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Important topics in the Tapering forum and FAQ


Altostrata

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--------HOW FAST SHOULD YOU TAPER?--------

Why taper by 10% of my dosage?
The general philosophy of gradual tapering

The slowness of slow tapers
Some people can tolerate tapering only by very small amounts over a long time.

Why taper? SERT transporter occupancy studies show importance of gradual change in plasma concentration
Discussion of a scientific journal article with data supporting a very gradual taper. If your doctor is a scientific type, print the journal article out and give it to him or her.

--------PREPARING TO TAPER--------
 
Taking multiple psych drugs? Which drug to taper first?
If you're not having an adverse reaction from the other medications, taper the most activating drug first. This is usually an antidepressant or stimulant (ADHD drug).

Preparing to taper
Taking care of yourself so you are prepared to taper.

 

Dose Equivalents for Antidepressants and Second-Generation Antipsychotics
If you have to make a switch.
 
Taper more than one drug at a time?
Try this only if you know your withdrawal symptom pattern and know how to control your taper with various tapering techniques.
 
Drug Interactions Checker -- use it to reduce your drug burden
If you are suffering adverse effects from a combination of drugs, this can help determine which drug is the key culprit to reduce first.

 

DrugBank.ca - drug database website

User-friendly website to look up your drug to find what size doses it comes in, market availability (i.e. which country it's available in), mechanism of action, water solubility, and other useful information.  

 

Find the name of your pills in any country

 

Daily Med

US government site with FDA information for consumers. Enter the generic name of the drug in the search box. 

 

Drug Half-Life Calculator


Keep daily notes of drug schedule and symptoms to track patterns and progress
Keeping a record of your withdrawal symptom pattern so you can manage it.

Dr. Joseph Glenmullen's withdrawal symptom checklist
Use this to track symptoms.

 

Recommended doctors, therapists, and clinics

If you can recommend others, please post their contact information in this topic.

 

Benzo-wise doctors who will assist in benzodiazepine tapering
 
How do you talk to a doctor about tapering and withdrawal?

 

PRINT OUT leaflet: Guidance on stopping antidepressants by UK's Royal College of Psychiatrists

 

--------METHODS OF TAPERING--------

 

NEVER SKIP DOSES TO TAPER

 

How to calculate dosages and dilutions? Spreadsheets and calculators

 

Help with math for tapering


Using a scale to weigh and measure doses
Digital scales can measure less than 1mg by weight


Did I go wrong with my nailfile? Filing or shaving a tablet
Filing a tablet is popular but inexact. Taking a liquid is more consistent and reliable.
 
How to cut up tablets or pills
Using a pill cutter -- flat, round tablets easier to cut accurately

Which tablets or pills may be split or crushed?
Most tablets that are not extended-release may be split or crushed


How to make a liquid from tablets or capsules
General instructions on making a homemade liquid suspension


Using an oral syringe and other tapering techniques
How to use oral syringes, gelatin capsules, powdered tablets, and do-it-yourself liquid solutions


Pharmacy liquids to make suspensions
Liquid bases for medication

 

Questions and answers about liquid medications

How to calculate dosages of liquids and other tips

 

Cross over from tablet to liquid OR changing the brand


Counting beads in a capsule versus weighing

Compounding pharmacies (US, UK, and elsewhere)
These pharmacies can make up custom dosages and liquid medications

 

Prescription compounded tapering strips from the Netherlands
Netherlands pharmacy will customize tablets of most psychiatric drugs to prescription specifications.


Micro-taper instead of 10% or 5% decreases
Decreasing your dosage by very tiny amounts more often might be more tolerable than 5% or 10% decreases. Know your symptom pattern first so you can estimate how often you can reduce.

 

The Brassmonkey Slide Method of Micro-tapering

One way you can micro-taper.


The Prozac switch or "bridging" with fluoxetine
Substituting one drug for another for easier tapering

 
--------AT THE END OF A TAPER--------
 
When to end the taper and jump to zero?
How do you determine a good stopping point?

Experiences after tapering to zero
How do people feel after finishing a taper?

