Using Prozac as bridge off of Effexor

[uhmocksuhsillen]

Have a patient who is very sensitive to Effexor taper. Thinking of using Prozac to bridge her. Seems simple enough but just wanted to run it by the gallery here. She's currently on 225mg. Would it be as simple as stopping the Effexor in favor of 60-80mg Prozac and then decreasing over a few days until shes off Prozac?

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[Stagg737]

Why not just decrease slowly by 37.5mg or less every other week?

 

[calvnandhobbs68]

Yeah typically would taper off slow and then if they can't tolerate that last little wean off start really low dose prozac and then wean off the last of the Effexor. There's basically no chance you get serotonin syndrome from 37.5mg of Effexor and 10mg of prozac.

I'm assuming what you're saying above is that you'd just immediately cross 225mg Effexor to 60mg Prozac and then wean off the prozac, which is likely to be much more rough than a cross taper. Also, you don't really need to wean off prozac (although I'll drop the dose typically a bit if I have someone at 60mg+ and want to get them off) and I would never "wean" prozac over a few days (it doesn't even make sense from a pharmacology standpoint).

 

[uhmocksuhsillen]

Why not just decrease slowly by 37.5mg or less every other week?

She wants to get off it quickly which is why I'm thinking about the best way to expedite this for her. I would prefer to just do what you described.

 

[mistafab]

Yeah, it doesn't really make sense.

I would just discuss with this patient that venlafaxine has an especially uncomfortable wean and that getting creative is unlikely to help.

Slow and steady wins the race.

 

[comp1]

This is a definite never start drug for me because of the withdrawal. I've had patients cut the 25 mg into 1/8's. Never tried prozac. Not sure it would help. Would've been better had they been on Prozac from the beginning....

 

[ObsequiousAplomb]

She wants to get off it quickly which is why I'm thinking about the best way to expedite this for her. I would prefer to just do what you described.

The fastest way is to have them stop it but give them 7 pills of Ativan 2 mg for the withdrawal symptoms. For people who aren't willing to work with me on a taper, that's what I do.

As for what other people have said about Prozac, I definitely have patients that act as if they need to take down 1 mg every month, and oral solution is great for that specific set of patients.

 

[Stagg737]

She wants to get off it quickly which is why I'm thinking about the best way to expedite this for her. I would prefer to just do what you described.

Then you can just decrease every 3-7 days to speed things up for her as long as she tolerates it. I just don't see how switching to prozac is going to be better than just tapering.

This is a definite never start drug for me because of the withdrawal. I've had patients cut the 25 mg into 1/8's. Never tried prozac. Not sure it would help. Would've been better had they been on Prozac from the beginning....

Imo it's not a never start drug, but I do agree it's one of my least favorite of the newer antidepressants, probably only second to paroxetine.

The fastest way is to have them stop it but give them 7 pills of Ativan 2 mg for the withdrawal symptoms. For people who aren't willing to work with me on a taper, that's what I do.

As for what other people have said about Prozac, I definitely have patients that act as if they need to take down 1 mg every month, and oral solution is great for that specific set of patients.

Idk, this seems like a great way to introduce highly sensitive patients to benzos that will numb their problems and get them asking why they can't just keep taking the benzo.

 

[ObsequiousAplomb]

Then you can just decrease every 3-7 days to speed things up for her as long as she tolerates it. I just don't see how switching to prozac is going to be better than just tapering.


Imo it's not a never start drug, but I do agree it's one of my least favorite of the newer antidepressants, probably only second to paroxetine.


Idk, this seems like a great way to introduce highly sensitive patients to benzos that will numb their problems and get them asking why they can't just keep taking the benzo.

Yep, that's why you say exactly what it's for, that they will not get any refills. Nobody gets dependent on fewer than 14 days of benzos. Avoiding benzodiazepines when they're indicated is a great way to ruin the chances a patient will ever seek treatment again.

