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Elexis: Tapering fluoxetine/Prozac - did I come off too fast?

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Elexis

Hi folks,

 

Just looking for a bit of advice. I'd been on Prozac, 25mg a day, for 9 months, for depression and wanted to come off them. I was advised by my doctor to take a 25mg tablet on alternating days for 1 month and then stop completely.

 

I did this and have now been off for 4 weeks. Asides from some rather severe depression symptoms my main withdrawal issue has been PGAD (Persistent Genital Arousal Disorder), something which I suffered with 2 years ago.

 

What I'm wondering is, does this mean I tapered off too quickly? I should also mention I have M.E. and tend to respond strongly to drugs. Is the best plan of action to just ride this out and hope the symptoms go or to go back on the Prozac and taper off again much slower?

(my doctor did tell me if I go back on the Prozac I'd have to stay on for 2 years but I really don't want to do that.)

 

Any advice appreciated,

 

Thanks

Edited by scallywag
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scallywag

Hi Elexis -- Welcome to Surviving Antidepressants (SA)
 
I've moved your post to the Introductions Forum so that more people will see your question.
 
That is a fast taper, even for Prozac.  The "skip-a-day" approach is more harmful than reducing dosage; as one of the moderators described it, your brain and central nervous system (CNS) are like a ping-pong ball bouncing between the two doses.
 
You could try reinstating 25% of your dose, so about 6 mg. You are early enough after your last dose that a reinstatement could work. A few cautions:

  • Reinstatement works for many people, but not all.  For the lucky ones, symptoms diminish to being tolerable or resolve completely.  For others, the reinstatement has no effect on symptoms or worsens them.  We can't predict how your brain and central nervous system will respond to the reinstatement of Prozac.
     
  • You need to give the reinstatement time. Prozac reaches a steady state in 6-7 days (longer than other drugs with shorter half-lives). 10-14 days on a reinstated dose will allow enough time for your CNS to register that the Prozac is there and stop reacting to its absence (the symptoms).
     
  • Our recommended taper is 10% reduction from current dose on a monthly basis. This harm-reduction approach requires some patience and discipline. To go from 6 mg to 3 mg -- or any gradual 50% reduction -- takes about 6 months. To go from 3 to 1.5 is another 6 months.

Reading this discussion topic about Reinstating may be helpful as well as the one on Prozac:

About reinstating and stabilizing to reduce withdrawal symptoms

Tips for tapering off Prozac (fluoxetine)


Which option feels better to you -- the decision is yours based on your self-knowledge and intuition.

A request: Would you summarize your history in a signature -- drugs, doses, dates, and discontinuations & reinstatements, in the last 12-18 months particularly? Any drugs prior to that can just be listed (optionally with start and stop years). Please put your withdrawal history in signature

You may way want to follow this topic so that you get notifications when someone posts in your thread. Click the gray "Follow this topic" button. A dialog box appears: select one of the notify options, then click follow this topic in the dialog box.

Setting this web page as a bookmark or favorite in your browser will help you navigate back to it.

 

I'm glad you found this site as you investigate your questions.  Please feel free to ask questions here and to post in other topics around SA.

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Elexis

Hi scallywag, thanks very much for taking the time to help me :) reassuring to have a clear view of my options, was getting quite panicky before.

 

A little update - been off for 6 weeks now (approx.), my symptoms have improved. I've had no further depression symptoms and the only mood trouble is irritability. This may be due to the PGAD which is unfortunately still here. However I would say it now comes and goes and only from time-to-time is severe. However, I really, really hate it. It makes relaxation so difficult which is a nightmare when you also have M.E.

 

So, I'm wondering, does the improvement I've had mean I'm best to just ride this out? I'm happy to reinstate if needed and take as long as necessary tapering... is 6 weeks too late for that to be an option? Desperate to make this PGAD go away :(

Would have to make a liquid for doses under 25mg, 25mg pills are all the doctors will give me (they insist I can't have withdrawal for this long, having read around online I beg to differ).

