Tips for tapering off desvenlafaxine (Pristiq)

[ChessieCat]

Observations about returning emotions at lower Pristiq doses:

 

31 minutes ago, Andie said:

My emotions came roaring back at about 15 mg mark and are becoming stronger.  Its like someone suddenly turned the volume up. I am very shocked at how numbed out I have been. I didn’t think it was even possible.  I was a plank of wood. I would rarely get emotional about things but I would get very irritable and angry. A few people in my life pointed out to me that I didn’t seem ‘right’ and that I had changed.  I thought I was just standing up for myself and had gained more confidence. I didn’t believe them. 

 

58 minutes ago, ChessieCat said:

The lower our dose gets the less numbed our emotions are.

 

April 2017 I bought a new car when I was at 25mg Pristiq.  In October/November 2017 I was at 19mg.  I got very excited when I unexpectedly saw some whales when we were checking out a car that my daughter was looking at and the seller's house was on the coast.  I even jumped up and down on the spot which I noticed because I had been having trouble raising my legs high enough to step up the gutter (this has slowly improved).  I realised then that when I got my car it was a dulled excitement.

 

[ChessieCat]

Spoke to my compounder and he said he can make capsules of any dose.  When I get my next batch I will need to provide 50mg tablets instead of 100mg because he said it will be easier for him.  I didn't even think about that.

[Altostrata]

You're handling this Pristiq taper brilliantly, Chessie.

[ChessieCat]

Thanks Alto.  I'm very thankful for what I have learned from here about the no more than 10% reduction every 4 weeks.  It's been a bit fiddly having to work with the various capsule doses to create a similar reduction timeline to SA's protocol, but what I'm doing seems to be working okay.  I think once I stopped being concerned about the length of time it's going to take and just working it out the best I can keeping the reduction under the 10% has helped.  I also decided right from the start that I was not going to change to venlafaxine or generic.

 

I've already worked out my reductions for the next section of the taper (will calculate required capsules closer to when I need them).  But the one after that is going to be a bit trickier.  Instead of going down by 0.125 each time it would be 0.0625 so I might go to 0.06 or even 0.05 just to make it easier.  I'll just need to do it when my brain is fairly clear.  And not leave it until the last minute and have to do it in a panic.

 

Edited November 16, 2018 by ChessieCat

[ChessieCat]

Getting off Pristiq is achievable!!!  😊

 

Depending on your compounding pharmacist, you might be able to get your Pristiq compounded in the dose you need to make a 10% reduction and get 28 capsules made up for a 4 week hold.  My compounder makes capsules in dose batches of 100 so I have had to adjust my tapering to suit the capsules.

 

I thought it might be helpful for other members tapering Pristiq to know what doses and length of holds I've done using compounded capsules.  In Australia we can only get 50mg and 100mg tablets.  In some other places 25mg tablets are available so you can use 50mg and 25mg tablets combined with capsules whenever possible.  I got my Pristiq compounded in the largest amount (eg 40mg, 30mg, 10mg) and then use 5mg, 2mg, 1mg, 0.5mg and 0.25mg to make up the full dose.  In the table I've included how I have already tapered on the right (doses from lowest to highest) and on the left is my proposed taper to 1.25mg (doses from highest to lowest).  Obviously if issues arise I will hold for longer.

 

I did a long hold of about 3 months on 50mg (a tablet dose so convenient) and about 7 weeks at 20mg (I had extra 20mg capsules available so I took the opportunity to hold).  I accidentally reduced my dose by half going from 9.5mg to 4.5mg instead of to 9mg for 5 days when I used the 0.5mg bottle of capsules instead of 5mg (yes, my anxiety did increase for a while).  I held for longer because of the error.  I also held for an extra week at 8mg.  I had dental issues from May 2018 and the accidental dose reduction mentioned.  And there might be info in my Intro topic for the other hold times which aren't 21 or 28 days:  chessiecat-so-im-not-the-only-one

 

When I got to 8.5mg I started taking a smaller part of the dose in the evening.  The amount varies, depending on what dose I am taking.  For example when taking 6mg I took 1mg at night (dose made up of 5mg and 1mg capsules) and at 5.5mg I took 0.5mg at night.  I'm now down to 5mg but my dose is made up of 4mg and 1mg capsules so I take 1mg at night.  Member Andie has just started taking 4mg capsules 3 times a day for his her 12mg dose.  (Andie has informed me that they are a girl - sorry Andie)

 

Sorry it's blurry.  It's not bolded but came out that way.  I tried but couldn't create a JPG and had to use PNG and this is how it turned out.  EDIT:  Thanks to my daughter's suggestion of using the "snip tool" to create this is now clearer.

