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Tips for tapering off Pristiq (desvenlafaxine)

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#1 Altostrata

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Posted 16 July 2011 - 08:52 AM

To reduce the risk of withdrawal symptoms and post-discontinuation prolonged withdrawal syndrome, as with other psychiatric drugs we recommend reducing Pristiq by 10% per month, calculated on the last dosage. (The amount of the reduction gets progressively smaller.) See Why taper by 10% of my dosage?

However, Pristiq is difficult to taper properly as it comes in only 2 dosages: average and excessive.

Do not alternate doses of Pristiq to taper -- this will cause the levels of this medication in your brain to go up and down and is second only to cold-turkey in causing withdrawal symptoms. AND DON'T COLD-TURKEY EITHER!!!!!!!!!


PLEASE READ THIS ENTIRE TOPIC BEFORE GOING OFF PRISTIQ.

Pristiq is a relatively new drug made of Effexor's (venlafaxine) active metabolite, O-desvenlafaxine. Pristiq is to Effexor as Lexapro is to Celexa -- a tweaked and more powerful isomer molecule. In effect, Pristiq is concentrated Effexor.

It is available only by brand name in extended-release tablets of 50 mg and 100 mg; the more common dosage is 50mg.

Unlike Effexor, which is metabolized primarily by liver enzyme P450 CYP2D6, Pristiq is metabolized via conjugation and liver enzyme P450 CYP3A4. It attains peak plasma concentrations in about 7.5 hours.

I was unable to ascertain the half-life of Pristiq with its extended-release formulation. The mean half-life of desvenlafaxine, without the extended-release matrix formulation, is around 11 hours.

The official prescribing information from the FDA contains this:
 

Discontinuation of Treatment with Pristiq
Discontinuation symptoms have been systematically and prospectively evaluated in patients treated with Pristiq during clinical studies in Major Depressive Disorder. Abrupt discontinuation or dose reduction has been associated with the appearance of new symptoms that include dizziness, nausea, headache, irritability, insomnia, diarrhea, anxiety, fatigue, abnormal dreams, and hyperhidrosis. In general, discontinuation events occurred more frequently with longer duration of therapy.

During marketing of SNRIs (Serotonin and Norepinephrine Reuptake Inhibitors), and SSRIs (Selective Serotonin Reuptake Inhibitors), there have been spontaneous reports of adverse events occurring upon discontinuation of these drugs, particularly when abrupt, including the following: dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesia, such as electric shock sensations), anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania, tinnitus, and seizures. While these events are generally self-limiting, there have been reports of serious discontinuation symptoms.

Patients should be monitored for these symptoms when discontinuing treatment with Pristiq. A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose, but at a more gradual rate.....


There is no way to decrease Pristiq "at a more gradual rate." The tablets come in only two dosages and, officially, they should not be cut up. See http://www.primaryps...?articleid=2464

In a phone conversation with Pfizer medical information (1-800-438-1985), I learned that the extended-release characteristic is incorporated into the tablet itself (Thank you, oaklily, for this information about the matrix formulation.)

Rather than a timed-release coating, the coating on the Pristiq tablet is only protective.

According to Pubmed on Desvenlafaxine: "....The extended-release tablet does not dissolve in the stomach after swallowing. It slowly releases the medicine as it passes through your digestive system. You may notice the tablet coating in the stool...."
 

Can the desvenlafaxine tablet be cut or crushed?
Desvenlafaxine is an ER formulation for once-daily administration that is designed to release desvenlafaxine over the course of the dosing interval.3 Desvenlafaxine tablets contain 76 mg or 152 mg of desvenlafaxine in a matrix formulation that is designed to gradually release the equivalent of 50 mg or 100 mg of desvenlafaxine, respectively.3 To maintain the integrity of the ER formulation and prevent “dose dumping” (ie, rapid release of drug from an ER formulation), desvenlafaxine tablets should not be divided, crushed, chewed, or dissolved.3

3. Pristiq [package insert]. Philadelphia, PA: Wyeth Pharmaceuticals Inc; 2008.

 
There is a description of the similar matrix formulation for quetiapine XR (Seroquel XR) here http://survivinganti...dpost__p__33069

PROTEST THIS DANGEROUS DRUG

  • Phone Pfizer, Pristiq's manufacturer, to make a complaint: (800) 438-1985 in the US

    Pfizer has not provided any specific information on how to taper from a dosage of 50mg extended-release Pristiq, the usual recommended daily dosage.

    They may suggest alternating dosages to taper Pristiq. Don't do this -- it's like playing ping-pong with your brain.

    File a complaint that there's no way to taper off Pristiq -- the range of dosages is inadequate.
  • Also complain to the FDA 1-800-FDA-1088 Mon–Fri between 8:00 a.m. and 4:30 p.m. EST.

OPTIONS FOR TAPERING PRISTIQ
Since medicine knows nothing about tapering Pristiq, the following are all informal suggestions. Try any of them at your own risk. Please let us know how you do by posting in this topic.
 
Cut up Pristiq tablets
Despite the warnings not to cut it up, patients have tried cutting up Pristiq tablets to taper.

When you cut Pristiq up, it becomes desvenlafaxine, with an 11-hour half life.

From reports on the Web, results are inconsistent. It does seem to work for some but it makes others ill, possibly because of "dose dumping" (see above) when the entire dose is released at once, instead of being gradually released through the matrix formulation.

It seems to sometimes cause stomach upset, which may be reduced by taking it with food.

Conceivably, like regular Effexor, one might get around the slow-release problem by taking smaller divided doses of Pristiq, more than once a day.

You may find you need a precise way to measure your tablet fragments. See Using a digital scale to measure doses

Or, as you get down to a low dose, you may wish to switch to Effexor to more precisely control dosage decreases, see below.
 
Crush Pristiq tablets, weigh powder with a digital scale
This is similar to cutting up tablets in risk -- Pristiq is a "do not crush" medication -- as it has a time-release coating.

Conceivably, dividing the dose and taking a measured amount of powder more than once a day, like regular Effexor, may make this method feasible.