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Elexis

I should have added in my original post - the PGAD didn't start until about 2 weeks off the Prozac. The depression symptoms hit first. Not sure if that has any significance but thought I should mention just in case.

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scallywag

Elexis, You're welcome and thanks for letting me know the information was reassuring.
 
Thanks for completing your signature. You've done a great job.  It would be even more helpful if there were approximate dates for when you started 25 mg every other day and for when you stopped.  "6 weeks ago" means a different date every week. ;)

 

Are you taking either amitriptyline or Lyrica currently? 

 

If one or neither, please post that.

 

If you are taking both, please check for drug interactions. Follow the link below to get your report. Just select the text, copy it and paste it in a post here.

 

Drugs_dot_com Drugs Interactions Checker.
 

There is a PGAD topic in our Symptoms and self-care forum. You might find useful insight from other members who have dealt with or are dealing with PGAD or at least bit of comfort in knowing there ARE others who have been thrown into this state by withdrawal.

We're in such a crummy situation. We all have to do these 1-person experiments because the only way to find out if reinstating will ease symptoms is to reinstate.  :angry:
 
Six weeks is still well within the time window where a reinstatement will work. I'll ask the other moderators with more experience to have a look at your situation. One or more of my esteemed colleagues will likely post with comments,  questions, and a dose for you to test as a reinstatement. You'd probably be best to wait to hear from others before cracking open the prescription bottle to reinstate.

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Elexis

Signature edited :) If I'm missing any other useful info please let me know.

 

Got the drug interactions - should I post them here or in my signature? (am taking lyrica and amitriptyline currently and they do interact)

 

Thanks for the link to the PGAD thread, I'll check that out. :)

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scallywag

Thanks for the update.  You can paste the interactions report in a new "reply" post. 

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Altostrata

Welcome, Elexis.

 

Have your symptoms improved since you started amitriptyline? What is your daily symptom pattern, when do you take your drugs, and what are their dosages? Please keep notes on paper.

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Elexis

Hi,

 

I've been on the amitriptyline since long before the PGAD (went on it in 2012 at 50mg, taken at night, not been off since) though I think it has a beneficial  effect as about a year ago my doctor tried reducing the dosage to 40mg and that created a flare up of vulvodynia pain. Was only on 40mg for about 5 days then went straight back to 50mg.

 

The Lyrica I started in 2014 (150mg twice a day) in response to onset of PGAD symptoms in October 2014. This seemed to help, the PGAD slowly went away over the course of a few months and was replaced with vulvodynia. I'd not had any PGAD symptoms since then until this recent problem.

 

The PGAD symptoms started up again approx. 2 weeks since tapering off Prozac. It was pretty much  constant for a couple of weeks and now more recently it comes and goes. It's not painful, just a very annoying 'arousal' feeling, like an itch you can't scratch. Ice packs are the only thing that seems to help.

 

Hope that all made sense, if you need any more details please let me know :)

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Elexis

Drug Interactions Report:

 

Moderate

amitriptyline  pregabalin

Applies to: amitriptyline, Lyrica (pregabalin)

MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.

MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.

 

I also included the interactions for both my drugs with Prozac, in case that's  relevant when considering reinstating it.

 

 

Major

amitriptyline  fluoxetine

Applies to: amitriptyline, fluoxetine

GENERALLY AVOID: Coadministration with fluoxetine may significantly increase the plasma concentrations of some tricyclic antidepressants (TCAs). The proposed mechanism is fluoxetine inhibition of CYP450 2D6, the isoenzyme responsible for the metabolic clearance of many antidepressant and psychotropic drugs. Seizures and delirium have been reported, as well as a fatality attributed to fluoxetine-induced chronic amitriptyline toxicity. Pharmacodynamically, the combination of fluoxetine (or any other selective serotonin reuptake inhibitor) and a TCA may potentiate the risk of serotonin syndrome, which is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5HT1A receptors.