--------TAPERING OFF SPECIFIC PSYCHIATRIC DRUGS--------
 

Tips for tapering off agomelatine (Valdoxan)

 

Tips for tapering off amitriptyline
 
Tips for tapering off amphetamine/dextroamphetamine (Adderall)
 
Tips for tapering off aripiprazole (Abilify)

 

Tips for tapering off asenapine (Saphris)


Tips for tapering off buproprion (Wellbutrin, SR, XR, XL)

Tips for tapering off buspirone (Buspar)

 

Tips for tapering off citalopram (Celexa)

 

Tips for tapering off clomipramine (Anafranil)

 

Tips for tapering off desvenlafaxine (Pristiq)

 

Tips for tapering off dosulepin / dothiepin (Dothep, Prothiaden)

 

Tips for tapering doxepin (Sinequan, Zonalon)


Tips for tapering off duloxetine (Cymbalta)
Aka Ariclaim, Xeristar, Yentreve


Tips for tapering off escitalopram (Lexapro)
Aka Cipralex, Seroplex, Lexamil, Lexam

 

Tips for tapering off fluvoxamine (Luvox)


Tips for tapering off fluoxetine (Prozac)
Aka Rapiflux, Sarafem, Selfemra, Fontex

 

Tips for tapering off gabapentin (Neurontin)
 

Tips for tapering off imipramine


Tips for tapering off lamotrigine (Lamictal)

 

Tips for tapering off lisdexamfetamine dimesylate (Vyvanse)

Tips for tapering off lithium
 
Tips for tapering off lurasidone (Latuda)
  
Tips for tapering off milnacipran (Savella)

 

Tips for tapering off mirtazapine (Remeron)

 

About going off mirtazapine plus venlafaxine (Effexor) aka "California rocket fuel"
 

Tips for tapering off nefazodone (Serzone)


Tips for tapering off nortriptyline 
 
Tips for tapering off olanzapine (Zyprexa)
 

Tips for tapering off oxcarbazepine (Trileptal)


Tips for tapering off paliperidone (Invega)
Tablets and injectable Invega Sustenna


Tips for tapering off paroxetine (Paxil, Seroxat)

 

Tips for tapering off pregabalin (Lyrica)
 
Tips for tapering off risperidone (Risperdal)

 

Tips for tapering off quetiapine (Seroquel)


Tips for tapering off sertraline (Zoloft)
Aka Lustral

 

Tips for tapering off sodium valproate and valproic acid (divalproex sodium, Depakote, Depakene)


Tips for tapering off Tramadol
 
Tips for tapering off trazodone
Aka Oleptro, Beneficat, Deprax, Desirel, Molipaxin, Thombran, Trazorel, Trialodine, Trittico, and Mesyrel


Tips for tapering off venlafaxine (Effexor)
Aka Efexor, Elafax, Venlafaxina, Venlor, Ventab, Alenthus


Tips for tapering off vilazodone (Viibryd)

 

Tips for tapering off vortioxetine (Trintellix, previously called Brintellix)
 

Tips for tapering off ziprasidone (Geodon, Zeldox)

Tips for tapering off Z drugs for sleep (Ambien, Imovane, Sonata, Lunesta, Intermezzo, etc.)
 
--------TAPERING OFF OTHER COMMON DRUGS--------
These drugs commonly prescribed and can cause drug-drug interactions with psychiatric drugs or other health problems.
 
Tips for tapering off stomach acid blockers or PPIs...

 

Tapering Alpha Blockers or Beta Blockers

 

Antihypertensive Clonidine Withdrawal: Psych Meds not the only drugs to cause PAWS

 

Tips for tapering off propranolol

 

SAM-e (S-adenosyl-L-methionine)

 

Papers about domperidone withdrawal syndrome

 

--------"OFFICIAL" GUIDES TO TAPERING PSYCHIATRIC DRUGS--------
 
Guides to tapering off psychiatric medications
From medical societies and other organizations, including the American Psychiatric Association and UK National Health System
 
--------FROM THE SYMPTOMS AND SELF-CARE FORUM--------
 
What is withdrawal syndrome?
 
About reinstating and stabilizing to reduce withdrawal symptoms
 
The Windows and Waves Pattern of Stabilization

 

Hypersensitivity and Kindling

 

Edited by Altostrata
updated

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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  • 2 weeks later...
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How about taking my medication every other day to reduce my dosage?
 

DO NOT TAKE YOUR MEDICATION EVERY OTHER DAY TO TAPER.

 

(See this comparison graph:  Skipping Days vs Every Day Dosing Graph)


If your medication is not designed to take every other day (very few are), don't try to taper by alternating doses. The half-lives of almost all psychiatric drugs are too short for this to make sense. It causes the amount of the medication in your bloodstream to go up and down, battering your nervous system, and makes withdrawal worse.