Crushing the tablet and making sure the shell fragments are evenly distributed in the powder would be a more precise way of tapering than cutting up tablets.

Peer discussion of this method starts here http://survivinganti...dpost__p__27417
 
Have Pristiq made into smaller dosage capsules by a compounding pharmacy
Compounding pharmacies can crush the tablets and put the powder into smaller capsules by weight.

According to my compounding pharmacy, they can put in a slow-release additive distributing absorption over 8-10 hours. This is not as long as the Pristiq time-release coating, but at least it's something. Check with your compounding pharmacy about this.
 
Switch to Effexor or Effexor XR
Note: If you've had an adverse reaction to Effexor before, do NOT switch from Pristiq to Effexor.

"Desvenlafaxine (O-desmethylvenlafaxine) is the major active metabolite of venlafaxine."

Since the relationship is so close, switching to regular Effexor tablets, which you can cut up or make into a liquid, this may be the best way to taper off Pristiq. Because it has a mean half-life of 5 hours, you'd have to take regular Effexor twice a day.

According to FDA Prescribing Information for venlafaxine (Effexor), the usual dose of Effexor is 150mg per day.

Like Pristiq, Effexor XR is released gradually and needs to be taken only once a day.

Since 150mg Effexor and 50mg Pristiq are both "normal" dosages of their respective drugs, they may be roughly equivalent. (See discussion of Effexor and Pristiq dosage equivalency starting http://survivinganti...dpost__p__42249 )

You'd have the difficulty of tapering off Effexor or Effexor XR -- themselves notorious for withdrawal difficulties -- but at least you can do that gradually. See Tips for tapering off Effexor and Effexor XR (venlafaxine).

Advice from a psychiatric pharmacist
I have been corresponding with a professor at a prominent US university pharmacy department. Here is his best guess at how to taper Pristiq (he does not want his name published):
 


One may want to consider the following options:

  • Always taper to lowest available strength (ie – 50mg) before attempting to discontinue
  • Switch to venlafaxine IR [regular Effexor immediate-release] product (a non-coated tablet which is splittable) and taper further. [See above.] Although there is no absolute dosing equivalence between the two products, a reasonable assumption might be that 50mg of desvenlafaxine is roughly equivalent to 100-150mg of venlafaxine.
  • OR Switch to low-dose fluoxetine (eg – 10mg) [See below.]

 
Then taper off fluoxetine (Prozac). See Tips for Tapering Prozac

The psychiatrist who writes the 1boringoldman.com blog reports success in switching one patient from Pristiq to Effexor, then tapering Effexor, here (see comments)
 

I had a lady who could not tolerate coming down on the dose for the reason you mentioned. So we moved to Effexor which went fine and then after two weeks, came down successfully.


Another psychiatrist said when he tried this, the switch from Pristiq to Effexor was "seamless."
 
Advice from Dr. Stephen Stahl, author of the manual Essential Psychopharmacology
In his widely read psychopharmacology manual, eminent psychopharmacologist Stephen Stahl advises titration by crushing the tablets and mixing in fruit juice, see http://survivinganti...dpost__p__14799

According to our member oaklily, Stahl is wrong. Making a liquid from Pristiq does not work, see http://survivinganti...dpost__p__24822

Dr. Stahl intends to correct his book, according to this correspondence 09/15-9/16/13 with him:

....I am most appreciative of your input.  It is only by thoughtful suggestions like yours, and colleagues who take the time to email me, that I am able to incorporate the best possible information.  Many, many thanks.

In answer to your question about comparing the doses of venlafaxine to desvenlafaxine, there are three articles attached, published in the journal I edit, CNS Spectrums which may be of use to you.  Generally, my thinking is that 50 mg desven may be close to 75 mg venlafaxine, and so on up the titration scale....


In the absence of cutting pills or diluting, the best way to come off these agents is to start fluoxetine and then try to taper Pristiq, every other day or every third day, maintaining Prozac which has a very long half life.  Then after a few weeks you can stop fluoxetine.


Of course, even taking a drug once a day has fluctuations, but there is less fluctuation if one half life is skipped than if it is stopped.  A masochist could take each pill one hour later, at 25, then 26, then 27 hours until you get to 48 hours but problems doing this at night.  If unable to tolerate every other day fluctuations, have to cross titrate to a long acting substitute such as fluoxetine.

 

Reducing from 100mg Pristiq to 50mg Pristiq

Drug switches incur additional risk. Before trying a switch to Effexor or Prozac (fluoxetine) from 100mg Pristiq, it's probably wise to go down to 50mg Pristiq first, if possible.

  • You might use a 50mg tablet plus 3/4 of a 50mg tablet (37.5mg) to make the first reduction to 87.5mg
  • Second reduction: a 50mg tablet plus 1/2 of a 50mg tablet (25mg) to go to 75mg
  • Third reduction: a 50mg tablet plus 1/4 of a 50mg tablet (12.5mg) to go to 62.5mg
  • Fourth reduction: a 50mg tablet

If withdrawal symptoms occur, some people have found taking an additional fragment of a tablet can smooth the transition from one dosage to another.

 

Once at 50mg, stabilize for a month at least and consider your plan for the next stage of tapering.

 

"Bridging" with Prozac or another antidepressant
Prozac is regularly used to "bridge" off Effexor. Given that Pristiq is a cousin of Effexor and Effexor XR, it is possible that one can, similarly, use Prozac to withdraw from Pristiq.

Attributed to Joseph Glenmullen, the "bridging" technique is described by a doctor here http://www.bipolarwo...2005/ph1354.htm

Read this entire topic before attempting a switch to Prozac: The Prozac switch or "bridging" with Prozac

Later, taper off Prozac. At least Prozac comes in a liquid.

Remember, any drug change incurs additional risk. A switch to Prozac from Pristiq may not work -- they are very different drugs -- or you might have adverse reactions to Prozac. To do this, consult a doctor knowledgeable about this technique.