MANAGEMENT: In general, the use of fluoxetine (or other SSRIs) with TCAs should be avoided if possible, or otherwise approached with caution if potential benefit is deemed to outweigh the risk. Pharmacologic response and plasma TCA levels should be monitored more closely whenever fluoxetine is added to or withdrawn from therapy in patients stabilized on their existing antidepressant regimen, and the TCA dosage adjusted as necessary. Patients should be monitored closely for signs and symptoms of TCA toxicity (e.g., sedation, dry mouth, blurred vision, constipation, urinary retention) and/or excessive serotonergic activity (e.g., CNS irritability, altered consciousness, confusion, myoclonus, ataxia, abdominal cramping, hyperpyrexia, shivering, pupillary dilation, diaphoresis, hypertension, and tachycardia). Due to the long half-life of fluoxetine and its active metabolite, norfluoxetine, the risk of interaction may persist for several weeks after discontinuation of fluoxetine.

 

Moderate

amitriptyline  pregabalin

Applies to: amitriptyline, Lyrica (pregabalin)

MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.

MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.

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scallywag

Elexis one of the ways to get a sense of potential next steps is to understand the daily pattern of your symptoms over a few days. What we need is something like:

 

7 am 100 mg Lamictal

 

11 am felt dizzy and light-headed getting up after sitting for 2 hours

 

5 pm 100 mg Lamictal

 

6:30 pm very drowsy

 

7:00 pm PGAD increase from 5 out of 10 to an 8  for a little over an hour 2 hours


10:30 pm 100 mg Lamictal + 50 mg amitriptyline

 

11 pm bed, asleep fairly quickly

 

3 am woke up anxious and couldn't get back to sleep

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Elexis

Ah I see, no problem, I'll keep notes over the next few days and get back to you

 

Thanks again guys :)

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scallywag

I've been remiss in not mentioning magnesium and Omega 3 fatty acids (fish oil) as supplements.  Most of us in the western world are deficient in both because of industrial farming and how we eat. Mag and O3 seem to be the supplements that people with a sensitized CNS can tolerate.
 
The same caveat applies to supplements as pharmaceuticals:  add one at a time, start low and go slow. Because magnesium is generally calming you might consider starting with that.

Magnesium, nature's calcium channel blocker

Omega-3 fatty acids (fish oil)

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Elexis

glad you mentioned those, I've got both in the house (I'm supposed to be on high-dose omega-3 for my severe dry eyes) but keep forgetting to take them - guess I have an added incentive to get  back to them now!

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Elexis

Just been reading the thread on magnesium, really interesting, I didn't know it could help with anxiety. Wish doctors would suggest these things rather than just handing out endless pills...

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KarenB

It might help if doctors were able to see a person in front of them, instead of a diagnosis.  Imagine if their first port of call was to give people a link to Non-Drug Techniques to manage emotional symptoms!

 

Imagine it were as easy to see a counselor as a doctor! 

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Elexis

Off to have a nice long read of that thread too now :)

 

Couldn't agree more about counselling, I remember one time years ago I went to my GP saying I was struggling to cope with a family member's  illness. I was hoping they'd refer me to a counsellor. Instead they immediately offered me anti-depressants. I hadn't even mentioned any depressive symptoms! They hand these drugs out like candy :angry:

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Elexis

Here's my symptom diary for the past 3 days. Can do for longer if it would be helpful.

 

9th July

  • 2.30pm: Got up. No symptoms
  • 3.30pm: PGAD - 3
  • 4pm: took Lyrica 100mg
  • 5.30pm: PGAD went from a 3 to a 6
  • 7pm: PGAD - 7. Difficult to relax.
  • 8pm: took Omega3 950mg. PGAD - 5
  • 10.30: PGAD - 6
  • 12am: Took lyrica 100mg and Amitriptyline 50mg.

 

10th July

  • 2pm: Got up. PGAD - 1
  • 3pm: Took lyrica 100mg
  • 5pm: PGAD - 6 after sitting for two hours
  • 7.30pm: PGAD - 2
  • 8pm: Took omega3 950mg
  • 12.30am: Took lyrica 100mg & amitriptyline 50mg.

