How to taper long-term, low-dose Seroquel user

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novopsych

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Just received a patient from a doctor who retired. Female, 29, nonsmoker. For at least 10 years has had a diagnosis of OCD and Tic Disorder NOS. Patient came to me on 30 mg Paxil and 50 mg Seroquel.

The patient wants off the Seroquel. She has been taking it nightly at 50 mg for at least 10 years, and very dutifully (as in never having missed a day). She says that she never liked the way it made her feel and that it was never prescribed for sleep. It was prescribed originally as a daytime med for OCD and tics. Her doctor moved the dosing to night because she couldn't stay awake on it.

The patient now complains that after she takes it, her heart races and pounds, and she is breathless. Patient already has a diagnosis of idiopathic tachycardia and POTS, for which her treatment is exercise and hydration. She has resisted beta-blockers.

She wants to come off Seroquel, and I would like her too, as well. I checked her A1C and it was 6.4. She is overweight (BMI of 29.9). I was under the impression that Seroquel at a dose like this only acted on histamine receptors.

Is there any reason I couldn't take her off cold turkey? Or should his be tapered? Her smallest pills are 25 mg, but she says she can split them. I'm not quite sure what this dosage has been doing for her if anything except cause sleepiness. Because I can't find any information on long-term, low dosage use, I also don't know what we should expect in terms of how withdrawing the drug will affect her.

Any suggestions on handling this? She doesn't seem to be concerned about insomnia, so I guess I am OK there.

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you could probably just stop it, but in this patient who sounds like the anxious sort I wouldn't. Given she has said she can split the pills she obviously wants to taper off. the risk of physical withdrawal may be low, but psychological withdrawal is high. She is already describing side-effects, though well known with seroquel could definitely be related to anxiety/panic. These patients are victim to the nocebo effect par excellance. I would cut her down to 25mg for two weeks, then 12.5mg for two weeks, then either stop, or if she is still anxious about it, can give it every other day and then stop. the key here is assuaging the patient's anxiety.
 
I absolutely agree with splik. Although I've stopped much higher than doses than this with no taper and no problems, this sounds like a very anxious patient. I would taper it if for nothing else than to decrease her anxiety.
 
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All good advice. In a non-acute situation, it's not uncommon to see bad things come from a too-fast taper, but you almost never see bad things come from a too-slow taper.
 
I checked her A1C and it was 6.4. She is overweight (BMI of 29.9). I was under the impression that Seroquel at a dose like this only acted on histamine receptors.

Can someone clear this up for my brain? If it is only acting on the histamine receptors isn't the metabolic syndrome still expected?
 
I don't see why it was given. 1) If you want serotonin effect, you could've used other meds such as buspirone, raising Paxil to the maximum dosage, etc. 2) If you want antipsychotic-D2 blockage to treat the tics, Seroquel was at a low dosage where you wouldn't expect much if any D2 blockage.

And she's got diabetes? Not a good choice IMHO unless after she was given it, she did notice a significant benefit.

Out of the atypicals, Seroquel causes the biggest amount of QT prolongation. Not a good first choice atypical for with someone with POTS and other heart issues.

I'm also not understanding why someone would want a slow taper unless they have some type of psychological obsession with it. Per all the guidelines you could taper it much faster than people here are writing. I'm not saying the people here are wrong, just that I don't understand their logic. Please inform me what your train of thought is.
 
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Can someone clear this up for my brain? If it is only acting on the histamine receptors isn't the metabolic syndrome still expected?

Firstly, it isn't only acting on H1 receptors. When people say low dose quetiapine is only an antihistamine at low doses what they mean is, quetiapine doesn't have any discernible D2 blockade. It still blocks alpha-1 receptors, 5-HT2A receptors, 5-HT1A receptors, M1 receptors and H1 receptors at low doses. In addition, it isn't really true that low dose quetiapine doesn't block D2 receptors at low doses. What is the case, is no one has been able to show D2 receptor occupancy with PET studies below sometimes as high as 450mg quetiapine, and even then it only occupies 30% of receptors. This led ****ij Kapur to propose the mechanism of fast-dissociation of atypical antipsychotics. Low dose quetiapine could potentially have some effect on D2 receptors, but so rapidly and weakly it is not perceptible with functional neuroimaging.

Secondly, blocking H1 receptors (and M1 too probably) causes weight gain, so even if you are prescribing low dose seroquel you are still going to make your patients obese, and obesity can lead to metabolic syndrome. Although 5-HT2c and M3 receptor blockade has been suggested as contributing to metabolic syndrome, the truth is we don't have a good model of how these drugs are exerting their effects. As such, we must assume and counsel patients that the side-effects of low dose seroquel including obesity, metabolic syndrome, and possibly even tardive dyskinesia.
 
I don't see why it was given. 1) If you want serotonin effect, you could've used other meds such as buspirone, raising Paxil to the maximum dosage, etc. 2) If you want antipsychotic-D2 blockage to treat the tics, Seroquel was at a low dosage where you wouldn't expect much if any D2 blockage.

And she's got diabetes? Not a good choice IMHO unless after she was given it, she did notice a significant benefit.

Out of the atypicals, Seroquel causes the biggest amount of QT prolongation. Not a good first choice atypical for with someone with POTS and other heart issues.