Edited by Altostrata, 07 October 2014 - 05:21 PM.
updated information

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#2 Altostrata

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Posted 16 July 2011 - 09:10 AM

Wyeth, the manufacturer of Pristiq (now merged with Pfizer), was well aware of withdrawal issues. Here's a 2008 interview with Dr. Phil Ninan, the Vice President of Wyeth Medical Affairs, Neuroscience:

"....Dr. Grohol: There’s been more talk in recent years about greater concerns about withdrawal syndrome. And so I was wondering what the research has shown what the withdrawal profile on Pristiq looks like compared to other drugs in its class.

Dr. Ninan: First of all, I think, one should distinguish what is a withdrawal syndrome from what we would call discontinuation symptoms. Withdrawal is traditionally associated with medicines that one has got physiologically dependent on. And there is a whole set of not only symptoms, but physiological changes that occur that can be potentially dangerous.

You see that with alcohol, you see that with benzodiapams, the anti-anxiety and sleep medications that can cause physiological dependence. And you see that with pain medications, particularly opiates and that class of medications. So, those can be medically problematic and potentially dangerous in some people.

We should distinguish that from discontinuation symptoms, where those medical risks are not present. And these are not medicines that you become physiologically dependent on, but you can get adaptive changes that have occurred, that then the body and the brain needs to readapt to not having those medications onboard.

And you see this with blood pressure medications where if you suddenly stop certain blood pressure medications you can get a rebound increase in blood pressure that is very transient. And you see that with several other medications. You see that if you take Benadryl on a regular basis and you suddenly stop taking the Benadryl, there are rebound symptoms that could occur.

So, what we have here are discontinuation symptoms that have been reported with antidepressant medications that get out of the system very quickly. And most medicines that get out the quickest are more likely to have discontinuation symptoms, because the brain is not having a chance to adapt to not having that medication occupy the receptors in the brain.

And the longer you’re on the medication, the more the adaptation has taken place, and therefore the more likely you are to have the discontinuation symptoms. So, we know that there were medicines that were the biggest culprits in terms of having discontinuation symptoms. Effexor was one. Paxil is the other.

And Pristiq being an active metabolizer effecter and also having a fairly short half-life, we would expect would have the potential to discontinuation symptoms. And that is exactly what we have found in our clinical trials.

So, these discontinuation symptoms can be anything from just physical kinds of symptoms, which would be things like dizziness, headaches, nausea, those kinds of symptoms that are common side effects of these medications to symptoms that might be unique.

So, patients who are coming off Effexor and Paxil have described various words like "brain shivers" and things like that, which we consider to be under a term called paresthesia, which are physical symptoms that you might be having within your body. And you can also have associated anxiety depressive symptoms.

Now unfortunately, the scales that we use to measure these are not very good. Because what we find is that anywhere from 20 to 30 percent of patients who are on placebo are also demonstrating some of these symptoms. And so there’s the high level of noise in the mechanisms that are standard in the field to try and measure these symptoms.

What we find is that what happened in our studies is when we discontinued these medications rapidly, was that a substantial number of people had these discontinuation symptoms. So, when we started tapering the medication, a number of these patients who were having discontinuation symptoms were reduced. But, they were still present.

And so we would recommend clinically that if a patient is planning to stop the medication, they should do it under medical supervision so that they’re being guided about what are the mechanisms that you can use to reduce the discontinuation symptoms, so that they don’t cause excessive distress, and they can be managed medically. ...."

Edited by Altostrata, 26 March 2013 - 02:38 PM.
added emphasis

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#3 Altostrata

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Posted 16 July 2011 - 09:26 AM

From: Altostrata Subject: Advice on how to taper off Pristiq?

Date: July 16, 2011 10:23:42 AM PDT

To: philip.ninan@emory.edu

 

Dr. Ninan:

 

This is in reference to your 2008 interview with Dr. John Grohol on PsychCentral at http://psychcentral....q 50mg per day.

 

The lowest dosage available for these extended-release tablets is 50mg. As they are extended-release, one assumes they cannot be cut up. Or can they? What is the tapering technique to safely discontinue Pristiq? Exactly how can this be done? Not even an experienced medical specialist can conjure lower dosages appropriate for tapering.

 

Here is a patient who is suffering from Pristiq withdrawal syndrome: http://survivinganti...om that dosage?

 

On the face of it, it’s irresponsible for Wyeth (now Pfizer) to recommend a conventional dosage of 50mg per day but not make available a lower-dosage extended-release tablet to enable tapering. Effexor, as we all know, has a brutal withdrawal syndrome (you may know it as discontinuation syndrome), as it also causes physical dependency, but at least people can cut up the tablets or open the Effexor XR capsules to gradually reduce dosages.

 

Thank you,

 

Altostrata


Edited by Altostrata, 23 January 2014 - 11:10 AM.
fixed text

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#4 compsports

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Posted 16 July 2011 - 10:21 AM

Hi Alto, Someone on Dr. Bob's psychobabble site posted this suggestion which I am not sure is medically feasible or not. http://www.dr-bob.or...sgs/986940.html He has provided a link for purchasing enteric coded capsules that would allegedly allow you to safely break up the Pristiq pill that currently you can't do. And of course, taking the prescription to a compound pharmacist is an option if that works for people financially. But I am glad you write this guy. It will be interesting to see if he responds. CS
Drug cocktail 1995 - 2006
Tapered off of Adderall, Wellbutrin XL, Remeron, and Doxepin for nearly 4 years
Drug free since June 10, 2010

#5 Altostrata

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Posted 16 July 2011 - 12:05 PM

Thanks for searching, cs. Unfortunately, that's a post where one person on a forum site is speculating what another person might do. He hasn't tried it himself.

I've never heard of being able to buy empty enteric-coated capsules. It took a while for that link (on a UK site) to open up, and there were no specifications for the capsules.

It's impossible to even guess what breaking up Pristiq and putting it into a capsule like that would do. It would take analysis by a pharmacist to determine if the enteric coating on the capsule would do the same thing as the enteric coating on the tablet. This is a highly hypothetical solution.

If anyone gets any real info about this, please post it here. Our Cymbalta taperers might appreciate it, too.

Whether you can cut up Pristiq and safely put it into an enteric-coated capsule is a question for a compounding pharmacist. Otherwise, I believe when you cut up Pristiq, you get a turbo-charged Effexor -- and I don't have the faintest idea what that would do.

