Paresthesias during SSRI wean?

[Hard24Get]

Wondering if any of you have experience with managing paresthesias while weaning Zoloft or another SSRI. If a patient complains of such sensory disturbances, lethargy, or emotional lability, does that mean the wean is too fast? How long do these paresthsias last? In your experience, are they a harbinger of a depressive rebound to follow?

Thanks!

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[sunlioness]

I, um, actually had them myself coming off of cymbalta. It happened the day after each reduction in dose and felt like the foot falling asleep from Hell. Coming off of Cymbalta was actually a bit of an emotional roller coaster too, but things did settle out eventually. So I don't know that paresthesias would necessarily mean that the pt is going to fail.

Sorry I don't have any experience tapering others, I start outpatient this July.

 

[whopper]

Well I've never seen an actual standard of care on how long you should take to wean someone off of an SSRI or SNRI.

I have checked sources and found reccomended weaning strategies differing.

If someone does know a standard or at least something they'd consider a good source please tell us.

I've just been decreasing the dose by pill type...switch to the next smaller pill dose about a week at a time in outpatient, every 2-4 days inpatient.

If you have a patient experience side effects, slow down the taper.

From my experience and the studies and data back this up, the only 2 meds I've seen where a patient had some bad side effects during weaning was with Effexor & Paxil and those 2 meds are the ones with the shortest half lives. Makes sense.

Actually had 1 pt who claims she cannot get off of Effexor XR. We got her to take the smallest dose possible and you can't split it since its a capsule. She claims she can't get herself off of it. I figured since it was XR (longer t1/2) she'd have no problems getting off of it after she got onto the smallest dose that was available.

One day she freaked out and went to the ER and told the ER doc she was having Effexor withdrawal, and he gave her a script for a very high dose of it, so it was like starting her over again on the taper off.

Don't know if her case is real or if its a manifestation of some type of psychological dependency on her med, she's got a lot of Cluster B traits.

 

[sunlioness]

I had a thought once, again based on my own experience, but I am wondering if it would work . . . I was on Effexor XR and switched to Cymbalta because I couldn't tolerate the s/e of Effexor (I was having hot flashes, diaphoresis). I also know that I would have had baaad Effexor withdrawal because if I didn't take it every day, by the end of the day I'd be so dizzy I could hardly stand up.

Switching from Effexor to Cymbalta was easy. And coming off of Cymbalta about a year later wasn't too difficult either (I was on 60mg. I went to 30mg daily for a week and then QOD x 4 days). So I was wondering, if it would help to get someone off of Effexor (which has nasty withdrawal) by first switching them to something like Cymbalta (which does not).

 

[Demosthenes]

So I was wondering, if it would help to get someone off of Effexor (which has nasty withdrawal) by first switching them to something like Cymbalta (which does not).

The best advice I've seen is to use a small dose of Prozac -- SRI with long half-life -- to ease the last bit of Effexor withdrawal. I've heard it called "self-tapering," because its half-life is so long.

While Effexor and Paxil have the worst repututation for withdrawal, any of the ADs can cause some rebound depression. It can sometimes be hard to tell whether you're looking at withdrawal, relapse, or rebound depression.

And as for the Cluster B chick, she really may be having trouble with that last bit of Effexor. I'd recommend Benadryl, and about 20mg of Prozac. Should only take one or two Prozac to do the trick. If you tell her that, she might find it even easier...

 

[OldPsychDoc]

...Actually had 1 pt who claims she cannot get off of Effexor XR. We got her to take the smallest dose possible and you can't split it since its a capsule. She claims she can't get herself off of it. I figured since it was XR (longer t1/2) she'd have no problems getting off of it after she got onto the smallest dose that was available.
....

If she has sufficient OCD traits, she actually could open a 37.5 mg capsule and count granules. (Yes, I learned this from a patient... )
The rep confirmed that for Effexor, the XR features are maintained in the individual granules within the capsule (which are kind of chunky--not like a powder or crystals), so she could go down to 18.375, 9.1875,...etc by counting out the individual grains. Hopefully after a few days of this she'd get tired and just give up!

 

[whopper]

Good advice.

I actually did consider telling her this. I was thinking maybe telling her to open up the capsules, and cut the dosage by half, and then save the remaining powder.

My attending though wasn't too keen on the idea. Not that it was a bad idea but I don't think this particular attending is open to thinking too much outside the box.

Switching her to cymbalata was another thing I did consider. Didn't consider a switch to prozac though that did also make sense. Hadn't seen that patient again. I'm only with this attending 1 day a week and I think that patient had scheduled her next appointment with that attending on a different day.

It had been her 5th attempt to wean her off of the Effexor XR at the minimum dose, and each time you tell her you're going to stop it she would have an emotional breakdown in the office. She more than once would freak out and go to the ER doc who'd give her pretty much whatever she wanted which sabotogued our efforts.

The other sad thing about the case was I was thinking that she really didn't need any psychoactive medications. She seemed to be just a big cluster B patient who wanted a med to solve her problems, and psychotherapy was what she really needed.

I guess I just should've been glad that she eventually stopped her benzos and didn't go to the ER doc to have that refilled.

 

[Anasazi23]

The best advice I've seen is to use a small dose of Prozac -- SRI with long half-life -- to ease the last bit of Effexor withdrawal. I've heard it called "self-tapering," because its half-life is so long.

While Effexor and Paxil have the worst repututation for withdrawal, any of the ADs can cause some rebound depression. It can sometimes be hard to tell whether you're looking at withdrawal, relapse, or rebound depression.

And as for the Cluster B chick, she really may be having trouble with that last bit of Effexor. I'd recommend Benadryl, and about 20mg of Prozac. Should only take one or two Prozac to do the trick. If you tell her that, she might find it even easier...

We've had a few threads on tapering SSRIs and SNRIs, and the advice remains largely the same - first off....remember tha this is not life threatening, and that it is self limited and at worst, uncomfortable and inconvenient.

The Prozac taper is something that I suggested when you get down to a final dose or two of medication. Prozac is considered self-tapering due to its t-1/2 and pharmacokinetics. Substituting a final dose of effexor or paxil (recently had a complaint with escitalopram as well) can often smooth the transition.

As a general rule of thumb, and this is general (might depend on the patient and any concomitant p-450 substrates), you can decrease a dose by about half every 4-5 days. Some drugs might require you to use a more graduated step down...for convenience sake, you'll have to take into account the dosages of pills available to the patient, the need to write additional prescriptions, and capsule vs. tablet (and scored) form for convenience.