Why taper by 10% of my dosage?

[JohnM]

Hello all,

 

I have seen that in this forum often the terms hyperbolic and exponential are used synonymously or interchanged. However, they are 2 different mathematical functions (see also for example https://simplicable.com/new/exponential-vs-hyperbolic).
Sometimes it is written that a tapering which reduces 10% in a certain period of time would be hyperbolic, in fact it is an exponential tapering and not a hyperbolic one. A hyperbolic tapering uses a different mathematical formula, and in particular is not the same for every drug, moreover it also depends on the drug dose. So the calculation is a bit more complicated than with the exponential method, and there is no generic formula which is applicable for all drugs and dosages, e.g. 10% reduction within a certain time.

[Altostrata]

Hello, @JohnM

 

The staff is aware that hyperbolic and exponential tapering are not the same, though an exponential taper approximates a similar curve. Nowhere do we claim that an exponential 10% taper is a hyperbolic taper.

 

The term "hyperbolic taper" came into use in 2019, with the publication of Horowitz, M. A., & Taylor, D. (2019). Tapering of SSRI treatment to mitigate withdrawal symptoms. The Lancet Psychiatry, 6(6), 538–546. https://doi.org/10.1016/S2215-0366(19)30032-X

 

I know because I was involved in the discussions of the draft of that paper. Peter Gotzsche pointed out the curve was hyperbolic.

 

Now, the hyperbolic taper for antidepressants is also called the Horowitz-Taylor Method. 

 

We do not give people instructions for a hyperbolic taper because we do not have the calculations for each drug. Mark Horowitz is writing a manual containing this information for doctors. However, the 10% exponential taper is good enough, it's relatively easy to implement, and that's what we talk about here.

 

See Why taper by 10% of my dosage?

Why taper? SERT transporter occupancy studies show importance of gradual change in plasma concentration

 

Horowitz , 2019 Tapering of SSRI treatment to mitigate withdrawal symptoms

Discussion of a scientific journal article with data supporting a very gradual taper.

 

[JohnM]

Hi Altostrata,

 

Thanks a lot for your reply. I am glad that you think that the two methods are indeed different.
I myself am very reluctant to speak of an approximation of the two curves, because there are constellations where they are quite different.
And it is indeed the case that in the forum it is claimed that the 10% method is hyperbolic; for example, also in the article you linked (see below). 
I hope to have contributed to more clarity in this matter with my critical remarks and thus to have served the purpose.

"In a nutshell, the 10% taper method recommends a 10% dosage reduction every 4 weeks, with the 10% calculated on the last dosage. The amount of decrease is proportionate to the last dosage (not the original prescription) and keeps getting smaller.  (See graph comparisons at the bottom of this post.) 

(In mathematical terms, this is a logarithmic progression yielding a hyperbolic curve.)

 

A linear reduction of 10% on the original dose results in reductions being a larger and larger proportion of the dosage you're taking currently.  (See graph comparisons at the bottom of this post.)  These larger decreases tend to be destabilizing and cause withdrawal symptoms.
Those finding the 10% hyperbolic reduction method too slow can speed up by making 10% (or less) reductions more often. Making smaller changes more often is less likely to perturb your nervous system than larger changes less often. However, if you get withdrawal symptoms, your nervous system is telling you that you are tapering too fast."

 

 

The following shows a HYPERBOLIC taper of 10% every 4 weeks. 

This shows tapering from 100mg to 0mg, but the curve would be the same for any starting dose.

 

 

 

[Altostrata]

When it comes to psychiatric drug dosing and receptor occupancy rates, the exponential reduction method and hyperbolic reduction method are close enough.

 

Exponential reduction requires no special calculations other than a percentage of the last dose and may be used when specific drug receptor occupancy rate charts are not available.

 

Post #1 corrected, thanks for the pointers.

[Nicolas45140]

https://willhall.net/comingoffmeds/
 

[MattNNN]

Should that 10% per month figure be modified based on how long you were taking the drug?