Edited by Altostrata, 12 March 2014 - 08:43 AM.
fixed text

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#6 Altostrata

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Posted 22 July 2011 - 03:05 PM

I talked to a knowledgeable doctor about tapering off Pristiq. He said, "It's like jumping off a cliff. There is no way to taper off." He would switch to Prozac to get people off Pristiq. Don't try this at home, find a doctor who has experience in doing this to help you.
This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

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#7 Altostrata

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Posted 30 July 2011 - 07:03 PM

I am getting reports that people are cutting up Pristiq tablets to taper. I do not know how effective this is for gradual weaning.
This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

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#8 myself

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Posted 03 August 2011 - 04:28 PM

Hi! Any new news on tapering off of Pristiq? I've been cutting them in half for about two weeks now, at the advice of my psychiatrist (not that I actually trust his knowledge very much) and my pharmacist- it seems to be going relatively ok. I have only really started noticing withdrawal symptoms in the past few days. Depersonalization, headaches, brain fog... I keep scouring the Internet for posts from others on how to taper off of Pristiq, and haven't found much. The only other advice I read was to take a pill every other day. I tried that method first (for one day), and it put me out of commission for about a week. Not good. I suppose I could always try triating? Anywho, wanted to let you know that someone is following this thread! “Depression is not a disease, the end point of a pathological process. It is a sign that our lives are out of balance, that we’re stuck. It’s a wake up call and the start of a journey that can help us become whole and happy, a journey that can change and transform our lives.” James S. Gordon M.D. Unstuck

Have taken psychiatric meds since 2002.
Wellbutrin, Lexapro, Zoloft, Effexor (not sure of the dosages, or how long I took them...); have taken Clonazepam (1mg, as needed) since 2002 as well.
I was prescribed Adderall in late 2009 (after saying I had problems losing weight), stopped taking it cold turkey in Feb. 2011- made me very anxious, obviously.
Currently: Have been on Pristiq 50mg since 2008, I think. Still taking Clonazepam. Began cutting down my Pristiq dosage on July 22, 2011.

Also- it is my last year of grad school! I am looking forward to graduating, being med-free, and starting a new stage in my life!

#9 Baxter

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Posted 03 August 2011 - 04:38 PM

Hi, Myself. SNRIs are all pretty miserable to get off of, so if/when your symptoms get worse (and don't let it go on too long), the switch to prozac may be your best bet. I know that I am just repeating advice offered by others, but it is the best advice on offer. If you want to just continue the Pristique taper, you could try cutting the pills into smaller pieces. 50% is a huge drop, and likely to cause you more anguish than entirely necessary... Hang in there.
ct Serax and Inderol April 2007
Cymbalta 60mg to 30mg 2007-2010
July 2010 - June 2011 on hiatus due to worsening w/d symptoms
June 2011 - 28mg Cymbalta

#10 Altostrata

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Posted 03 August 2011 - 05:11 PM

Welcome, myself. As you have found, alternating dosages is a recipe for withdrawal symptoms. Can you cut a 50mg tablet into quarters? Two weeks is about right for getting hit with withdrawal symptoms. You might want to go up to 37.5mg (a 25% reduction from 50mg) to reduce the abruptness of your 50% reduction. Since you've breached the time-release coating anyway, I would think if desvenlafaxine could be made into a liquid compound, you could try that. Or use an electronic scale to weigh fragments of a tablet. Otherwise, the switch to Prozac could be a solution -- but you'd have to find a doctor who has experience with this.
This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

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#11 myself

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Posted 03 August 2011 - 05:17 PM

Hi Baxter, Thanks for the reply. I have read about the switch to Prozac being the most helpful thing- I guess mentally I am just ready to be done with these meds, and kind of don't even want to think about going on another one, you know? Also, I don't think I could rationalize with my psychiatrist that switching to Prozac would be a helpful thing to do. Do you know of a good way to find sympathetic psychiatrists? I have tried asking my friends, therapist, acupuncturist, etc., but they don't know too many like-minded psych's- or the ones they can recommend are aren't taking new patients. I'll see how I feel tomorrow, and then consider finding a new psych. and/or upping my Pristiq dosage by a 1/4 for a while. I'm working on my Thesis, and I need all the brainpower I can get! Thanks again

Have taken psychiatric meds since 2002.
Wellbutrin, Lexapro, Zoloft, Effexor (not sure of the dosages, or how long I took them...); have taken Clonazepam (1mg, as needed) since 2002 as well.
I was prescribed Adderall in late 2009 (after saying I had problems losing weight), stopped taking it cold turkey in Feb. 2011- made me very anxious, obviously.
Currently: Have been on Pristiq 50mg since 2008, I think. Still taking Clonazepam. Began cutting down my Pristiq dosage on July 22, 2011.

Also- it is my last year of grad school! I am looking forward to graduating, being med-free, and starting a new stage in my life!

#12 Altostrata

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Posted 03 August 2011 - 05:25 PM

myself, you are near the nest of mainstream psychiatry -- Harvard and Massachusetts General. Many partners.org (Mass General) psychiatrists did the early research on withdrawal syndrome. You might work your way through the phone list at partners.org for withdrawal advice: http://www.partners....ianResults.aspx I would start with Baldessarini: http://www.partners....jvrgyIKAmmOaQ== He's at McLean in Belmont, Mass. If anyone can refer you to someone who knows how to do the Prozac switch, it's probably him. Or Rosenbaum http://www.partners....m4y/hU/3V0v~A== Or Alpert http://www.partners....jURCVgl9zky/A== You may have to be persistent in asking them if they know of anyone with expertise in either getting people off Pristiq or the Prozac switch. Please let us know what you find out!
This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

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#13 myself

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Posted 03 August 2011 - 05:27 PM

Welcome, myself.

As you have found, alternating dosages is a recipe for withdrawal symptoms.

Can you cut a 50mg tablet into quarters?

Two weeks is about right for getting hit with withdrawal symptoms. You might want to go up to 37.5mg (a 25% reduction from 50mg) to reduce the abruptness of your 50% reduction.