 

 

Edited December 17, 2018 by ChessieCat
changed gender of Andie/changed table

[ChessieCat]

I've just done a quick google search and found this here https://www.rxlist.com/pristiq-drug.htm#indications

 

(10 mg doses?  Must have been made specially for the clinical studies.)

DOSAGE AND ADMINISTRATION

General Instruction For Use

The recommended dose for PRISTIQ is 50 mg once daily, with or without food. The 50 mg dose is both a starting dose and the therapeutic dose. PRISTIQ should be taken at approximately the same time each day. Tablets must be swallowed whole with fluid and not divided, crushed, chewed, or dissolved.

 

In clinical studies, doses of 10 mg to 400 mg per day were studied. In clinical studies, doses of 50 mg to 400 mg per day were shown to be effective, although no additional benefit was demonstrated at doses greater than 50 mg per day and adverse reactions and discontinuations were more frequent at higher doses.

 

The 25 mg per day dose is intended for a gradual reduction in dose when discontinuing treatment. When discontinuing therapy, gradual dose reduction is recommended whenever possible to minimize discontinuation symptoms [see Discontinuing PRISTIQ and WARNINGS AND PRECAUTIONS].

[ChessieCat]

On 3/14/2019 at 9:01 AM, DWeb said:

I'm having a very hard time finding a compounding pharmacy that will compound Pristiq for me. Most of them just say it's impossible. I called the Peoples RX in Texas and they no longer ship out of state. 

 

Does anyone have a good solution for finding a compounding pharmacy that will do slow release formulations that can either mail to me in Washington OR is actually in Washington State?

 

Thanks

 

On 3/15/2019 at 7:17 AM, DWeb said:

Yeah, I went to PCCAR and looked for compounding pharmacies. Called about 10 or 12 and none would work with Pristiq.

 

I have contacted the pccarx because I think it is important for them to know that 1) it is possible to compound Pristiq if they don't already know this, and 2) to advise their members that it is possible

 

I have provided my compounding pharmacist's contact information in the above and following correspondence.

 

I have also contacted these pharmacies:

 

https://paramountpharmacy.com/contact/

 

https://www.keycompounding.com/contact/

 

I will let you know if I get a response from them.

[ChessieCat]

On 3/17/2019 at 11:25 AM, ChessieCat said:

I have contacted the pccarx

 

And I have received a response ☺️

 

I have not provided Ranel's address because it may change in the future if this person leaves the organisation but this is the one I used and you can send it   Subject:   ATTN:  Clinical Compounding Pharmacist

 

customerserviceexternal AT SYMBOL pccarx DOT com

 

Thanks so much for contacting us regarding this.  There are definitely some options on compounding this product and we are happy to assist a pharmacy with the knowledge on how to do this.  We have many member pharmacies within the state of Washington that are PCCA members and would be able to assist this patient.  Do you know where in Washington State your contact is located?  If you can provide that information I can direct them to a pharmacy that is a PCCA member.  That pharmacy is welcome to contact me through our members only website or by calling customer service and I can assist them with a formulation. 

Thank you and have a wonderful day!

Ranel A. Larsen, Pharm D, RPh | Clinical Compounding Pharmacist

PCCA | 9901 South Wilcrest Dr. | Houston, TX 77099-5132

Ph: 800.331.2498    

Fax: 800.874.5760 | PCD Fax: 713-234-6009

www.pccarx.com

 

[DWeb]

20 hours ago, ChessieCat said:

 

And I have received a response ☺️

 

I have not provided Ranel's address because it may change in the future if this person leaves the organisation but this is the one I used and you can send it   Subject:   ATTN:  Clinical Compounding Pharmacist

 

customerserviceexternal AT SYMBOL pccarx DOT com

 

Thanks so much for contacting us regarding this.  There are definitely some options on compounding this product and we are happy to assist a pharmacy with the knowledge on how to do this.  We have many member pharmacies within the state of Washington that are PCCA members and would be able to assist this patient.  Do you know where in Washington State your contact is located?  If you can provide that information I can direct them to a pharmacy that is a PCCA member.  That pharmacy is welcome to contact me through our members only website or by calling customer service and I can assist them with a formulation. 