 

11th July

  • 11.30am: Up. Last night's sleep poor due to anxiety. PGAD - 2
  • 1.30pm:  PGAD - 6 after sitting for 2 hours
  • 3pm: took lyrica 100mg
  • 4pm: PGAD back to 2
  • 7pm: PGAD - 6, after sitting for 1hr
  • 9pm: took omega3 950mg. PGAD - 3
  • 1am: took amitriptyline 50mg, lyrica 100mg
  • 2am: took paracetemol 1000mg.

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scallywag

Elexis what patterns do you notice with the PGAD?  I'm seeing something, but wonder if you do.

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Elexis

I'm noticing sitting seems to be a really bad idea! I seem best first thing in the morning, almost no symptoms - maybe cos I'm lying down the whole night? Had never realised this till I did the symptom diary. What do you see?

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scallywag

I saw the relationship between increased intensity and sitting. Can you break up your sitting periods with some standing time? Maybe a chair pad or a different chair that puts less pressure on your pelvic region?

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Elexis

yeah, it's my desk chair I'm mostly sitting on  - hard cushions and no back support is a bad combo! I've got a sort of water-bed type cushion that I use on my wheelchair so I could borrow that (it's the comfiest thing ever!). Also think I will make an effort to be on the computer less (that's what all the sitting is for!), it's bad for my eyes on top of everything else.

 

Would it be worth me restricting the sitting time for the next few days and keeping a symptom diary to see if things improve? Might be able to avoid reinstating Prozac if they do?

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KarenB

That sounds like a really sensible idea Elexis - go for the least dramatic approach first!

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Elexis

Here's my symptom diary for the last 4 days, keeping sitting to a minimum

 

14th July

2pm - up. PGAD = 1

4pm - took Lyrica 100mg

7pm - PGAD = 4 after sitting for 45 minutes

9pm - took omega3 950mg PGAD = 6

12am - took Amitriptyline 50mg and Lyrica 100mg. PGAD = 3

 

15th July

1pm - up. No symptoms.

2pm - took lyrica 100mg

5pm - PGAD = 4 (after sitting for 2hrs on comfy seats)

9pm - PGAD = 1.

12am - took amitriptyline 50mg, lyrica 100mg. No symptoms.

 

16th July

2pm - up. PGAD = 1

3.30pm - took lyrica 100mg

7pm - PGAD = 4 (after sitting for one hour)

8.30pm - PGAD = 1

9pm - took omega3 950mg

10.30pm - PGAD = 5

11.30pm - took lyrica 100mg and amitriptyline 50mg.

12am - sleep. PGAD = 5

Anxious. Woke  up at 5am, very anxious but no PGAD symptoms

 

17th July

2pm - up. PGAD = 1

3.30pm - took lyrica 100mg

5pm - PGAD up to 6 for 45 minutes and then back down to 2

9pm - PGAD = 5. Took omega3. 

9.30pm - PGAD= 3

12am - took amitriptyline 50mg and lyrica 100mg. PGAD = 2

 

 

So it seems like my symptoms have improved quite a bit by avoiding sitting as much as possible. It wouldn't be practical for most people but I have M.E. so having to lie down all day isn't exactly unusual!

So in light of this what do you guys think regarding reinstating? The PGAD is troublesome from time to time and it's not always possible to avoid sitting but it's been sooo much better these past few days. How risky is reinstating - could I make things worse? (that's what really scares me!)

 

Thanks

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scallywag

Elexis, your last Prozac dose was 30 May, 25 mg.  You're still within the window for reinstatement. 

 

You could try a 1 mg dose of Prozac to test if you get a negative CNS reaction.  Give it 4-5 days to build to a steady daily cycle and then another 4-7 days for your CNS to catch up. Keep recording your symptoms on paper. If your symptoms worsen and affect your function, stop the reinstatement. After 7-10 days, we can evaluate how that trial has gone and look at where to go from 1 mg.

 

Let us know what you decide -- reinstate or not -- and how you're doing. 