Since you've breached the time-release coating anyway, I would think if desvenlafaxine could be made into a liquid compound, you could try that. Or use an electronic scale to weigh fragments of a tablet.

Otherwise, the switch to Prozac could be a solution -- but you'd have to find a doctor who has experience with this.


Thanks Alto!
You replied while I was replying to Baxter. ;)
It is hard to cut the 50mg tablet into halves as there is no indention line thingy (what's that called?)- so I think 1/4 would be stretching it. But I will see how I feel tomorrow and try that. Also, I'll research making liquid compounds and electronic scales tonight.
And, start working on a letter to Pfizer at some point.... Ughh.

Best, M

Have taken psychiatric meds since 2002.
Wellbutrin, Lexapro, Zoloft, Effexor (not sure of the dosages, or how long I took them...); have taken Clonazepam (1mg, as needed) since 2002 as well.
I was prescribed Adderall in late 2009 (after saying I had problems losing weight), stopped taking it cold turkey in Feb. 2011- made me very anxious, obviously.
Currently: Have been on Pristiq 50mg since 2008, I think. Still taking Clonazepam. Began cutting down my Pristiq dosage on July 22, 2011.

Also- it is my last year of grad school! I am looking forward to graduating, being med-free, and starting a new stage in my life!

#14 Altostrata

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Posted 03 August 2011 - 05:32 PM

A pill cutter will make it easier to cut the darn thing into quarters. They cost about $4 at the drug store.
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#15 myself

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Posted 04 August 2011 - 04:23 AM

oh yeah- i figured that out on the second day! :) however, the pill is rounded at the corners and the top and bottom of it are convex. and with no indention- it's a wiley little bugger! and alto- thanks for the advice on psych's to call. i will post whatever info. i get from them. hopefully something good...

Have taken psychiatric meds since 2002.
Wellbutrin, Lexapro, Zoloft, Effexor (not sure of the dosages, or how long I took them...); have taken Clonazepam (1mg, as needed) since 2002 as well.
I was prescribed Adderall in late 2009 (after saying I had problems losing weight), stopped taking it cold turkey in Feb. 2011- made me very anxious, obviously.
Currently: Have been on Pristiq 50mg since 2008, I think. Still taking Clonazepam. Began cutting down my Pristiq dosage on July 22, 2011.

Also- it is my last year of grad school! I am looking forward to graduating, being med-free, and starting a new stage in my life!

#16 Altostrata

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Posted 04 August 2011 - 06:42 AM

Or you could phone Philip Ninan at Emory and ask him what the heck with tapering Pristiq.
This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

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#17 myself

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Posted 04 August 2011 - 10:34 AM

ha! or that. :) little med update: before i even opened my eyes this morning i could feel head fog/ brain zaps. soooo...i messily cut up my 50 mg pill and took 3/4 of it instead of the 1/2 i had been taking. feeling better today. still a headache, but not as bad. woo!

Have taken psychiatric meds since 2002.
Wellbutrin, Lexapro, Zoloft, Effexor (not sure of the dosages, or how long I took them...); have taken Clonazepam (1mg, as needed) since 2002 as well.
I was prescribed Adderall in late 2009 (after saying I had problems losing weight), stopped taking it cold turkey in Feb. 2011- made me very anxious, obviously.
Currently: Have been on Pristiq 50mg since 2008, I think. Still taking Clonazepam. Began cutting down my Pristiq dosage on July 22, 2011.

Also- it is my last year of grad school! I am looking forward to graduating, being med-free, and starting a new stage in my life!

#18 Altostrata

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Posted 09 September 2011 - 04:06 PM

Hi again, myself. You deserve a nice little topic of your own, so I moved your post to the Intro forum http://survivinganti...0824#entry10824, where you can track your progress.
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#19 annej

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Posted 11 December 2011 - 11:07 AM

I successfully got off of Pristiq by doing the following under "doctor's" supervision: Pristiq 100 mg. ----------> 50 mg. Sick! Lexapro 10 mg. added onto Pristiq 50 mg. Felt much better in about 7 days. Lexapro 10 mg. and Pristiq 50 mg. x 2 weeks Lexapro increased to 20 mg. x 7 days (along with Pristiq) Pristiq discontinued - Lexapro 20 mg. continued A little bumpy for about 5 days but definitely tolerable. Lexapro 20 mg. for about 4 weeks - very well stabilized! Lexapro 20 mg. to 15 mg. - Did just fine. (Go at your own rate) Lexapro 15 to 10 mg. - VERTIGO - back to 15 mg. Lexapro - decreased by 2.5 mg. every 7 days until finished. Jumped after 7 days at 2.5 mg. Did OK. My taper was very complex due to many different meds being discontiued and a simultaneous benzo taper due to an ill-advised pdoc's plan. The Lexapro discontinuation once I got the hang of it was actually very tolerable. Take it slow. That is the best way to taper. :) Annej

My Intro
2000-Effexor and Klonopin
April 2011- C/T Adderall, lithium, Seroquel, Lunesta; Pristiq and Klonopin cut by 1/2 due to med-induced "rapid cycling"
May 2011- Pristiq/Lexapro bridge/taper
June, 2011- K cut to 0.5 mg (doctor)
July 18, 2011 - Lexapro done
October 2011- K taper started
Jan, 2012- Off K, Remeron started -bad idea
March 2012- Horrific Tardive Akathisa/TD (Dx: TA versus withdrawal akathisia secondary to K w/d)
May 2012- Reinstatement of K
Current Psych Meds: Klonopin 2 mg + Propanolol 15 mg and titrating up
As of June 2013: TA gone or suppressed - struggling with tolerance to benzos - beta blocker helping


#20 Altostrata

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Posted 11 December 2011 - 02:33 PM

It's interesting that your doctor crossed you over to Lexapro rather than Prozac. Perhaps he was not aware that Prozac is preferable for this kind of switch because of its very long half-life. In my opinion, that dosage of Lexapro is excessive, roughly equivalent to 200-300mg of Pristiq, but it seems you may be a fast metabolizer and able to handle high doses of a lot of things. And, it's great you found it tolerable to taper off Lexapro over a few months. Some people have problems with tapering Lexapro, but nothing like Effexor/Pristiq, Paxil, or Cymbalta. Also, that alternating dosages you did at the end would trigger terrible withdrawal symptoms in some people. We don't recommend it, but your nervous system seems to be quite hardy!
This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

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#21 annej

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Posted 11 December 2011 - 03:34 PM

It's interesting that your doctor crossed you over to Lexapro rather than Prozac.

