg tablets of Mirtazapine by 4 tablets) to get to a 120mg dissolution of the tablets. If these tablets do not dissolve in Ora-Plus it doesn't matter does it? I mean, I know the tablets will dissolve in water. If my trial of one 30mg tablet in a bit of Ora-Plus shows it won't dissolve in Ora-Plus, then I can surely dissolve the four 30mg tablets in water (I'm guessing it would take around an oz. of water for that.) Then transfer that water/tablet solution (or Ora-Plus) into the orange 120ML bottle and fill the remainder of the bottle with Ora-Plus.

 

I'm so sorry for writing an essay on all this. I don't see a way to condense the mathematics of it with the simple question: is this right?

 

Now, as to the withdrawal: those first two days were so easy I hardly had any bad withdrawal side effects. But on the third night! I got 1 and a half hours sleep. Woke up miserable. Terrible headache. Asthma, which I haven't had since I was a boy. Feeling "humid". Was short with my wife, a kind of irritation or impatience. Left side all around the lung "hurt like hell" (I wrote in my journal). Pins/needles left side and back. This lasted some 6 hours. Then during that day was an urgency; I guess it's called "manic"; working fast on many projects feeling I didn't have time to get anything done. Last night, the fourth night, I got 3 hours sleep. (This is 4½ hours sleep over two nights.) Same symptoms, headache worse. Lasted about 4 hours. Today, terrible confusion. All this from reducing down from 15mg to 13.5mg. Will this level out? Will it be this way for the month? Or are there going to be a certain number of nights and days until it gets better before reducing again down to the next level of 12.2mg? 

 

 

 

 

 

[Altostrata]

Your math is fine.

 

You can use Ora-Plus if you wish. I posted the information for people who mistrust their water.

 

Rebound sleeplessness is a withdrawal symptom we're trying to avoid with slow tapering. You might reconsider your tapering schedule.

[hankakston]

I received a note asking if I'd gotten off of Remeron. I wrote my answer thinking it was a new thread, not a note. So it reads like something to be read by all. I offer it here so that you all don't think I've dropped off the earth. And possibly it will be encouraging to some.

 

Thanks for asking. I didn't want to say much until I'm absolutely sure. I'm not yet off the Remeron, but close. I went a different route. I gave all my medical information including all medications' dosages and vitamins and supplements. Also my latest blood work. All this to a couple who do research on medical topics. Although not medical doctors, I've followed them with interest for years. She holds a Bachelor’s degree in biology from Houghton College (magna cum laude), and a Master’s and PhD in biology from SUNY-ESF. His is a Bachelor’s degree in Math/Chemistry/Biology from the University of California at Santa Barbara, in 1978. Their specialties are mostly cancer related. Not knowing if either could help me in medication withdrawal, I did contact them. It did cost me, but I couldn't not afford their advise if they could give it. This is their Basic research package. "Summary of traditional vs. alternative options, common nutrients/supplements, a condensed review of PubMed findings, and possible diagnostic tests. Basic treatment protocol suggestions. Limited feedback and Q&A (a 30 to 60 minute Skype call after sending the report). Approx. 5 hours of research. $495." Before hiring, I said what I was faced with: some two years of 10% per month withdrawal. That I needed a swift and not so painful withdrawal. (I don't know if I'm permitted here to give a link to them, but I suspect you can find them with the above information. If you're interested.) The report included a 120 day "Oil Change" that includes a list of vitamins and supplements I'd never taken. Along the way, it was calculated, according to my own needs (actually my lacking), for vitamins and supplement from most important on down. Nine altogether. Meanwhile to introduce 11 other supplements one at a time. (I found that of all of it there is only one I cannot tolerate: iron.) These supplements/vitamins/minerals cost me around $200/mo. A strict paleo diet. Well, this I cannot do and am not convinced of it's value. But I did stop all wheat products and other grains. And I stopped all my beloved, and convenient, sugary foods. Ex., my pop tart at 4AM when I usually get up. And then Frosted Mini-Wheat cereal for breakfast at 8AM. Finally, it was recommended slowly introducing a "bridge drug", close to mirtazapine: Prozac. Now here I was afraid because I don't then want to have to withdraw from that afterwards. But the way I did it was to take one 20mg tab Prozac two days before the mirtazapine reduction; then skip a day. Then on the day of reduction I took two Prozac. I'd take two for the first three days of the reduction. Then one. Skip a day. Then one. Then none. This I did for two weeks. The Prozac schedule was my own, based only on the fear of addiction to Prozac, and because of how the reduction did go. This is my schedule:

 

Start the vitamins/minerals/supplements. Start Prozac as I described it above. Then start the reduction. I started at 15mg mirtazapine. The first reduction was down to 10mg for two weeks. Then start the Prozac again as described, and reduce from 10mg mirtazapine to 5mg. Yes, this was the recommendation!