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Elexis

Hi,

 

I think I'll give reinstatement a go, at the low dose like you suggest I can't see it causing much harm. I've ordered a syringe from amazon as I'll need to make a liquid from my tablets - will let you know how I get on in a few days.

 

Thanks :)

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Elexis

Finally got my syringes from amazon, going to make a liquid of the Prozac and do the 1ml dose, will be back in a week or so with the results.

 

Just to check I've understood correctly how to make the solution... I have 25mg Prozac capsules. So I would empty them into 25ml of water and then take 1ml of the resulting solution (so a Prozac dose of 1mg). My syringes are 5ml in size.

Is that right?

 

Thanks

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scallywag

That is correct. :)

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Elexis

Hi,

So my PGAD seems to have had a flare up. I'm on day 4 of 1mg reinstatement (not taken today's dose yet). Have had a couple of days where symptoms were about usual and then yesterday it was up at 8 for most of the day (had to resort to using ice-packs, something I've not done for a long time), eventually settling down to a 3 around bedtime. Then I woke up today with it up at a 5 (it's more like a 6 now) which is unusual as well since I usually wake up with no or minimal symptoms.

 

Could this be a reaction to the reinstatement or is it too early to tell? Don't want to stop unnecessarily but a bit scared to take today's dose!

 

Thanks

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scallywag

Too early to tell. It seems as if you've been keeping notes. Post notes for the last few days or the next few days.

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Elexis

Okay, I've got detailed notes for today and yesterday. The two days before that I only have the note that I was experiencing symptoms of around a 7 or 8 for much of the day and was woken with it in the night on one occasion (at an 8 or 9).

 

Yesterday (31st July):

2pm: up. PGAD = 3.

4pm: PGAD = 8, after 2hrs of sitting. Severe and ice-pack provided temporary relief.

7pm: PGAD still = 8

8.30pm: PGAD = 6

10pm: PGAD = 3

 

Today (so far) - 1st August

12pm: up. PGAD = 6

2pm: PGAD = 8

6pm: PGAD = 7 (did a couple of hours of sitting but was on soft cushion so shouldn't have had much  of an impact)

 

Should I take today's dose and keep going a while longer do you think?

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Elexis

Does it do any harm if I end up stopping the reinstatement early? Not necessarily going to do that but this flare is really freaking me out (PGAD now up at about an 8.5), it's the worst I've felt in a while, so just want to be aware of my options.

 

Thanks :)

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scallywag

Elexis, please put the date you started the 1 mg in your signature. July 29?

 

When do you take the 1 mg?

 

One of the reasons we suggest a very low dose to test your response is so that there's less risk of symptoms and lower risk if you need to stop the reinstatement compared to reinstating a low-moderate dose.

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Elexis

yes, it was the 29th was my first 1mg dose, I'll add that to my signature.

 

I usually take it when I get up (so 2pm) but forgot yesterday and took it at bedtime so will take it at bedtime tonight & from now on for consistency.

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Elexis

Updated symptom diary after 8 days on Prozac reinstatement:

 

1st August

Today (so far) - 1st August

12pm: up. PGAD = 6

2pm: PGAD = 8

6pm: PGAD = 7 (did a couple of hours of sitting but was on soft cushion so shouldn't have had much  of an impact)

10pm - PGAD = 4

 

2nd August

1pm: PGAD = 2

3pm: PGAD = 5

6pm: PGAD = 4

9pm: PGAD = 6

11pm: PGAD = 3

 

3rd August

1.30pm: PGAD = 2

4pm: PGAD = 4

7pm: PGAD = 6

11.30pm: PGAD = 4

 

4th August

2pm: PGAD = 2

6pm: PGAD = 4 (sitting most of the day but on padded cushion)

8pm: PGAD = 6

11pm: PGAD = 3

 

5th August

2pm: PGAD = 2

4pm: PGAD = 6

7.30pm: PGAD = 4

11pm: PGAD = 2

 

So as you can see it's settled down quite a lot (such a relief!). Am I correct in thinking the trial reinstatement lasts 10 days? Today would be day 9.

 

Thanks :)

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