Perhaps he was not aware that Prozac is preferable for this kind of switch because of its very long half-life.

In my opinion, that dosage of Lexapro is excessive, roughly equivalent to 200-300mg of Pristiq, but it seems you may be a fast metabolizer and able to handle high doses of a lot of things.

And, it's great you found it tolerable to taper off Lexapro over a few months. Some people have problems with tapering Lexapro, but nothing like Effexor/Pristiq, Paxil, or Cymbalta.

Also, that alternating dosages you did at the end would trigger terrible withdrawal symptoms in some people. We don't recommend it, but your nervous system seems to be quite hardy!


Hi Altostrata,

I agree with many of your points as to my rather inept doctor-ordered taper. My story was not meant as prescriptive, but rather as a narrative of my experiences.

Unfortunately, Prozac did not work for me. I should have mentioned that.

Lexapro 10 mg did not cover my extreme withdrawal symptoms. This is why it was increased to 20 mg. It might be "excessive", but
it was effective and got me out of severe, acute withdrawals and I would have to say that once I started tapering at 2.5 mg. a week, my symptoms were tolerable.

I think most of us would agree that the best overall strategy in getting off of SSRI/SNRI's is do a slow taper.

:) annej

My Intro
2000-Effexor and Klonopin
April 2011- C/T Adderall, lithium, Seroquel, Lunesta; Pristiq and Klonopin cut by 1/2 due to med-induced "rapid cycling"
May 2011- Pristiq/Lexapro bridge/taper
June, 2011- K cut to 0.5 mg (doctor)
July 18, 2011 - Lexapro done
October 2011- K taper started
Jan, 2012- Off K, Remeron started -bad idea
March 2012- Horrific Tardive Akathisa/TD (Dx: TA versus withdrawal akathisia secondary to K w/d)
May 2012- Reinstatement of K
Current Psych Meds: Klonopin 2 mg + Propanolol 15 mg and titrating up
As of June 2013: TA gone or suppressed - struggling with tolerance to benzos - beta blocker helping


#22 Altostrata

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Posted 11 December 2011 - 07:05 PM

Do you have any idea why he chose Lexapro? Or was that just a shot in the dark? I see he had you drop the Pristiq completely after 3 weeks on the two drugs and a week after the boost to 20mg Lexapro.
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#23 annej

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Posted 11 December 2011 - 08:14 PM

Do you have any idea why he chose Lexapro? Or was that just a shot in the dark?

I see he had you drop the Pristiq completely after 3 weeks on the two drugs and a week after the boost to 20mg Lexapro.


Hi Altostrata,

My pdoc said I could choose any SSRI with the exception of Paxil that also was manufactured in a liquid form. We both assumed I would need a liquid in which to titrate off. I never used the liquid though.

I honestly believe that I was successful this time because I knew that my medication "cocktail" was no longer sustainable. It was truly a life or death situation. I simply had to dig deep in order to pull this off.

As I mentioned before, if I can do this while suffering from symptoms that made me appear very seriously mentally ill (and I sure felt ill) then I have every faith that any motivated person can be successful! :) annej

My Intro
2000-Effexor and Klonopin
April 2011- C/T Adderall, lithium, Seroquel, Lunesta; Pristiq and Klonopin cut by 1/2 due to med-induced "rapid cycling"
May 2011- Pristiq/Lexapro bridge/taper
June, 2011- K cut to 0.5 mg (doctor)
July 18, 2011 - Lexapro done
October 2011- K taper started
Jan, 2012- Off K, Remeron started -bad idea
March 2012- Horrific Tardive Akathisa/TD (Dx: TA versus withdrawal akathisia secondary to K w/d)
May 2012- Reinstatement of K
Current Psych Meds: Klonopin 2 mg + Propanolol 15 mg and titrating up
As of June 2013: TA gone or suppressed - struggling with tolerance to benzos - beta blocker helping


#24 Altostrata

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Posted 12 December 2011 - 08:08 PM

Well, at least your pdoc had the sense to think about titrating a liquid. I agree with you, your experience is a tribute to how a determined person can overcome unnecessary polydrugging and take responsibility for her own recovery! You've brought intelligence and focus to getting yourself off drugs -- thank you for encouraging everyone reading this.
This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

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#25 Altostrata

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Posted 24 December 2011 - 11:09 AM

Many doctors consider Stahl's Essential Psychopharmacology: The Prescriber's Guide: Antidepressants by Stephen M. Stahl to be the Bible of antidepressant prescribing.

If you read this closely, you will see much of the advice is conflicting, which explains why even doctors who are conscientious about looking things up will be terminally confused about how to taper people safely off antidepressants.

Here is Dr. Stahl's advice about discontinuing deslavenlafaxine, from page 61 of the 2011 edition:

(My comments in red.)

  • Do not break or chew tablets, as this will alter controlled-release properties
  • For patients with severe problems discontinuing desvenlafaxine, dosing may need to be tapered over many months (i.e., reduce dose by 1% every three days by crushing tablet and suspending or dissolving in 100 mL of fruit juice, and then disposing of 1 mL while drinking the rest; 3-7 days later, disposing of 2 mL, and so on). This is both a form of very slow biological tapering and a form of behavioral desensitization.
    Wouldn't crushing tablets conflict with the first point? Desvenlafaxine is stronger than venlafaxine, wouldn't destroying the coating release an unaccustomed high dose quickly? Furthermore, it's preferable to mix crushed tablets in water so you can see how well the particles are distributed.
  • For some patients with severe problems discontinuing desvenlafaxine, it may be useful to add an SSRI with a long half-life, especially fluoxetine, prior to taper of desvenlafaxine. While maintaining fluoxetine dosing, first slowly taper desvenlafaxine and then taper fluoxetine
    How would you know a patient has severe problems tapering desvenlafaxine until the patient has tried it? This point implies a previously unsuccessful taper with severe withdrawal symptoms. (Yet, as usual, does not explain what "severe" means.)