 

[Sushirolls]

Prozac et al other SSRIs have hit or miss for effexor reduction influences. My clinical observations is no recipe exists for a perfect taper in those who might have issues.

Sounds more like telling the patient they get to pick to do a slower taper of 37.5mg step downs at 1-4 week intervals, to make it smoother (rather than usual 75mg), or they get the speed they want, but risk getting some unpleasant symptoms.

Some times you don't always get what you want.

 

[FlowRate]

I do this on a regular basis since PCP's around here love starting people on venlafaxine as the first or second drug they try.

Does the patient want to be off of meds altogether or just off of venlafaxine but wants something for depression/anxiety symptoms?

If the former, start 10 or 20mg of fluoxetine for about 1-2 weeks at a stable venlafaxine dose. Then taper venlafaxine as tolerated (would usually slow the pace and lower the increment of the taper but if she's in a hurry then you could go in whatever speed/amount she can tolerate.) Then, after off of venlafaxine, stop fluoxetine.

If she just wants to be on something else then do a more standard cross titration. I'd usually use escitalopram or sertraline.

These "other SRI" assisted venlafaxine tapers are more art than science and so I agree with sushi that there's not a one-size perfect recipe.

 

[Candidate2017]

It seems this patient has higher frustration tolerance and lower anxiety than you about tapering Effexor.

She understands there will be pain coming off Effexor, and many rational people choose to quickly rip off the band aid because pain is more tolerable when it's not prolonged. I'm sure no soldier in history has ever asked their surgeon to take it nice and slow when it comes to amputating a limb.

Let them know it's going to suck in the moment, but they'll be fine, and hack away. I've met a number of patients came off Effexor and Paxil quickly prior to seeing me. They all said it sort of sucks, but seem to shrug it off.

 

[Celexa]

Venlafaxine discontinuation symptoms suck but aren't dangerous, and go away rapidly when restarted on the med. Like others mentioned I would first take her down on the venlafaxine pretty rapidly and see how she does. Can always stop at a dose for a bit longer if needed. Would only add in Prozac at the end if necessary.

I have a love hate relationship with venlafaxine. Not my favorite med by any means but have seen it be very effective too often to discount it.

 

[Stagg737]

Yep, that's why you say exactly what it's for, that they will not get any refills. Nobody gets dependent on fewer than 14 days of benzos. Avoiding benzodiazepines when they're indicated is a great way to ruin the chances a patient will ever seek treatment again.

But are they really indicated here or are we just catering to patients to make them more comfortable? They're certainly not necessary, so not even really a valid harm reduction argument there.

No, they're not going to get dependent on it, but I had plenty of patients in residency where we were only going to use a benzo for 1-2 weeks who came back complaining repeatedly that they couldn't understand why they couldn't just have a benzo because they supposedly worked so much better than anything else. Imo that's more likely to kill any chance of a therapeutic relationship than just telling them they'll be uncomfortable for a few days.

 

[comp1]

I'm really afraid of benzos, but I think that comes from my inpatient population. I've never met anyone who didn't really want to continue it...

 

[ObsequiousAplomb]

But are they really indicated here or are we just catering to patients to make them more comfortable? They're certainly not necessary, so not even really a valid harm reduction argument there.

No, they're not going to get dependent on it, but I had plenty of patients in residency where we were only going to use a benzo for 1-2 weeks who came back complaining repeatedly that they couldn't understand why they couldn't just have a benzo because they supposedly worked so much better than anything else. Imo that's more likely to kill any chance of a therapeutic relationship than just telling them they'll be uncomfortable for a few days.

If we go broad enough, nothing is indicated at all. We only do the Prozac or the other things for comfort. I wonder why you care so much more about the 7 pills of Ativan than you do about any other aspect of treating SSRI discontinuation symptoms.

 

[Liquid8]

If the patient is wanting a fast taper against OP's advice of a slow one, would just go with that and see how they manage.