Thank you and have a wonderful day!

Ranel A. Larsen, Pharm D, RPh | Clinical Compounding Pharmacist

PCCA | 9901 South Wilcrest Dr. | Houston, TX 77099-5132

Ph: 800.331.2498    

Fax: 800.874.5760 | PCD Fax: 713-234-6009

www.pccarx.com

 

 

Interesting. Is any pharmacy that you can find on there websites "Find a Pharmacy" feature going to be a PCCA member or does that just mean that particular pharmacy is a customer? Or is there even a difference?

 

I'm just trying to figure out the best way to approach one of these pharmacies that has already turned me away. I will probably go in person, for one. 

[ChessieCat]

You could ask the compounding pharmacy to contact the compounding association.

 

At least now you can tell them that you have it from the horse's mouth that it can be done.  And you can even tell them who provided the information:  Ranel A. Larsen, Pharm D, RPh | Clinical Compounding Pharmacist

[liz419]

Hi everyone! Thanks to this thread I got the idea of going to a compounding pharmacy to taper off Pristiq. I called several that all told me it was impossible to do. However, I finally found one that said they could do it! I gave my capsules to the pharmacist and he used them to create a liquid solution. He's having me taper down 5 mg every month and I just took my first dose today. I will keep you all updated on how it goes, I am super excited because I have been on this medication for over 7 years and had begin losing hope if I'd ever be able to get off of it.

 

Edited May 9, 2019 by ChessieCat
removed link to picture which may have member's real name

[Andie]

18 hours ago, liz419 said:

gave my capsules to the pharmacist and he used them to create a liquid solution

Hi There 

 

Did any of the Pharmacies you called tell you why it is impossible to compound Pristiq? 

 

I am curious as to how the Pristiq is being made into a liquid when it’s a modified release formulation.

 

[ChessieCat]

19 hours ago, liz419 said:

I gave my capsules to the pharmacist and he used them to create a liquid solution.

 

Were you advised to take it twice daily?  Once the tablet is crushed it will be immediate release and will have a very short half life.

[liz419]

2 hours ago, Andie said:

Hi There 

 

Did any of the Pharmacies you called tell you why it is impossible to compound Pristiq? 

 

I am curious as to how the Pristiq is being made into a liquid when it’s a modified release formulation.

 

Hi! Like you said, they told me they couldn't do it because it is extended release. I'm not sure how the pharmacist is able to do it. I did some research into him and apparently he is a well renowned researcher and instructor on compounding drugs so I think he has his own cutting edge technique. Here's a picture of the bottle: https://imgur.com/a/rr8ADoYhttps://imgur.com/a/rr8ADoY

[liz419]

1 hour ago, ChessieCat said:

 

Were you advised to take it twice daily?  Once the tablet is crushed it will be immediate release and will have a very short half life.

Hi! No, I am only taking it once a day.

[Altostrata]

17 hours ago, liz419 said:

Hi! Like you said, they told me they couldn't do it because it is extended release. I'm not sure how the pharmacist is able to do it. I did some research into him and apparently he is a well renowned researcher and instructor on compounding drugs so I think he has his own cutting edge technique. Here's a picture of the bottle: https://imgur.com/a/rr8ADoYhttps://imgur.com/a/rr8ADoY

 

It's not possible for a liquid to be extended-release. The pharmacist is probably getting pure desvenlafaxine powder and making a liquid from it.

 

As I recall, the half-life of pure o-desvenlafaxine is about 11 hours. Ordinarily, you'd need to take an antidepressant with this short a half-life twice a day, but if once a day works, it works.

 

I updated post #1 of this topic with the information about making desvenlafaxine liquid, thanks, @liz419

[ChessieCat]

On 5/9/2019 at 3:24 PM, liz419 said:

I gave my capsules to the pharmacist and he used them to create a liquid solution.