 

The exact doses and the rate of taper vary a lot from one person to another. I can offer some rough guidance, but only as a starting point. You should customize this approach in consultation with a knowledgeable prescribing physician. [i am my own "knowledgeable prescribing" patient]

 Start on a low dose of Prozac (20 mg)

 Keep the Mirtazapine dose constant

 Continue on both drugs for about two weeks

 Reduce Mirtazapine by 5 mg

 Wait about two weeks

 Reduce Mirtazapine by another 5 mg

 Repeat until off of the Mirtazapine entirely

 Begin tapering off of the Prozac by 5 mg every week or two

 

If you have problems at any stage, then back-off and slow down. It takes longer for some people than others.

It’s possible that a first attempt won’t work, but after the diet and supplement changes I suggest below have a chance to take effect (so your neurotransmitter levels have increased), a second attempt will succeed.

 

So, I started at 15mg mirtazapine on Aug. 1 for two weeks. Aug. 15 down to 10mg. Sept. 1 down to 5mg. Sept. 15 down to 0! However, that last drop proved impossible. There were no withdrawal side effects those first six weeks. None. But going from 5mg to 0mg I finally hit the misery of withdrawal that I had way back in June before I started this new regimen. Only much worse. That first night I got up from no sleep, clammy feeling and “crazy” feeling. I have a bottle of 7.5mg mirtazapine pills cut in half. I did the best I could, not caring much that it wasn’t very precise. I cut one of those halves in half with a razor blade. This gave me approximately just under 2mg. In an hour I got good sleep and all was well again. Next day I dropped four 30mg tabs mirtazapine in an amber plastic 120ml jar with warm tap water, just enough water to cover them. Let them dissolve for an hour. Shook it gently. Then added Ora-Plus to the 60ml line, and Ora-Sweet to the 120ml line. Shook it for a good two minutes. Using a syringe that night I drew out 1.5ml and everything was good. (I’d taken two Prozac that morning.) Two Prozac for two more days, with 1.5ml liquid mirtazapine at night. Then one Prozac, 1.5ml liquid. Skipped a day of Prozac, 1.5m. mirtazapine. One more day of Prozac, mirtazapine the same. Then 1.5ml liquid at night. And that night all the misery again! (I lay there and figured it out…) Got up with the half 7.5mg mirtazapine pills, cut in half and got my good sleep. The liquid had gone bad in only 6 days! I fixed up a new batch with water only, and all was well again that night at 1.5ml without Prozac. Next day I did some research on compounding. Found a site for pharmacy students, a lecture on compounding. It’s here, if it’s allowed: http://pskills.pharm.ku.edu/ios/html5/html5-compoundingvideos/html5-revised-lecture-video/Suspensions/Suspensions.pdf

 

There, I saw something that made me say “Of course!” You have to use distilled water or the solution will come unbound. So I made a new batch with water only. I’m still at 1.5ml.

In every event, this is not bad. From 15mg to 1.5mg in some nine weeks, as opposed to some two years. But from here, I’m taking it very slow. I’ll be testing at 1.0ml in a few days or a week. Except for the few days of awful withdrawal symptoms, due to mistakes, I’ve been symptom free. I’m just going to be very careful. I’ll keep you posted.

[brassmonkey]

Hi Hank--  This is a great description of the standard procedure called a "Prozac Bridge".  A process we do not recommend because  more often than not it does not work.  If you are lucky the Prozac will "cover up" some of the WD symptoms for the short term.  But the fact remains that you are still CTing off of the Mirtazapine and that will haunt you for a long time.  These drugs work by making physical changes to the structure of the brain that require the presents of the drug to remain in affect.  Remove he drug abruptly and the brain goes into chaos trying to sustain the changes, and WD symptoms ensue.  Prozac is not interchangeable so it does not fulfill the need, in just blunts the pain a bit.  This leaves you with a two fold problem of being in CTWD from the Mirtz, and addicted to the Prozac.  Mirtz has a very bad reputation for being hard to get off of.  By following this plan you are doing yourself no favors and will probably end up taking a lot longer to clean up the aftermath then it would have taken to do a nice slow taper.

[Altostrata]

You could have saved yourself $495 by reading The Prozac switch or "bridging" with Prozac (it's possible your researchers consulted this site for some of their information).

 

Prozac is in no way a drug equivalent to or related to mirtazapine. However, many doctors use it as "bridge" to get people off other antidepressants.

 

Good to hear your taper is going well.

[DD44]

On 10/12/2015 at 9:28 AM, hankakston said:

Finally, it was recommended slowly introducing a "bridge drug", close to mirtazapine: Prozac. Now here I was afraid because I don't then want to have to withdraw from that afterwards. But the way I did it was to take one 20mg tab Prozac two days before the mirtazapine reduction; then skip a day. Then on the day of reduction I took two Prozac. I'd take two for the first three days of the reduction. Then one. Skip a day. Then one. Then none. This I did for two weeks. The Prozac schedule was my own, based only on the fear of addiction to Prozac, and because of how the reduction did go. This is my schedule:

 

I found someone who did what I am considering. Anyone who can shed light is appreciated. I have only successfully reduced my Mirtazapine by about .6 of a milligram in one year.