For outpatients have dropped doses by 75mg every 1-2 weeks without too much issue although when I hit 75mg, will either go down to 37.5mg or cross taper depending on plan. Often find that adding mirtazapine helps with SNRI withdrawal - recently had someone on Pristiq 300mg and Mirtazapine 60mg who wanted to come off the former and try a TCA. Due to other issues we managed this as an inpatient over 2-3 weeks which is arguably quite aggressive, but withdrawal symptoms were surprisingly minimal.

 

[Stagg737]

If we go broad enough, nothing is indicated at all. We only do the Prozac or the other things for comfort. I wonder why you care so much more about the 7 pills of Ativan than you do about any other aspect of treating SSRI discontinuation symptoms.

Because ime the fallout of giving even a 1 week supply of benzos to some patients has consistently been far worse than them just being uncomfortable for a few days. I'm not totally against benzos, but the longer I practice the more I loathe them for anxiety, sleep, and "short courses" in general.

I prescribe SSRIs and other antidepressants because patients aren't capable of functioning fully (or sometimes at all) without them due to their various MH problems. I don't often see the worried well and when I do I'm very up front that 99% of the time therapy and lifestyle changes (correct diet, exercise, appropriate sleep, etc) will likely benefit far more acutely and chronically than our pills will.

 

[annoyedpsychiatrist]

I have a patient struggling with this as well, but ultimately I think the best case scenario is gradual reduction of the effexor and going off if shes wanting to go off. it can be unpleasant for people but its transient discomfort, rather than permanent discomfort. You can introduce low doze prozac once shes on a lower dose of effexor but that has been hit or miss really.

The benzodiazepine strategy mentioned above I think would have to be very patient dependent. No comorbidities/opioids/cluster b/etc and patients with strong insight, but i probably would do a very small dose of .5-1mg myself.

I am very meticulous with benzos though. If I use them chronically its at low doses typically (.25mg-.5mg) or for things like REM sleep behavior disorder, again at low dose. I prefer them to be used for as needed, 1/3 days out of the month or less. The people on moderate doses of benzos with me are because I inherited them and they have insight/are working with me, and were doing gradual reduction.

Tbh I have a general distaste for benzos, but recognize they have a usefulness in certain situations.

 

[tr]

Just adding that I have had a fair number of patients who find even a 37.5 mg decrement very uncomfortable.

For these people I will often step down in alternating doses - e.g. doing a week or two of 75/37.5 qod between the 75qd and the 37.5 qd, and then just 37.5 qod for a bit at the end before stopping.

 

[MacDonaldTriad]

Prozac 60 - 80 mg? Holy cow. That would be a lot more than the middle Effexor dose of 225 mg. Effexor IR was approved to 375 mg in IR form. The only reason it was stuck on 225 mg is because XR was only studied up to 225 mg. I doubt XR is less tolerable than IR. Prozac does almost self taper as 9-hydroxy-Fluoxetine has a half life of a week. Still, 60 - 80 mg is double the PDR limit of approval. Gosh help any patients on a CYP 2D6 metabolized drug. I hope they are not on Risperdal. Trading one SNRI with a high dose of SSRI doesn't seem sound. Just tapper the SNDRI.

 

[ObsequiousAplomb]

Prozac 60 - 80 mg? Holy cow. That would be a lot more than the middle Effexor dose of 225 mg. Effexor IR was approved to 375 mg in IR form. The only reason it was stuck on 225 mg is because XR was only studied up to 225 mg. I doubt XR is less tolerable than IR. Prozac does almost self taper as 9-hydroxy-Fluoxetine has a half life of a week. Still, 60 - 80 mg is double the PDR limit of approval. Gosh help any patients on a CYP 2D6 metabolized drug. I hope they are not on Risperdal. Trading one SNRI with a high dose of SSRI doesn't seem sound. Just tapper the SNDRI.