Your brain likes stability, to be treated gently. The object is to gradually accommodate it to lower and lower dosages. Don't throw it off a cliff every day. Move it slowly down a ramp by gradually decreasing dosage by an amount it may hardly notice. A 10% reduction in dosage may be appropriate. Stay at that dosage for 3-4 weeks, then decrease again -- by 10% of your last dosage. Your decreases will be progressively smaller the lower you go in dosage.

Some people can quit cold turkey and not notice. Some people can alternate dosages and not notice. If you are having withdrawal symptoms, you are not among those people.

We don't know why some doctors, pharmacists, and alternative practitioners recommend tapering by alternating dosages. It's terrible advice. Don't do it.

Why do I need to taper? Why can't I just quit?

Withdrawal syndrome may occur after you stop taking a psychiatric medication and can last weeks, months, or years. Symptoms can be distressing, debilitating, or even disabling.

While some people may be able to quickly stop taking these medications without serious symptoms, severe and prolonged withdrawal syndrome can happen to anyone.

You don't know in advance if you'll be one of the unlucky ones.

Tapering off the medication is the only known way to reduce the risk of withdrawal syndrome. Don't risk the integrity of your nervous system -- do not suddenly stop taking any psychiatric medication.

Your nervous system has become dependent on the medication. Gradual tapering enables your nervous system to return to its original state.

A 10% reduction in dosage every 3-4 weeks is a good harm reduction plan.

Edited by Shep
Alto updated and expanded/CC added graph link, Shep fixed link

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

All postings © copyrighted.

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I'm not sure I have withdrawal symptoms. What are they?

 

When you withdraw from a neurologically active medication, your nervous system has to adjust back to a normal state. While it is adjusting, you experience withdrawal symptoms.

 

The autonomic nervous system, which controls the "automatic" functions of the body, is strongly affected. This is one reason withdrawal symptoms are so various.

 

Withdrawal symptoms can include:

- Electrical feelings in the head or "brain zaps"

- Surges of anxiety, agitation, or excitation

- Hypomania or mania

- Inability to concentrate

- Disorientation

- Dizziness

- Diarrhea

- Sensitivity to light or sound

- Nausea

- Waves of fear or weepy melancholia

- Sleep problems

 

For scientific papers about withdrawal symptoms, see Diagnosis of antidepressant withdrawal syndrome

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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What is antidepressant withdrawal syndrome?

Although medicine avoids recognizing it, there are about 200-300 scientific papers and many anecdotal patient reports that indicate antidepressant withdrawal syndrome:

-- In most cases, is autonomic instability, with probable disinhibition of the locus coeruleus, generating unprecedented symptoms of anxiety, fear, and panic, contributing to a very common unrelenting insomnia
-- Develops in the context of the serotonergic desensitization caused by all antidepressants
-- Is not degenerative or progressive
-- Has a set of symptoms that are fairly common
-- Very gradual, halting recovery pattern

Withdrawal syndrome often causes hypersensitivity to subsequent psychiatric medications, which are usually unhelpful and often exacerbate symptoms.

Tapering off a psychiatric medication too quickly or stopping suddenly ("cold turkey") can lead to prolonged withdrawal syndrome. Recovery can take months or years.

 

Read more in these topics What is withdrawal syndrome?

(For scientific papers about withdrawal symptoms, see Diagnosis of antidepressant withdrawal syndrome)

Edited by Altostrata
updated

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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  • 3 weeks later...
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What does half-life mean? Why is it important?

"Half-life" means the amount of time it takes for the level of the drug in your bloodstream to be reduced by half, as measured by scientific tests.

For example, Cymbalta has an extraordinarily short half-life of about 12 hours.

Over the next 12 hours, your body will continue to metabolize the medication, but some may still be in your bloodstream after 24 hours, due to individual variation and uneven rates of clearance. Researchers believe "washout" requires 5-7 half-lives; to be safe, psychiatrists are advised to wait 2 to 6 weeks between drugs to avoid drug-drug interactions (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215520/). (The longer period is for drugs with very long half-lives, such as fluoxetine or Prozac, or MAOIs, which are notorious for interactions.)