 

I thought the time to get off a drug was supposed to vary based on how long you were on it.

[Nicolas45140]

1 hour ago, MattNNN said:

Should that 10% per month figure be modified based on how long you were taking the drug?

 

I thought the time to get off a drug was supposed to vary based on how long you were on it.

Tried 10% every month after 23y of AD. Well, I couldn’t handle it. Had to go back and I might try 5% next time. 

[laura77]

I have a question: does the potency of the drug make a difference?  For instance, 25mg seroquel is about equivalent in effect to 2.5mg olanzapine.  However reducing from the 25mg seroquel pill would take a lot longer than reducing the 2.5mg olanzapine.  100mg trazodone is supposed to be equal to 15mg mirtazapine.  So 10% reductions on the trazodone will have much less effect on the nervous system than 10% reductions on mirtazapine.  

 

Also I'm confused about receptor occupancy...with mirtazapine, for instance, there is supposed to be barely any serotonin occupancy under 15mg, so the dropping off a cliff phenomenon would occur at several points during the taper, not just at the end.  There may be several points where one needs to slow down as the percentage receptor occupancy becomes steeper for the various neurotransmitters.

[RobertZ]

On 1/26/2024 at 9:47 PM, laura77 said:

For instance, 25mg seroquel is about equivalent in effect to 2.5mg olanzapine.

It's a bit more complicated than that because these two drugs have very different affinities for the receptors that they target -  dopamine is only one of them. If you're looking specifically at D2 receptor occupancy, they differ a lot miligram-for-miligram (and this is just for the D2 receptor; there are five types of dopamine receptors in humans):

Quetiapine dose (mg)	D2 occupancy (%)
1200	38.0
1000	36.3
800	34.1
600	30.9
400	26.1
200	17.8
100	10.9
50	6.1
25	3.3
0	0

 

 

Olanzapine dose (mg)	D2 occupancy (%)
40	89.9
30	87.0
20	81.6
15	76.9
10	69.0
5	52.6
2.5	35.7
1.25	21.7
0	0

 

 

 Source: "sbab017_suppl_supplementary_materials" at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8266572/

Other than dopamine, these two drugs also target serotonergic, histaminergic, adrenergic and cholinergic receptors - again, with wildly varying affinities.

 

I'm trying not to overthink all of this stuff while tapering and guide myself by the symptoms. The 10% (or less/more based on tolerance) rule seems to work the best for me and many others here.

[Daniel1269]

On 1/12/2023 at 3:40 AM, Altostrata said:

Hello, @JohnM

 

The staff is aware that hyperbolic and exponential tapering are not the same, though an exponential taper approximates a similar curve. Nowhere do we claim that an exponential 10% taper is a hyperbolic taper.

 

We do not give people instructions for a hyperbolic taper because we do not have the calculations for each drug. Mark Horowitz is writing a manual containing this information for doctors.

Hi @Altostrata

 

Now that ‘The Maudlsey Deprescribing Guidelines’ is available to read and therefore drug specific guidance and tapering advice is available, would it be wise to use his drug specific tapering schedules (based on risk of WD from what risk you are classed as from the dosage, duration, AD type etc. , the hyperbolic calculations for the specific drug) as a guideline rather than the 10% rule?

 

Upon doing some calculations his ‘moderate taper’ guidelines decreasing up to 5% SERT points (for the SSRI Sertraline) each reduction equates to varying reduction %es from the previous dose i.e  50mg - 40mg which is 20% , but when you get lower down say from 12mg to 9.8mg - as per the table - this is approx 18.33% reduction, then when you nearing the endgame of your taper day from 1.4mg to 0.9mg, this is approx 35.71% reduction?

 

Any advice at all is appreciated, just trying to ascertain if I should still follow the 10% rule or lean toward this (AS A GUIDELINE, NOT STRICTLY), as if it I carried out the hyperbolic taper this would be superior in terms of the length of the taper?