Per the FDA Package Insert, page 4:
"Major Depressive Disorder
Initial Treatment
Adult — Initiate PROZAC 20 mg/day orally in the morning. Consider a dose increase after several weeks if
insufficient clinical improvement is observed. Administer doses above 20 mg/day once daily in the morning or twice daily
(i.e., morning and noon).The maximum fluoxetine dose should not exceed 80 mg/day."

https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/018936s108lbl.pdf

Per PDR:
"For the treatment of major depression. For the treatment of major depression. Oral dosage (immediate-release)Adults
20 mg PO once daily, initially. May increase the dose after several weeks if inadequate response and depending on tolerability. May divide doses of 20 mg/day or more in 2 doses (e.g., morning and noon). Max: 80 mg/day. Consider a lower or less frequent dosage in older adults. Periodically reassess the need for continued treatment."

Drug Summary

Please clarify what you mean by "double the PDR limit of approval" with that comment, because I can't tell.

 

[whopper]

The problem with Venlafaxine is even if you get them to ER 37.5 mg daily for over a week discontinuation is still very common. I just switch them to Desvenlafaxine. The discontinuation is less with Desvenlafaxine.

Despite that discontinuation is supposed to be from serotonin withdrawal, I've tried using other serotonergic based meds such as an SSRI and for whatever reason even with this there's still a lot of discontinuation sx going on.

 

[ObsequiousAplomb]

Yeah, one thing I will add here is that I only ever start venlafaxine if that patient has a history of migraines, they have tried Elavil or Inderal with minimal success, and they have not tried any of the newer migraine medications (or at least, they have not met the Prior Authorization requirements for the newer migraine prevention drugs. Otherwise, I would start Pristiq or any of the drugs that have a reasonable half-life instead of Effexor first. that's the easiest way to stop effexor: don't start it in the first place.

 

[aim-agm]

The problem with Venlafaxine is even if you get them to ER 37.5 mg daily for over a week discontinuation is still very common.

I have found the IR formulations helpful in those cases, although I'm not sure how available the 37.5 and 25 mg tablets are generally

 

[MacDonaldTriad]

FDA package inserts admit that they are not a recommendation for best clinical practice, but a guideline that places guardrails on safety. The very fact that they are recommending a BID strategy for a drug that has 7-hydroxy fluoxetine active metabolite with a half life of 7 days should tell us something. Find me any respectable literature that shows 60 or 80 mg of Prozac has been shown to be superior to 40 mg and I will stand corrected.

 

[Stagg737]

FDA package inserts admit that they are not a recommendation for best clinical practice, but a guideline that places guardrails on safety. The very fact that they are recommending a BID strategy for a drug that has 7-hydroxy fluoxetine active metabolite with a half life of 7 days should tell us something. Find me any respectable literature that shows 60 or 80 mg of Prozac has been shown to be superior to 40 mg and I will stand corrected.

What are you trying to use it for? If depression, then 40-50mg seems to be greatest therapeutic dose without excessive side effects per the literature. For anxiety up to 60mg has data and I've never heard an OCD specialist say they felt anything less than 40mg provided any benefit and many titrate straight to 60-80mg. I've had patients over 100mg because nothing below 80mg touched their OCD symptoms.

60mg daily is the recommended STARTING dose for bulimia per Maudsley and K&S and standard dosing for bulimia is 60-80mg daily. Maudsley also recommends titration up to 0.8mg/kg/day for autism, so for a 220lb+ autistic person recommended dose is 80mg/day.

Data for fluoxetine for BN, increased efficacy at increased doses up to 60mg (doses were placebo, 20mg, and 60mg):

ClinicalKey

www.clinicalkey.com

More for fluoxetine 60mg for BN:

https://www.sciencedirect.com/science/article/pii/S0163725820301972?via%3Dihub

For OCD (can't see full text), fluoxetine 40mg and 60mg showed responses better than placebo and 60mg showed greatest improvement with no differences in tolerability or discontinuation:

https://www.sciencedirect.com/science/article/abs/pii/0924977X9390266O?via%3Dihub

Also curious where you're seeing the BID dosing thing as I didn't see that in the packet insert and have never heard of anyone suggesting this...