 

4 hours ago, Altostrata said:

The pharmacist is probably getting pure desvenlafaxine powder and making a liquid from it.

 

Member provided the "capsules".

[Altostrata]

As near as I can tell, prescription desvenlafaxine comes only in tablets.

 

Whatever was provided isn't necessarily what was used. No matter what the liquid was made of, it's going to be immediate-release.

[Andie]

Hi @liz419

 

Keep us informed on how you are are feeling on your liquid Pristiq. If you create an introductions topic for yourself we can get to know you a bit better and follow your taper. I am coming off Pristiq too. 

 

 

 

 

[liz419]

1 minute ago, Andie said:

Hi @liz419

 

Keep us informed on how you are are feeling on your liquid Pristiq. If you create an introductions topic for yourself we can get to know you a bit better and follow your taper. I am coming off Pristiq too. 

 

 

 

 

Will do! I've been on it for 2 days now and so far have no side effects. I created one, it should show soon after it gets approved! Best of luck with your taper, it's such a hard drug to get off of

[ChessieCat]

@liz419

 

Q:  Where you advised of the use by date after opening your liquid?

 

I spoke to my compounding pharmacist today asking about Pristiq being made into liquid and he said yes it can.  However, it would have to be disposed of after 1 month.

 

I also asked him specifically if the efficacy of the drug reduces and he said yes.

[liz419]

On 5/21/2019 at 10:26 PM, ChessieCat said:

@liz419

 

Q:  Where you advised of the use by date after opening your liquid?

 

I spoke to my compounding pharmacist today asking about Pristiq being made into liquid and he said yes it can.  However, it would have to be disposed of after 1 month.

 

I also asked him specifically if the efficacy of the drug reduces and he said yes.

The bottle says "discard by 6/25/19" and we picked up the bottle at the beginning of May, so it seems like mine is set to be disposed of after around 2 months.

[Andie]

How are you coming along on your liquid Pristiq Liz? 

 

The Pharmacy I use are investigating if they can make my medication in liquid form. If they can obtain the raw Desvenlafaxine power they may be able to do it. 

[liz419]

I'm doing great! Right now I am at 17.5 mg and will be down to 15 mg by June 8. The only side effect I've noticed is getting brain zaps when I take the dose too late past my usual time. I also have been able to remember my dreams, which I wasn't able to do before. That's so exciting that they may be able to do it for you, I definitely think the pharmacist used the raw powder to make mine!!

On 5/26/2019 at 2:50 AM, Andie said:

How are you coming along on your liquid Pristiq Liz? 

 

The Pharmacy I use are investigating if they can make my medication in liquid form. If they can obtain the raw Desvenlafaxine power they may be able to do it. 

 

[ChessieCat]

For people who can't get their Pristiq tablets compounded, or can't afford the additional cost this might work:

 

You could try using a nail file (a metal one would be better than an emery board/sandpaper type) and file off some of the edge of a tablet and weigh it.  At least then you will keep the tablet "whole" so would still retain most of the extended release character of the tablet.  Please read the following which explains how Pristiq tablets are made:

 

On 7/17/2011 at 2:52 AM, Altostrata said:

Pristiq's extended-release formulation

According to this paper, the extended-release formulation releases desvenlafaxine over 24 hours. The mean half-life of desvenlafaxine, without the extended-release formulation, is around 11 hours. The extended-release formulation is a monolithic matrix -- it's in the glue that holds the tablet together, not in the coating.

 

I confirmed this in a phone conversation with Pfizer medical information (1-800-438-1985). (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. The extended-release mechanism is part of the tablet matrix, or the glue that holds the tablet together. This is called a monolithic matrix tablet.

If the tablet is split, the matrix is damaged and may not reliably be extended-release, depending on the size of the fragments. Larger fragments are more likely to retain some extended-release capability.
 
When the tablet is CRUSHED, the matrix is completely destroyed. The particles should be assumed to have NO extended-release capability. A Pristiq fragment becomes desvenlafaxine, with an 11-hour half life.

 

[Altostrata]

Ingenious, Chessie!

 

Usually the nailfile method is too inexact at small dosages, but weighing is a good way to verify the dosage.