It is thought the short half-life antidepressants, such as Paxil and Effexor, have the worst withdrawal symptoms and subsequent withdrawal syndrome because a reduction in dosage happens so quickly the nervous system doesn't have time to adapt to it.

In medical studies, Paxil, Effexor, Zoloft, and Luvox -- all with short half-lives -- have been reported to have the worst withdrawal issues, hence the conclusion that half-life is key to withdrawal syndrome. However, since statistics on antidepressant withdrawal are so poor, half-life may or may not be a determining factor.

One thing is clear, if you are inconsistent in taking any medication with a short half-life, you will feel withdrawal effects very quickly, as so many people who have forgotten to take their medication have found.

Edited by Altostrata
updated

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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  • 1 month later...
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What is the difference between withdrawal symptoms and withdrawal syndrome?

 

While you are tapering, or if you quit suddenly, you may soon experience what are known as acute withdrawal symptoms. These symptoms indicate you may need to taper more gradually. If your taper is too fast, they may persist beyond the few weeks or months that medicine expects.

 

If withdrawal symptoms persist for a long time after you stop taking the medication -- sometimes they do not become obvious for weeks -- they are called post-acute withdrawal symptoms or, collectively, withdrawal syndrome.

 

It is called a syndrome because it is a symptom pattern seen in many people but is not a disease.

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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  • 1 month later...
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From the Icarus Project http://theicarusproject.net/alternative-treatments/mind-uk-coping-with-coming-off-psych-drugs-guide

 

Am I addicted?

 

Addiction means being physically dependent on the drug, with a need to increase the doses to get the same effect, and having a compulsive psychological need to take it. Many people who experience unpleasant symptoms when they withdraw, consider themselves to be 'addicted' to the drug. Many doctors and pharmaceutical companies prefer to call it 'dependence', or even 'withdrawal symptoms' or 'discontinuation symptoms'. The language used, however, doesn't alter the fact that some people have extreme difficulty when coming of psychiatric medication and only achieve it with great determination.

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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Why should I taper by 10% of my dosage? I know people who just quit with no problem.

 

The very conservative approach of a 10% taper every 3-4 weeks protects people who are sensitive to fluctuations in dosage. You can't know you are one of these people until you try a reduction in medication. We recommend trying a 10% initial reduction to see how you do with a small decrease. If you have no problems, you may be able to taper faster.

 

A more complete explanation is here.

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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  • 8 months later...
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Can I go any faster than 10% reduction per month?

 

It's best to go slowly to find out how you tolerate a reduction. Once you damage your nervous system with withdrawal symptoms, it can take a very long time to feel good again.

 

But -- many people do fine with a faster taper. Are you one of them? You can't tell. We advocate a harm reduction approach to tapering:

 

  • Initially, make a 10% reduction and hold there for a MONTH. It can take several weeks for withdrawal symptoms to emerge. Do that again the second month.
  • If you have very minor or no symptoms from these 2 reductions, you can try reducing by 10% every 3 weeks. Do that twice. If no problems, reduce by 10% every 2 weeks. Do that twice.
  • If no problems after 4.5 months of very gradual reduction, you may be able to reduce by 10% every week.
  • If significant withdrawal symptoms appear, make smaller cuts or go slower. Listen to your body.

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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  • 2 months later...
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What is a micro-taper?

 

There is a lot of discussion on this site about a technique we call micro-tapering, in which tiny dosage reductions, as small as .01mg (or even less), are made more frequently than in a regular taper.

 

Often, this isn't any faster in total than a 10% or 5% reduction, but for people whose nervous systems are exceptionally sensitive, it may be more tolerable than the relatively larger reductions.

 

Only people who already understand their withdrawal symptom pattern and nervous system tolerance for dosage changes should try this. As with any tapering schedule, if withdrawal symptoms appear, the patient is advised to slow tapering or hold on the current dosage until the nervous system stabilizes.

 

Liquid solutions are helpful for micro-tapers because they enable very gradual, controlled tapering. Many drugs are available in liquid solution form, or they can be made into a liquid by a compounding pharmacy. Some drugs, such as Prozac, can be made into a solution with water at home. Use the Search box in the upper right for more information about this.

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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  • 2 weeks later...
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Why do so many people have such a difficult time at the end of the taper?