 

[whopper]

Only 2 antidepressants where I've seen discontinuation syndrome even when you get the patient off slowly is Venlafaxine (IR or ER) and Paroxetine, and it makes pharmacologic sense because these two antidepressants have the shortest half-lives.

What I don't understand is if these sx are based off of serotonin withdrawal that a serotonergic med given at the same ought to head off the sx, but I've tried this several times without success with various serotonergic antidepressants such as Fluoxetine or Sertraline.

I usually don't give out benzos, but I am willing to prescribe a temporary amount for patients trying to get off of Venlafaxine or Paroxetine. I've seen this significantly calm patients with discontinuation syndrome.

 

[aim-agm]

Only 2 antidepressants where I've seen discontinuation syndrome even when you get the patient off slowly is Venlafaxine (IR or ER) and Paroxetine, and it makes pharmacologic sense because these two antidepressants have the shortest half-lives.

What I don't understand is if these sx are based off of serotonin withdrawal that a serotonergic med given at the same ought to head off the sx, but I've tried this several times without success with various serotonergic antidepressants such as Fluoxetine or Sertraline.

I wonder if, at least for paroxetine, the issue is going from a very low-half life very high potency SRI (i.e. gets to and from therapeutic levels quickly) and trying to play catch-up with longer half life, lower potency SRIs which might not get to enough SRI activity quickly enough to control the withdrawal.

 

[whopper]

I've speculated on this. I really don't know. I just do know that some type of serotonin enhancing med ought to help based on the theory of how Discontinuation Syndrome operates, but yet if this is true then WTF is going on when other serotonergic meds aren't helping? When doing the bridge attempt, I've only tried SSRIs at starting dosages.

In the case of Venlafaxine I speculate it's not just serotonin withdrawal, but also norepinephrine withdrawal, but never tested that theory.

 

[tr]

What I don't understand is if these sx are based off of serotonin withdrawal that a serotonergic med given at the same ought to head off the sx, but I've tried this several times without success with various serotonergic antidepressants such as Fluoxetine or Sertraline.

I feel like SNRIs have worse discontinuation syndrome effects than SSRIs across the board even with comparable half-life, and Paxil is kind of an SNRI.

Psychiatry Online

ajp.psychiatryonline.org

Estimates of Serotonin and Norepinephrine Transporter Inhibition in Depressed Patients Treated with Paroxetine or Venlafaxine - Neuropsychopharmacology

Paroxetine and venlafaxine are potent serotonin transporter (SERT) antagonists and weaker norepinephrine transporter (NET) antagonists. However, the relative magnitude of effect at each of these sites during treatment is unknown. Using a novel blood assay that estimates CNS transporter occupancy...

www.nature.com

 

[calvnandhobbs68]

I feel like SNRIs have worse discontinuation syndrome effects than SSRIs across the board even with comparable half-life, and Paxil is kind of an SNRI.

Psychiatry Online

ajp.psychiatryonline.org

Estimates of Serotonin and Norepinephrine Transporter Inhibition in Depressed Patients Treated with Paroxetine or Venlafaxine - Neuropsychopharmacology

Paroxetine and venlafaxine are potent serotonin transporter (SERT) antagonists and weaker norepinephrine transporter (NET) antagonists. However, the relative magnitude of effect at each of these sites during treatment is unknown. Using a novel blood assay that estimates CNS transporter occupancy...

www.nature.com

So maybe but I have to say I've had plenty of people come off Cymbalta just fine and it's a much more potent NET inhibitor than Effexor. I actually use Cymbalta not infrequently since it's on label for GAD for kids.

I've also had many people stop Strattera cold turkey which is also a very potent NET inhibitor and don't seem to do as bad as Effexor or Paxil.