 

I have not yet started my taper, and this is my first time on an AD in my life so no prior experience of WD to go off. Starting my first ever taper attempt next week. 18 years of age.

 

Many Thanks,

Dan

[Daniel1269]

Obviously looking to avoid damaging my CNS and spending months recovering if it can be avoided by simply following 10% rule

[Altostrata]

8 hours ago, Daniel1269 said:

Now that ‘The Maudlsey Deprescribing Guidelines’ is available to read and therefore drug specific guidance and tapering advice is available, would it be wise to use his drug specific tapering schedules (based on risk of WD from what risk you are classed as from the dosage, duration, AD type etc. , the hyperbolic calculations for the specific drug) as a guideline rather than the 10% rule?

 

You can follow the Maudsley handbook if you like. We're not going to reproduce it here, that would be unnecessary duplication of effort.

 

As explained above in this topic, the 10% exponential taper approximates the hyperbola described by Dr. Horowitz. For those who do not have the handbook or cannot follow its tapering charts, calculating a 10% (or lesser) exponential reduction is a user-friendly way to taper.

 

The Maudsley handbook calculates more precise jumping-off points at the end of the taper, but they're not carved in stone. Whether they taper exponentially or hyperbolically, people will need to use their judgment, based on their tapering experience, to figure out when they can end their taper. Either exponentially or hyperbolically, the end will be somewhat less than 1/40 of the original dose and a fraction of a milligram for most drugs.

[Daniel1269]

Hi @Altostrata,

 

Thank you so much for taking the time to respond.
 

I appreciate his writings are tailored to the masses and not to the individual, would you still go with the 10% method rather than the drug specific hyperbolic method? Is there any preference in a situation like this?

 

I’ve noted that you have stated (in an interview with doctor josef) that you believe when reducing by 25% initially (as per hyperbolic method) this should be closely monitored by medical professionals and that we have no way of knowing each individual’s receptor occupancy, therefore it is wiser to go the 10% route, rather than the hyperbolic route? 
 

Does your opinion on this still stand now even when there is drug specific hyperbolic tapering guidance available?

 

Thank you so much,

Dan

[Altostrata]

5 minutes ago, Daniel1269 said:

I appreciate his writings are tailored to the masses

 

The Maudsley publication is for medical professionals, not the masses. The hyperbolic method requires monitoring by a medical professional.

 

We would much rather people taper with the assistance of a medical professional regardless of method. It is only because of a vacuum of knowledge in medicine that this has fallen to peer support.

 

If you want to do it yourself by either method, you will need to use your own judgment. The reason we put so much effort into peer support for tapering is to assist in monitoring, since people generally don't know anything about their withdrawal symptom pattern until they've made a bunch of mistakes that trigger it.

[Daniel1269]

@Altostrata

 

Yes, of course, my mistake, and yes unfortunately with most GPs (including mine) they suggest the classic “half the tablet for two weeks then stop”, and are also actively against gradual tapering whether that be with liquids or tablets (due to cost most likely) claiming that there is a very tiny chance of anything serious happening by following their methods, even despite me educating my medical professional on proper WD practices and some of the harrowing course of events that can happen through the posts you’ve suggested and Mark’s work in other forums.

 

In situations like these if I were to follow my medical professional’s advice I could’ve ended up in a pretty bad spot, so it is going to be inevitable that I will have to carry it out myself by any means necessary, as all of my GPs/ PCPs are ignorant of the true risks associated with WD.

 

As hyperbolic requires monitoring from a medical professional, the 10% rule shall be more suitable.

 

Is this something that most go through with their medical professionals? So very frustrating.

 

Thank you so much again.

 

[Altostrata]

Just about everyone who's ever joined this site has had the exact same experience with medical professionals. That is why this site exists.

[Daniel1269]

@Altostrata,

 

Please can you advise if the 10% per month reduction could be split into 5% every two weeks?