    This advice would have the patient taking a double dose of antidepressant, Pristiq with Prozac, for an extended period of time but does not address the possibility of adverse effects, such as serotonin syndrome, from the excessive dosage.

    Dr. Stahl apparently subscribes to the belief, common among psychopharmacologists, that the patient's nervous system is made of an endlessly elastic rubber-like material.
  • Be sure to diffentiate between re-emergence of symptoms requiring re-institution of treatment and withdrawal symptoms
    Easier said than done, Dr. Stahl!

How to Stop

  • Taper to avoid withdrawal effects (dizziness, nausea, diarrhea, sweating, anxiety, irritability)
    True enough. Okay, so how to taper Pristiq, which comes in only two doses, high and higher?
  • Recommended taper schedule is to give a fully daily dose (50mg) less frequently
    In case you were wondering where your doctor got the idea of alternating dosages, here's one source. THIS IS A TERRIBLE IDEA. DON'T DO IT. ALTERNATING DOSAGES IS SECOND ONLY TO COLD-TURKEY IN TRIGGERING SEVERE WITHDRAWAL SYMPTOMS.
  • If withdrawal symptoms emerge during discontinuation, raise dose to stop symptoms and the restart withdrawal much more slowly
    If your doctor followed this advice, you would have been alternating dosages and experienced severe withdrawal syndrome. Doesn't it make more sense to taper gradually from the start?

As near as I can tell, there are no footnotes indicating where Dr. Stahl got his information about tapering desvenlafaxine. He is such a towering authority that doctors accept his advice without question -- although it is well-known that he has gotten a great deal of pharma funding throughout his career, and is currently flogging the new antipsychotic Latuda.
This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

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#26 Christine

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Posted 28 January 2012 - 05:50 PM

I was wondering if anybody knows how to taper off slowly from Pristiq? It only comes into 50 or 100 mg and it is one solid square tablet that is hard to split. Anyone knows how you get down to 40, 30, 20mg, etc... Thanks!

#27 alexejice

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Posted 28 January 2012 - 07:13 PM

Hi Christine,

Welcome to the forum. I was briefly on Pristiq as it is not too dissimilar molecularly from Effexor. However, the switch between the two didn't go as planned so I went back on the Effexor from which I tapered. My taper was too rapid resulting in a longer and unpleasant w/d process for me.

To help avoid prolonged and, potentially, very difficult withdrawal most (myself included) recommend a conservative approach to going off any antidepressant (or psych med generally). This means tapering and doing so gradually.

A good place to start for information specific to desvenlafaxine is the thread Altostrata created on Tapering Pristiq. I'd also recommend browsing the site a bit as well. There's a lot of information here.

I'm sure some other members of the community will chime in on your question as well.

Again, welcome to board.

Alex

Visit my site:

notcrazyafterall.com


#28 Jemima

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Posted 30 January 2012 - 03:12 PM

I was on Pristiq (50 mg. time-release) for five months and it made me really hyper. Although I don't especially recommend this, my doctor switched me to 10 mg. of Lexapro with no problems. (For all I know, these may be equivalent doses.) Getting off of Lexapro has been a rough ride, mostly due to food sensitivies (which, thank God, are going away), insomnia (ups and downs, here), irritability, and unusual sensitivites to the environment. It may not be the best choice of drugs to switch off to for tapering, but there may be something in the same drug family that wouldn't be as trying as Lexapro, something that comes in a tablet or liquid form so you can reduce the dose very gradually.

Psychotropic drug history: Pristiq 50 mg. (mid-September 2010 through February 2011), Remeron (mid-September 2010 through January 2011), Lexapro 10 mg. (mid-February 2011 through mid-December 2011), Lorazepam (Ativan) 1 mg. as needed mid-September 2010 through early March 2012

"Never attribute to malice that which is adequately explained by stupidity." -Hanlon's Razor


Introduction: http://survivinganti...oducing-jemima/

 

Success Story: http://survivinganti...r-dickhead-too/

Please note that I am not a medical professional and my advice is based on personal experience, reading, and anecdotal information posted by other sufferers.

 


#29 Altostrata

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Posted 31 January 2012 - 03:21 PM

There is nothing in the Pristiq-Effexor drug family (SNRI) that comes in liquid form.

Switching to Prozac may be an option, but it is by no means a sure thing.

Please read Important topics in the Tapering forum.

Jemima, it sounds to me like something in your tapering journey must have sensitized you. Was it an unsuccessful taper attempt or the switch to Lexapro?
This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

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#30 Giacomo

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Posted 13 April 2012 - 10:43 AM

Seeking thoughts of those more experienced that I. I have begun my "tapering" off of Pristiq. Psychiatrist started me on 20 mg of Prozac a day, while at same time taking me from 100 mg of Pristiq a day to 50 mg of Pristiq a day. It took about 1 month before I "settled" into this new routine. Or, I think it took about 1 month for the Prozac to kick in. Now, after about 1 and 1/2 months of this new, just stated regimen, with my doctor's directions, I have begun this week to take the 50 mg of Pristiq every other day. This has been going on for about 1 week. First of the week was JITTERY, now more settled. Doc said to do this for 2 whole weeks, and to re-evaluate myself. Her goal, and mine, is to be rid of Pristiq all together. Then, we'll address the Prozac. At present, I was told after 2 weeks of the new regimen, to reevaluate. I can't believe the Doc is giving me so much latitude. Anyway, her optimal plan is: Eventually I stop the 50 mg Pristiq. If it is unbearable, I'm to increase the 20 mg of Prozac a day to 40 mg of Prozac a day. We'll see. I prefer not to increase. SO, HOW DO I GET WEENED from the 50 mg of Pristiq every other day? Once the 2 weeks are up, do I just QUIT cold turkey? OR, do I try to do the 50 mg every THIRD day? Any suggestions out there from those who have gone before me in this? THANKS.

