Vegan: Mirtazapine tapering - advise please

[Vegan]

Hi community! 

I am looking for support/recommendations and input regarding tapering of mirtazapine. I have been on mirtazapine15mg since November 2016 for anxiety. I have been doing cbt and lifestyle modifications so my doctor and I have agreed that I am ready to taper from the recommendation. She recommended a too fast taper - so I decided to taper over the next 6 weeks based on a pharmacist's input. Since the tablet comes scored, I can use a pill cutter to cut my doses. I am taking 3/4 tablet of a 15 mg dose so (11.25mg) which is a 25% dose cut. I am on day 2 of the taper and I intend to stay at each cut for at least 2 to 3 weeks before cutting the dose further. Liquid form of the medication isnt possible due to its expensive cost. I would really like some input regarding the 25% dose cuts and if someone has done this too?? Thanks so much! I appreciate it! 

[scallywag]

Vegan -- Welcome to Surviving Antidepressants (SA)

 

It's good that you've recognized that your doctor's suggested taper could be too fast. Your pharmacist's 6-week plan is just as risky, sadly. 

 

The CNS (central nervous system) adapts very quickly to these medications, usually within a month. These adaptations  down-regulate of the serotonin receptor/transmitter cells.  It takes gradual dose reduction to up-regulate the receptor/transmitter cells.

 

The pharmacist's suggested taper *might* be okay for you, but if your CNS is highly adapted to the medications you will be in for a world of hurt -- moderate to severe symptoms that hang around for many months. There is no way of knowing which individuals will have a strong negative reaction to a fast dose reduction.  We suggest, therefore, that people taper by reducing dose by 10% or less per month.  That taper takes longer but is a safer and more comfortable "ride." Please read:

Before you begin tapering -- what you need to know.

Why taper by 10% of my dosage?.

How your brain responds to psychiatric drugs - aka "Brain remodeling"

Tips for tapering off Remeron (mirtazapine)

 

For SSRIs such as mirtazapine, it takes about 4 days for a new steady state to be established after a dose change and another 7-10 days for your CNS to register the change.  Now that you're informed of the risks you could updose to 18 mg (which is 90% of 20 mg, a 10% reduction) because it's still very early in your taper. Whether you hold at 15 mg or updose to 18 mg, it's a good idea to monitor and record your symptoms. Please keep notes on paper of your symptoms and the times of your dose(s). This post has a useful format for a daily log:

Take notes of doses and symptoms.

 

A request:Would you summarize your history in a signature -- drugs, doses, dates, and discontinuations & reinstatements, in the last 12-24 months particularly?

• Any drugs prior to 24 months ago can just be listed with start and stop years.
  
• Please use actual dates or approximate dates (mid-June, Late October) rather than relative time frames (last week, 3 months ago)
  
• Spell out months, e.g. "October" or "Oct."; 9/1/2016 can be interpreted as Jan. 9, 2016 or Sept. 1, 2016.
  
• Please leave out symptoms and diagnoses.
  
• A list is easier to understand than one or multiple paragraphs.
  
• Link to Account Settings – Create or Edit a signature.
  
  

I've given you a lot to read or do. Please do have a look at the topics I've posted and also post a signature to make it easier for moderators and experienced members answer your questions. I hope you'll find the information in the SA forums helpful for your situation. I'm sorry that you are in the position that you need the information, but am glad that you found us.

[AliG]

Welcome to SA. You will find a lot of valuable information and support. Please read the links provided and add your signature. Come back with any further questions you may have.

Edited June 19, 2017 by AliG

[Vegan]

Thank you Scallywag for your valuable input. I have added a signature. And i have read the literature and links you have suggested. Thank you! 

 

I forgot to add an important note to my case. The reason my doctor wants me off the medication quickly is because I had an ecg that indicated an abormal qt interval which the emergency doctor said it could be related to the mirtazapine. A potential cardiac side effect that can be dangerous. Therefore I need to get off the remeron. I feel between a rock and a hard place. - i want to do a slow taper but my heart health is important and I don't want to compromise that.  Please any feedback would be so much appreciated. 

[scallywag]

Well that information might change things a bit. We had a discussion among moderators about abnormal QT intervals not that long ago. 

Did your doctor assess your cardiac rhythms before you started mirtazpine, i.e. do you have a baseline chart for comparison?

Did your doctor talk about the risk level -- how many people with this condition have serious cardiac consequences? 

 

If your basic risk of a caridac event is 1 in 100,000 a 10% increase in risk raises that to 1.1 in 100,000.  Knowing that statistic would help you understand it against the risk of severe and prolonged withdrawal from rapid discontinuation of Remeron.

[KarenB]

Hello Vegan,

 

I recently was diagnosed with an abnormal QT interval.  On further investigation, it was discovered to be a false positive.  Or in other words, I didn't have elongated QT intervals - the machine got it wrong.  So my advise for now is to get another test before you make any hasty decisions. 