 

i.e from 50mg , first two weeks down to 47.5mg, then next two weeks to 45mg, stil aligning with the 10% schedule but just making it slightly smoother in terms of reductions and allowing any withdrawal symptoms to show themselves?

 

Thanks.

[LotusRising]

@Daniel1269

 

Have you seen this thread?

 

 

[Daniel1269]

@LotusRising,

 

Yes, however unfortunately I don’t have access to that level of precision as I’m being denied the liquid solution, would 2 5% reductions over 4 weeks still be sufficient?

 

Many Thanks.

[Daniel1269]

@LotusRising @brassmonkey

 

Also would the “two week hold” be necessary with two 5% reductions over 4 weeks given it is less frequent reductions?
 

i.e from 50mg , first two weeks down to 47.5mg, then next two weeks to 45mg

 

Thanks!

[LotusRising]

@Daniel1269

 

I would still build in a hold period following the reductions.

[Daniel1269]

On 5/1/2012 at 6:29 PM, Altostrata said:

If no problems after 4.5 months of very gradual reduction, you may be able to reduce by 10% every week.

Hi,

 

Let’s say this was the case and you began reducing by 10% every week, does this not pose a risk of overlapping WD symptoms by not allowing for a sufficient observation period? 
 

Or is 6 half lives (roughly a week, depending on the drug obviously) sufficient to allow for observations if you have encountered no problems along your taper so far?

Many Thanks.

 

[Altostrata]

On 3/12/2024 at 2:10 PM, Daniel1269 said:

Let’s say this was the case and you began reducing by 10% every week, does this not pose a risk of overlapping WD symptoms by not allowing for a sufficient observation period? 

 

Yes, this frequency of reduction is higher risk than monthly reductions. We do not recommend it for that reason. Also, at low doses, reductions can get even more difficult.

 

However, we also know that some people can taper faster than others. We just cannot predict who those people are. If you've ever had withdrawal symptoms, you probably are not someone who can taper faster.

 

If you get withdrawal symptoms at any stage of the taper, it's wise to STOP TAPERING until the symptoms go away.

[Daniel1269]

 

4 minutes ago, Altostrata said:

Yes, this frequency of reduction is higher risk than monthly reductions. We do not recommend it for that reason. Also, at low doses, reductions can get even more difficult.

 

However, we also know that some people can taper faster than others. We just cannot predict who those people are. If you've ever had withdrawal symptoms, you probably are not someone who can taper faster.

 

If you get withdrawal symptoms at any stage of the taper, it's wise to STOP TAPERING until the symptoms go away.

Thank you Alto, I will pay attention to how I react to each stage of the harm reduction method and adjust/ hold when necessary if it comes to that.

 

All the best.

[Belajazi]

5 minutes ago, Altostrata said:

 

Yes, this frequency of reduction is higher risk than monthly reductions. We do not recommend it for that reason. Also, at low doses, reductions can get even more difficult.

 

However, we also know that some people can taper faster than others. We just cannot predict who those people are. If you've ever had withdrawal symptoms, you probably are not someone who can taper faster.

 

If you get withdrawal symptoms at any stage of the taper, it's wise to STOP TAPERING until the symptoms go away.

@Altostrata what will be reduction % if medication giving adverse reaction?? With adverse reaction during tapering if our symptoms become worse then in that case should we also stop tapering???? 

[Belajazi]

9 minutes ago, Altostrata said:

 

Yes, this frequency of reduction is higher risk than monthly reductions. We do not recommend it for that reason. Also, at low doses, reductions can get even more difficult.

 

However, we also know that some people can taper faster than others. We just cannot predict who those people are. If you've ever had withdrawal symptoms, you probably are not someone who can taper faster.

 

If you get withdrawal symptoms at any stage of the taper, it's wise to STOP TAPERING until the symptoms go away.

@Altostrata what will be reduction % if medication giving adverse reaction?? With adverse reaction during tapering if our symptoms become worse then in that case should we also stop tapering???? 