[ChessieCat]

On 5/11/2019 at 11:49 AM, Andie said:

I am coming off Pristiq too. 

 

5 hours ago, ChessieCat said:

Did you end up changing to enteric capsules?

 

40 minutes ago, Andie said:

Yes I am using the enteric but After switching over and giving it a few months I haven’t noticed a huge difference. 

 

The Pharmacists I have spoken to can’t agree on whether the capsule should be enteric or regular gelatin. 

 

[Andie]

I spoke with a compounding Pharmacy about the availability of bulk Desvenlafaxine powder for use in preparing custom doses. 
 

The Pharmacist advised that in Australia the bulk powder has not been approved for human consumption or therapeutic use and is available for research purposes only. An example being the testing of different drug delivery systems. 
 

 

 

[Yogendra]

Hi Yogendra here, I am making switch over from Desvenlaflaxine to Venflaxine as latter one consists of small beads in capsules and can be counted easily while reducing the doses.

 

Simultaneously I am reducing Desvenlaflaxine too by cutting and weighing though I know that it may no longer act as delayed release then. But I don't have any other method too owing to no compounding pharmacy here.

[ChessieCat]

I tried something this afternoon after a member posted about whether they would be able to add the contents of their compounded sertraline capsule to water.

 

My compounded Pristiq capsules have slow release formula added and I'm assuming that they might also have filler added.

 

I added the contents of a capsule to water.  Because I was only testing to see what happened I used a mini whisk and a plastic chopstick to mix it all up.  It went frothy like beaten egg whites.  But after that I left it to stand for several hours and everything dissolved.

 

Obviously this is not the best option but it's good to know that it is possible to do this.  However my biggest concern would be interdose withdrawal.

 

I will have to ask the compounding pharmacist about the liquid preparation he said he could make and whether that would be better than just using water.

[ChessieCat]

Interdose withdrawal:  Things that I have realised in hindsight.

 

Once I dropped below 50mg tablet (25mg is not available in Australia) I should have been dosing more than once a day.  I started dosing twice a day after 10mg.

 

Because the slow release formula only extends the drug for 6 hours I should have been dosing 3 times a day.

 

(I've only recently discovered that I can create a liquid from the compounded capsules.)

 

Once I started taking only capsules I should have combined capsules and liquid so that I could take even doses.

 

(Because I was limited to a minimum capsule dose of 0.125mg I would divide the dose into two as evenly as possible but if it was not in halve I would take the larger dose in the morning and the smaller amount at night.)

[Kevman2112]

On 7/16/2011 at 12:52 PM, Altostrata said:

As a chemical, before it's put into an extended-release tablet, desvenlafaxine has a half-life of around 11 hours.

 

Pristiq's extended-release formulation

According to this paper, the extended-release formulation releases desvenlafaxine over 24 hours. The mean half-life of desvenlafaxine, without the extended-release formulation, is around 11 hours. The extended-release formulation is a monolithic matrix -- it's in the glue that holds the tablet together, not in the coating

I am a bit confused by this.  All information that I have seen indicates that Pristiq has a half life of 11 hours unless some level of renal impairment is involved.  I have not found any indication that the half life is greater than 11 hours in extended release form.  Therefore, I would assume that desvenlafaxine ER either has a longer half life than 11 hours or without the extended release formulation it is less than 11 hours.  I researched this quite a bit but could not find any additional information.  Apologies if this was clear to others and I missed something.  Thank you in advance 

[ChessieCat]

I think you may have missed the following:

 

On 7/17/2011 at 2:52 AM, Altostrata said:

As a chemical, before it's put into an extended-release tablet, desvenlafaxine has a half-life of around 11 hours.

 

On 7/17/2011 at 2:52 AM, Altostrata said:

According to this paper, the extended-release formulation releases desvenlafaxine over 24 hours. The mean half-life of desvenlafaxine, without the extended-release formulation, is around 11 hours.

 

 

[ChessieCat]

I did not realise the above about the unextended drug having a half life of 11 hours.  That's actually good news because it means that splitting the liquid or compounded capsules into only 2 doses might, in most instances, be okay.  Anyone who gets interdose withdrawal due to being a fast metaboliser might find it better to dose 3 times a day.