I'm also not understanding why someone would want a slow taper unless they have some type of psychological obsession with it. Per all the guidelines you could taper it much faster than people here are writing. I'm not saying the people here are wrong, just that I don't understand their logic. Please inform me what your train of thought is.
From a purely technical perspective, I also was not aware of any reasons to taper from that dose; although, I've never encountered a patient who has been on this particular drug at such a low dose for so long. But as others here have picked up on, she has a mentality about tapering that seems to be based on a prior experience of having gone off Paxil cold turkey before and may be overgeneralizing that to all medications, thus the caution. She has not been diagnosed with diabetes yet. The A1C of 6.4 is the highest she's had, which I see as all the more reason to discontinue the Seroquel.

I appreciate everyone else's advice. Will go for a taper, with a bit of CBT.
 
Anxious people frequently require approaches that make no sense to anyone else. Giving an anxious person a perception of control and gradualness might be key for successful taper. Of course it doesn't "make sense," but if we expect our patients to "make sense," we might be expecting a bit too much!
 
Is there a good resource on psych med tapering? As in what meds should be tapered vs can be straight-up discontinued. And then if they need tapering, how to taper them?
 
Simply, you just have to follow the dosage guidelines. If you want to understand the more fundamental reasons as to why they are what they are, reading the PDR or a Stahl guide on psychopharmacology is a good first-step.

I thought this was supposed to be Geodon?

Geodon's QT prolongation problem hasn't been replicated in studies. The CATIE trial showed it to have a QT prolongation that was not as bad as anyone thought. All antipsychotics cause some QT prolongation on some level but Geodon's is nothing to be alarmed about in relation to the other atypicals.

When Geodon first came out, there was some data suggested that it was a QT prolongation bomb and the FDA plastered it with warnings through the wazoo. Despite that this data was not replicated, once the FDA puts a warning on, it pretty much never takes it off even if it was proven to not be true.

The rumor mill is Eli Lilly pushed and paid their way to get those FDA warnings slapped on because when Geodon came out, the only aypticals at the time were Risperdal, Zyprexa, and Clozapine, and they saw the potential of an atypical that didn't cause weight gain as a major threat to them.

There also is some published data to back up the Eli Lilly smear campaign.
http://online.wsj.com/news/articles/SB989269705437044678

But Lilly has zeroed in on Geodon's lengthening of a portion of the rest period between heartbeats, called the QT interval. In extreme cases, a prolonged QT interval can cause sudden cardiac death. In clinical tests of Geodon, two of 3,000 patients had QT intervals that exceeded a key clinical threshold. But these problems weren't tied to the drug, and no deaths in the trials were linked to the phenomenon.

I forgot to mention that if the patient has diabetes, Paxil is perhaps the worst first-line SSRI given that it causes the most amount of weight gain among the SSRIs. As for an atypical, Geodon, Abilify, or the newer atypicals such as Latuda would've been better choices from a metabolic perspective.

Only reason why I could see Seroquel and Paxil being sound choices is if other meds were tried and failed, and those two happened to work when others failed, but I don't see Seroquel creating any benefit at that dosage other than it's antihistamine effect, and at that dosage it's really just on the order of expensive Benadryl or Vistaril.
 
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When Geodon first came out, there was some data suggested that it was a QT prolongation bomb and the FDA plastered it with warnings through the wazoo. Despite that this data was not replicated, once the FDA puts a warning on, it pretty much never takes it off even if it was proven to not be true.

The rumor mill is Eli Lilly pushed and paid their way to get those FDA warnings slapped on because when Geodon came out, the only aypticals at the time were Risperdal, Zyprexa, and Clozapine, and they saw the potential of an atypical that didn't cause weight gain as a major threat to them....

It was actually fairly comical with the drug reps back then: Pfizer was handing out all kinds of patient education aids re: obesity, BMI, and metabolic syndrome, while Lilly was giving out EKG reference cards.
 
What you mentioned is the exact type of thing that becomes unknowns to the residents and students of today. These things ought to be published more so that there's a written history of it. I told some of this stuff to a medical student (a rather stuck up one) and her face turned red and she remarked that none of that type of stuff could ever happen.
 
What you mentioned is the exact type of thing that becomes unknowns to the residents and students of today. These things ought to be published more so that there's a written history of it. I told some of this stuff to a medical student (a rather stuck up one) and her face turned red and she remarked that none of that type of stuff could ever happen.

Like, why isn't atomoxetine an FDA-approved antidepressant?
Well, possibly the manufacturer didn't bother doing or submitting the studies, since they had a brand new SNRI coming to the market in that particular niche at the same time...
 
Like, why isn't atomoxetine an FDA-approved antidepressant?
Well, possibly the manufacturer didn't bother doing or submitting the studies, since they had a brand new SNRI coming to the market in that particular niche at the same time...
I've always been told that Lilly did them, and they were negative. Plus, Pfizer could never get reboxetine through the FDA for depression (or anything else). It's interesting reboxetine is used a lot in Europe specifically for panic disorder, which doesn't make much sense.
 
reboxetine turns out to be a terrible antidepressant in unipolar depression. anecdotally ive had several bipolar patient who loved it, so it at least seemed to make them a bit hypomanic. i've not heard it used in panic disorder, it certainly wouldn't be a first line treatment. moclobemide on the other hand is used in the treatment of panic disorder and some other anxiety states, and it seems to work fairly well. not sure why it didn't get FDA approval.
 
reboxetine turns out to be a terrible antidepressant in unipolar depression. anecdotally ive had several bipolar patient who loved it, so it at least seemed to make them a bit hypomanic. i've not heard it used in panic disorder, it certainly wouldn't be a first line treatment. moclobemide on the other hand is used in the treatment of panic disorder and some other anxiety states, and it seems to work fairly well. not sure why it didn't get FDA approval.

No money in it. Plain and simple.
I prescribed it a couple of times in residency--Canadian mail order.
 
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