[Daniel1269]

Just now, Belajazi said:

what will be reduction % if medication giving adverse reaction?? With adverse reaction during tapering if our symptoms become worse then in that case should we also stop tapering???? 

Read numbers 2, 3 and 4 at the beginning of the topic.

[Belajazi]

28 minutes ago, Daniel1269 said:

Read numbers 2, 3 and 4 at the beginning of the topic.

@Daniel1269 ok. Thank you

[Daniel1269]

On 8/5/2011 at 9:43 PM, Altostrata said:

Be prepared to adjust your rate of taper. When you get down to a lower dose, often you will have to taper SLOWER, or by even smaller percentages.

Hi Alto,

 

What is classed as a “lower dose” given that all antidepressant drugs at the lower doses still have significant effects?

 

Can you give an example of when to start slowing down based on receptor occupancy rates for Sertraline for example?

 

I.e should we start to slow down at say 40% RO which is roughly 6mgai Sertraline, or 30% RO which is roughly 4mgai etc. etc. ?

 

Is there a specific RO percentage we should consider to slow down at/ specific dose calculation we can utilise to figure out when to slow down? (This is for the faster harm reduction method I’m referring to)

 

Just trying to figure out how to maximise time efficiency whilst also prioritising safety

 

Many Thanks.

[Altostrata]

 

[Daniel1269]

@Altostrata,

 

So I’m guessing there’s no definitive answer essentially?

 

I was more referring to when we should start to slow down if we are encountering no problems that far in the harm reduction method, to minimise the risk of overlapping WD given the significant effects they still exhibit at the lower doses, rather than the difficulty of the final few mg of the taper.

 

The reason why I ask is, if there is no problems up until late on in the taper, if we are to “listen to our bodies” at this point, we could potentially risk severe WD by not allowing for sufficient observation at the low doses, but we would be none the wiser until it is too late.

 

So I’m trying to ascertain if there’s a sensible point to start to slow down in that scenario even if you have no symptoms, especially when listening to our bodies could put us in a bad spot. 
 

Is there any recommended RO/ dose you could suggest just as a guideline if one happens to be in that scenario?

 

Thank you!

[Altostrata]

On 3/18/2024 at 8:25 AM, Daniel1269 said:

Can you give an example of when to start slowing down based on receptor occupancy rates for Sertraline for example?

 

You'd have to look at Dr. Horowitz's book for this information.

 

If, for example, you follow a hyperbolic taper (according to receptor rates) and start to get withdrawal symptoms in the last third even though you're doing everything "right" according to the calculations, YOU NEED TO SLOW DOWN.

[Daniel1269]

5 minutes ago, Altostrata said:

You'd have to look at Dr. Horowitz's book for this information.

 

In the handbook it only states to make reductions every 2-4 weeks following the example regimens (as a guideline), it’s rather vague in terms of when to start slowing down  IF you have NO problems at the lower doses, therefore potentially risking WD by not allowing for sufficient observation, so is there basically no definitive answer for this specific scenario?

 

Just trying to see if there’s a preferred point in the taper (I.e last 30% RO or something) to slow down even if there’s no symptoms up until that point, which would be a massive achievement in its self!

 

Thank you very much.

[Altostrata]

1 minute ago, Daniel1269 said:

IF you have NO problems at the lower doses, therefore potentially risking WD by not allowing for sufficient observation, so is there basically no definitive answer for this specific scenario?

 

If you do not allow time for observation, your taper is higher risk.

 

Many people follow exponential or hyperbolic tapers and encounter no significant withdrawal symptoms at any point in the taper.

 

No one can predict if you personally will have more difficulty at lower doses. You will have to observe that for yourself. That is why we put so much effort into educating people about withdrawal symptoms. We cannot hold your hand throughout the taper.

 

I do believe you have investigated this particular aspect of tapering as much as it can be done. You'll have to take responsibility for the rest.

[Daniel1269]

@Altostrata,

 

Massively appreciate your response.

 

Thank you.