 

To help work out if you might be experiencing interdose withdrawal you keep daily symptom notes.  If you find that your symptoms worsen at a particular time of day every day then it may be interdose withdrawal. 

 

Assuming that you are currently taking your drug in the morning, if you want to take the cautious route (which is generally gentler on the nervous system) you would move part of your dose by 1 hour each day and be aware about how your sleep is being affected.  Continue keeping notes about symptoms.  You can always stay at the same time for more days and/or reduce the amount of time, eg instead of moving by 1 hour only move by 1/2 hour.  If your sleep starts being affected and you think that it is related to the drug (ie not other factors, eg a hot night, or being stressed - if in doubt then do not move your dose forward for the time being), then you could move your drug backwards.  You could move by 1/2 hour and stay there for a few days.

[Kevman2112]

15 hours ago, ChessieCat said:

I did not realise the above about the unextended drug having a half life of 11 hours.  That's actually good news because it means that splitting the liquid or compounded capsules into only 2 doses might, in most instances, be okay.  Anyone who gets interdose withdrawal due to being a fast metaboliser might find it better to dose 3 times a day.

 

To help work out if you might be experiencing interdose withdrawal you keep daily symptom notes.  If you find that your symptoms worsen at a particular time of day every day then it may be interdose withdrawal. 

 

Assuming that you are currently taking your drug in the morning, if you want to take the cautious route (which is generally gentler on the nervous system) you would move part of your dose by 1 hour each day and be aware about how your sleep is being affected.  Continue keeping notes about symptoms.  You can always stay at the same time for more days and/or reduce the amount of time, eg instead of moving by 1 hour only move by 1/2 hour.  If your sleep starts being affected and you think that it is related to the drug (ie not other factors, eg a hot night, or being stressed - if in doubt then do not move your dose forward for the time being), then you could move your drug backwards.  You could move by 1/2 hour and stay there for a few days.

I did a little bit more research and found that it might not be an apples to apples comparison using half life for immediate release to extended release.  This article https://n.neurology.org/content/84/14_Supplement/P1.249 has that general premise, but is a bit above my understanding.  To your point, essentially our reason for asking about half life is related to multiple doses per day and what the best time in between is.  I have inter-dose withdrawal in the mornings to early afternoon and then 0 symptoms after 2pm (I was taking the full 37.5mg in the morning around 730.  Yesterday I split it up and took 25mg in the morning and 12.5mg right before bed.  Woke up extremely irritable but we’ll see how today goes.  Appreciate your thoughts @ChessieCat, you seem to be a great resource on this site. 

[ChessieCat]

7 hours ago, Kevman2112 said:

I did a little bit more research and found that it might not be an apples to apples comparison using half life for immediate release to extended release.  This article https://n.neurology.org/content/84/14_Supplement/P1.249 has that general premise, but is a bit above my understanding.

 

That article is unrelated to the discussion of Pristiq.

 

I'll try to put it in simple terms.  If you were able to get and take the ingredient of pure desvenlafaxine then the half life is about 11 hours.  To make a Pristiq tablet, the desvenlafaxine is mixed with other ingredients to make a paste / glue (called matrix) which slows down the access to the drug in the tablet.  Imagine the drug being distributed evenly through an old-fashioned gob stopper (the one with different coloured layers) and as the layers dissolve in your mouth the colours change and also a bit more of the drug is made available.  The desvenlafaxine ingredient still has an ~11 hour half life but it is not accessed all at the same time but over a period of time.  It is the matrix which causes the extended release (released over time) of the drug.  The desvenlafaxine is still the same.  It's the delivery of the desvenlafaxine which is different.

 

If you cut a whole Pristiq tablet in half and take the two halves, the half life will be shorter than the ~24 hours.  If you cut the tablet into quarters and take the 4 quarters the half life will be even shorter.  When you crush the tablet finely then you still have the ingredient desvenlafaxine mixed with other ingredients but when you take the powder the other ingredients do not delay the release of the drug so the half life is ~11 hours, the same as if you took pure desvenlafaxine.

 

Think of making a fruit cake.  You begin with ingredients but the final product is a cake.  They both contain the same ingredients but they are different.