 

Then, find out if there is a history of it in your family.  If there is, it's probably not caused by the drug and so there is no need to taper super-fast. 

 

Also, if you look at the info on elongated QT, it's not as immediately dangerous as it first sounds.  Many people live with it here whole lives.  Just saying, so you can hopefully feel a little more relaxed while you get a second test done. 

 

Good luck!

Karen

[Vegan]

Thank you Karen and Scallywag on your insightful posts. I appreciate it so much. 

 

I do not have a family hx of cardiac issues and much less a prolonged at interval. Interestingly enough i did have a ecg done in Oct 2016 prior to starting mirtazapine. That ecg showed no abnormalities. And given that this current one did show an abnormality - the doctor recommended tapering off the mirtazapine sooner rather than later. 

He didn't discuss risk percentage with me. But strongly recommended I get off the mirtazapine and then retest the egg to see if there has been any change. I am doubtful they would send me for a repeat ecg now....they would be more inclined to wait until I am off the medication completely. 

 

I am feeling uncertain as whether I should continue with the 25% taper. Perhaps if I hold that cut for a month and if i feel symptomatic at all during that time frame, then i can reinstate a higher dose and then taper off at a slower rate. I guess because the doctor was concerned about my heart, light headedness and low blood pressure - they are thinking the mirtazapine is causing all of these side effects. Please keep the replies coming as it does help me sort this out. Thank you! 

[scallywag]

Check the patient information that comes with your prescription for side effects.  Most major pharmacy chains have data bases and will print out the information for you; check with the pharmacy you use to fill your prescription.  If you can't do that, here's the information about side effects from the U.S. patient information:

Mirtazapine - Side effects.

[KarenB]

If you've already done a 25% cut, perhaps hold for a month.  Even if there are w/d symptoms that's okay, as long as they are manageable.  You do want to get off this soon, so it's going to be a case of keeping good notes, and giving yourself plenty of self-care to support the taper. 

[Santino]

HI Vegan...

You are so lucky to only have taken 15MG and have not been on other Meds. I really believe you will have a bit of problem but not the tough times that some people in this forum have gone through. I used 15Mg for two months and i am taking almost one year to taper that off. Currently at 1.7Mg.

I would advice to be as slow as possible. If you have no symptoms you can go faster. When i say slow i mean hold at least one month after every 25% cut as other people are advising. Try to listen to your body and act accordingly.

I sent you a private message so check that out. 

All the best
Santino

[Vegan]

Hi Santino,

 

Thanks for your reply!

Yes I do agree that hopefully I will have an easier time tapering off mirtazapine as that is the only medication I am on. I guess what may make this taper journey a bit more difficult is that my doctor wants me to do the taper quickly in light of the prolonged qt interval they picked up at the emergency.

 

So I had started a 25% dose cut down to 11.25 mg and I held that dose for 2 weeks. Days 2 through 6 weren't fun as I had felt withdrawal symptoms such as increased anxiety which manifested through various physical sensations. I guess what I learned and can share is that for me the most important thing is not to panic when I do feel these sensations.

 

Am i tempted to up my dose? Yes. Does my mind wander to a dark place in regards to why I am physically feeling unwell? Yes.  But I do not panic or better said, I do not feed into the anxiety. I accept and acknowledge a symptom but I continue with engaging in my day in some regard. Keeping my mind engaged in a activity I enjoy and also letting my close support network know what is happening so they can help me.

 

I firmly believe we can do this. Difficult and scary - yes and yes. But doable. We all may do the taper differently and in a way that is best for each person. That's okay. Sadly the medical community has not been educated on how difficult tapering off AD can be. But thankfully there is a supportive online community such as this. 

 

Last night I started my second dose cut to 7.5 mg. If people would like, I can post how that goes. I'm also staying mindful of taking vitamins, Drinking water and staying away from sugar, caffeine and alcohol. Just because they can worsen feelings of anxiety or give me physical sensations that can mimic anxiety. 

 

Thanks 

Edited July 3, 2017 by scallywag
insert paragraph breaks for readability

[scallywag]

Vegan,  please hold at your current dose for longer than 2 weeks. You are making 25% decreases and your brain and CNS need time to catch-up to the new and lower dose. How frequently is your doctor doing follow-up assessments on the QT interval?  If the drug is causing this, lower doses should result in improvement?

 

Here's what I see in your posts about your dose decreases:

15 mg starting dose

June 17: 11.25 mg

June 29: 7.5 mg

 

You have decreased by 50% in two weeks. It is likely that you will have difficult symptoms if you continue at this pace. You've got non-drug coping skills and routines in place. Could you ask your doc to assess how you're doing at the half-dose? 

Edited July 3, 2017 by scallywag