 

There may be several reasons: Because the level of the drug has gotten so low:

  • the nervous system notices even small changes
  • due to half-lives, the drug is no longer distributed among affected receptors equally
  • some drugs, such as Paxil, inhibit their own metabolism and as you get to a lower dose, are metabolized faster, giving the effect of a larger proportional decrease
  • if the person is taking other medications, the drug ecology changes, producing symptoms that may have been masked by the lowered dosage of the drug being tapered

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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  • 2 months later...
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How long do you need to be taking an antidepressant to require tapering?

 

According to scientific papers on withdrawal, use of an antidepressant for more than a month increases the risk of withdrawal symptoms.

 

We suggest a 10% taper in those situations.

 

If you've been taking an antidepressant for a month, a faster taper may be tolerable, such as a 25% reduction per week.

 

If you've been taking an antidepressant for less than a month, you might be able to make more frequent dosage reductions to discontinue in a week.

 

Slow down and make smaller decreases if you get any withdrawal symptoms.

 

Unless you are having an adverse reaction, do not cold turkey.

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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  • 1 month later...
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What is washout?

Washout means the drug has been entirely metabolized by your body, none of it is left circulating in your bloodstream. (Whether or not minute amounts are stored in your tissues or fat is a moot point; those will be gradually metabolized, too. If you are tapering, this is only more tapering.)

 

To avoid drug-drug interactions, conscientious physicians will utilize a "washout" period to clear the first drug entirely from the body before starting a new drug. But because half-life clearance is logarithmic, it can take quite a while for the amount of drug to tail off. Washout is sometimes estimated as 5-7 half-lives, sometimes 10 half-lives. A washout of Cymbalta, for example, would be 5-10 times the drug's half-life of 12 hours, or 60-120 hours -- about 3-5 days.

 

Washout is based on drug half-life

 

On 5/22/2011 at 9:34 AM, Altostrata said:

What does half-life mean? Why is it important?

"Half-life" means the amount of time it takes for the level of the drug in your bloodstream to be reduced by half, as measured by scientific tests.

For example, Cymbalta has an extraordinarily short half-life of about 12 hours.

Over the next 12 hours, your body will continue to metabolize the medication, but some may still be in your bloodstream after 24 hours, due to individual variation and uneven rates of clearance. Researchers believe "washout" requires 5-7 half-lives; to be safe, psychiatrists are advised to wait 2 to 6 weeks between drugs to avoid drug-drug interactions (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215520/). (The longer period is for drugs with very long half-lives, such as fluoxetine or Prozac, or MAOIs, which are notorious for interactions.)

It is thought the short half-life antidepressants, such as Paxil and Effexor, have the worst withdrawal symptoms and subsequent withdrawal syndrome because a reduction in dosage happens so quickly the nervous system doesn't have time to adapt to it.

In medical studies, Paxil, Effexor, Zoloft, and Luvox -- all with short half-lives -- have been reported to have the worst withdrawal issues, hence the conclusion that half-life is key to withdrawal syndrome. However, since statistics on antidepressant withdrawal are so poor, half-life may or may not be a determining factor.

One thing is clear, if you are inconsistent in taking any medication with a short half-life, you will feel withdrawal effects very quickly, as so many people who have forgotten to take their medication have found.

 

When your drug has passed one half-life, half of it is still in your body. That amount will be processed in another half-life. The process is logarithmic, every cycle processes half of the remaining drug.

 

This means even one dose of the drug can take quite a while to completely leave your body -- although, as the drug is metabolized, effects and side effects usually progressively lessen. After even one half-life, you might not feel the effect of the drug at all. But the drug can still cause drug-drug interactions. This can be a major problem when switching between MAOIs and SSRIs, for example, because the drug-drug interaction can cause serotonin toxicity.

 

If you've taken the drug long enough to get it to a steady-state level in your bloodstream, or if you are taking multiple drugs, complete metabolization of one drug can take even longer, as your organs can process only so much at a time.

 

Estimating drug washout time

You can estimate how long it takes for the drug to be completely metabolized with the DRUG HALF-LIFE CALCULATOR

 

This is a simple mathematical calculation of the time to washout (0% of the drug left in your bloodstream) based on your drug's half-life. Please note other factors, such as other drugs you're taking or liver condition, will affect the metabolization of a drug, and consider this calculation only an estimate.

 

http://www.drugsdb.com/resources/drug-half-life-calculator/

 

Look up the "Half Life" of your drug at https://www.drugbank.ca/

Edited by Altostrata
updated

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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