#31 Altostrata

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Posted 13 April 2012 - 11:07 AM

Please read the information in the first post, such as:

....Do not alternate doses to taper -- this will cause the levels of this medication in your brain to go up and down and is second only to cold-turkey in causing withdrawal symptoms.

....
....Pristiq does not come in any less than a 50mg dose, making such gradual tapering impossible.

....
Cutting up the Pristiq tablets
There are reports on the Web that people are doing this.

Since the coating is responsible for the extended-release effect, it is unknown what would happen if you broke the coating by cutting up a tablet.

Pristiq is to Effexor as Lexapro is to Celexa -- a tweaked and more powerful molecule. Plus, the coating on Pristiq is timed-release. When pills are cut, they revert to desvenlafaxine. As time-release is removed, this could be a hit to the CNS.

Crushing Pristiq tablets and mixing in liquid
Eminent psychopharmacologist Stephen Stahl advises titration by crushing the tablets and mixing in fruit juice (or, I would assume, water, which is preferable because you can see how well the particles are distributed), see http://survivinganti...dpost__p__14799

.....
"Bridging" with Prozac
Given that Pristiq is a cousin of Effexor and Effexor XL, it is possible that one can, similarly, use Prozac to withdraw from Pristiq:

Attributed to Joseph Glenmullen, the "bridging" technique is described by a doctor here http://www.bipolarwo...2005/ph1354.htm Another doctor explained his technique to me:

For a "normal" dose of Effexor (150mg per day or more), he would switch to 10mg Prozac with a week of overlap. In other words, take both medications for a week and then drop the Effexor. Lower doses of Effexor require lower doses of Prozac as a "bridge."

Later, taper off Prozac. He acknowledged Prozac can have its withdrawal problems, but given Prozac's long half-life, gradual tapering should be much easier than tapering off Effexor. And, at least Prozac comes in a liquid.

To do this, consult a doctor knowledgeable about this technique.

Phone Pfizer, Pristiq's manufacturer, to make a complaint
(800) 438-1985

They may suggest alternating dosages to taper Pristiq. Don't do this -- it's like playing ping-pong with your brain.

Expect to file a complaint that there's no way to taper off Pristiq.

Giacomo, it seems that your doctor is fond of very high doses of antidepressants for you, and she does not know how to gradually taper.

Did she add in the Prozac intending to taper you off that later?

If I were you, I'd take a half a 50mg tablet of Pristiq per day rather than alternating doses. Do this for 2 weeks. If withdrawal symptoms are minimal, take 1/4 tablet for two weeks. If withdrawal symptoms are minimal, stop Pristiq. Then stay on 20mg Prozac for a month, to give your nervous system a chance to stabilize. Use Prozac liquid to gradually taper off Prozac. See Tips for tapering off Prozac (fluoxetine)
This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

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

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#32 Giacomo

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Posted 13 April 2012 - 08:00 PM

Psychiatrist added in the Prozac. She said that was her pattern used successfully with other patients to get them off of Pristiq. She said the Prozac might "stay" or "go" depending on whether or not I can get off the Prozac. She said we can and should try. But, she was willing to consider keeping me on the Prozac if needed. I think it was her "argument" to not frighten me then, when first discussing, by the thought of "no meds." I want "no meds" as my goal, but have to admit some fear at the notion of being all together free from the meds. I have engaged in talk therapy to assist me in dealing with issues, so my approach is not merely one of medication.

#33 NCLady71

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Posted 24 April 2012 - 10:57 AM

I was searching the web for info on Pristiq and came across this board. I am not looking to taper off Pristiq, I just want to be able to take it. This is my story. Started Paxil March 2011, was on it for 11 mos. I took myself off cold turkey because I could not handle the weight gain (40 lbs in the 11 mos on it) plus it really was not helping. My new doctor put me on Celexa, which was just as bad for about 2 mos. I was then put on Pristiq. The first several days were great, although I was still taking 1/2 dose of Celexa to wean off. Well, things took a nose dive big time. I felt like I was in hell, started crying all the time, on edge like I was going to snap and seriouslly thinking of death. Side note here, I have IBS, have had for as long as I can remember. I read on the packaging that you may see an empty shell in your stool when taking Pristiq. Well, I started noticing a whole pill undigested, still all the white powder intact. Nobody ever mentioned taking a time release if you have IBS may cause it to not absorb. So basically, I was not on any antidepressants for a few weeks. Taking a pill everyday, just to have it pass from my body undissolved. If I was getting any of the med, it was not nearly what I needed. So, I took matters in my own hands, started scratching off the coating and taking the pill like that. Within two days, I felt like a different person! No more crying or edginess! I don't know how safe this is, but I had to do something. Go back to doc next week and have to tell her what is happening to get her advice, but I'm having success with the Pristiq in an altered non-time release form! So, maybe you can remove the coating and cut the pill if you want to taper. Just a suggestion.

#34 psychfree88

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Posted 28 April 2012 - 06:30 PM

I called my doctor and he told me to take 25 mg for 6 days and quit...and let him know if anything happens.. Wow...why is it different for every one.. i was thinking of tapering for one month,and based on 10% rule it will be 4.5 months+

#35 LonelyMan

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Posted 10 June 2012 - 07:11 PM

I called my doctor and he told me to take 25 mg for 6 days and quit...and let him know if anything happens..

Wow...why is it different for every one..

i was thinking of tapering for one month,and based on 10% rule it will be 4.5 months+


Due to such a great decrease in tapering. I would strongly not advise doing this. But I dont know much about anything at all!

#36 Altostrata

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Posted 11 June 2012 - 10:37 AM

I called my doctor and he told me to take 25 mg for 6 days and quit...and let him know if anything happens..

Yeah, right, and if you get withdrawal symptoms, what is he going to do about it? If you're lucky, he'll know to reinstate the medication. He may or may not know about how to taper slowly after that.

It's much better for your nervous system not to put it through that kind of injury to begin with. But many doctors think the nervous system is made of rubber.
This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

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