Xanax Taper in pregnancy

[futuredo32]

Have an odd potential consult. Woman has severe GAD panic disorder with a documented history (read all medical records) of Panic Attack induced TIAs. She was taking oral contraceptives and is a few weeks pregnant and on 10 mg Xanax. . Tried and failed everything else (Librium never tried) no other benzo worked. Per psychiatry notes she was reluctant to take any benzo. According to her records before the Xanax she was not able to work, had severe agoraphobia, and lived like a hermit. After titrating up to 10 mg she got a job boyfriend, friends. She wants a second opinion. Her OB said that due to the severity of her panic attacks she should stay on 10 mg Xanax. daily. She's worried about the health of the baby. I would be willing to evaluate her, she sent me multiple envelopes of all of her records, but I have NO idea how to taper a pregnant woman off of Xanax. It has to be slow. I think she should be able to make an informed decision, she doesn't feel other benzos do anything, so she wants to taper off of Xanax, not add Valium or Klonopin to taper off of. I have googled for a few days. Taking her off too fast could cause miscarriage. Leaving her on could lead to multiple adverse outcomes. Thank you.

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[ObsequiousAplomb]

Aren't the majority of the major adverse effects early in pregnancy? Sure, at the end there's sedation and neonatal abstinence syndrome. But the major ones are usually first trimester is my understanding. Even then, there's plenty of literature indicating minimal risk, especially in people who genuinely have not got better options. I would talk with the OB personally and document the discussion. There are putative risks to tapering off, as you mentioned.

It sounds like you haven't had a full conversation with the patient yet. Maybe all she wants is reassurance but is defaulting to the stance of "no drug in pregnancy" even though the teratogenic window has already passed?

 

[futuredo32]

Cleft lip and palate in early pregnancy which is rare. The more severe side effects occur later in pregnancy, floppy baby syndrome, seizures, withdrawal, etc and they are dose dependent. The window hasnt passed

 

[deleted1100659]

Have an odd potential consult. Woman has severe GAD panic disorder with a documented history (read all medical records) of Panic Attack induced TIAs. She was taking oral contraceptives and is a few weeks pregnant and on 10 mg Xanax. . Tried and failed everything else (Librium never tried) no other benzo worked. Per psychiatry notes she was reluctant to take any benzo. According to her records before the Xanax she was not able to work, had severe agoraphobia, and lived like a hermit. After titrating up to 10 mg she got a job boyfriend, friends. She wants a second opinion. Her OB said that due to the severity of her panic attacks she should stay on 10 mg Xanax. daily. She's worried about the health of the baby. I would be willing to evaluate her, she sent me multiple envelopes of all of her records, but I have NO idea how to taper a pregnant woman off of Xanax. It has to be slow. I think she should be able to make an informed decision, she doesn't feel other benzos do anything, so she wants to taper off of Xanax, not add Valium or Klonopin to taper off of. I have googled for a few days. Taking her off too fast could cause miscarriage. Leaving her on could lead to multiple adverse outcomes. Thank you.

Whole thing sounds super sketchy to me. First off, shes on 10mg of xanax? Thats a pretty freaking high dose, wtf. That doesn't seem reluctant at all to me, seems sketchy. But she does want to come off the medicaiton, perhaps some strange psychiatrist put her on that and she somehow just didnt know any better.

I wouldnt trust her to drive once she left the house if shes taking 10mg of xanax, so even if she left the house thanks to xanax, its probably because its the equivalent of her drinking a 12 pack before she goes, lol.

From my experience in tapering benzos so far which has not been a fun experience, I usually do 25% of the total dose, reduced in increments of 1-2 weeks depending on how high the dose is, problems that may occur, and comorbidities. Once you start getting to lower doses, tapering more slowly for whatever the dosing increments allows. Faster taper in the beginning compared to the end.

Other option is switching to equivalent long acting and tapering but seems like shes set on doing it this way.

Regardless it will take her a good bit to get off 10mg xanax, so almost seems redundant in the sense that if I made a taper schedule for her I would want to check in intermittently and do follow up with her in the hospital to see how shes tolerating it.

But if shes this severe off the xanax, the question becomes what will happen once shes completely off the xanax, if shes reportedly as bad as they say she is? Will she be able to care for the baby? Heck, can she care for the baby on the max dose of xanax? Those are questions in itself.

This consult has many hidden questions besides the original consult question, in my opinion

 

[WisNeuro]

In my nearly decade of working with Neurological consults and inpatient stuff, this is the first time I have heard of a "panic induced TIA." And yeah, that is enough Xanax to put down a freakin elephant.

 

[futuredo32]

Whole thing sounds super sketchy to me. First off, shes on 10mg of xanax? Thats a pretty freaking high dose, wtf. That doesn't seem reluctant at all to me, seems sketchy. But she does want to come off the medicaiton, perhaps some strange psychiatrist put her on that and she somehow just didnt know any better.

I wouldnt trust her to drive once she left the house if shes taking 10mg of xanax, so even if she left the house thanks to xanax, its probably because its the equivalent of her drinking a 12 pack before she goes, lol.

From my experience in tapering benzos so far which has not been a fun experience, I usually do 25% of the total dose, reduced in increments of 1-2 weeks depending on how high the dose is, problems that may occur, and comorbidities. Once you start getting to lower doses, tapering more slowly for whatever the dosing increments allows. Faster taper in the beginning compared to the end.

Other option is switching to equivalent long acting and tapering but seems like shes set on doing it this way.

Regardless it will take her a good bit to get off 10mg xanax, so almost seems redundant in the sense that if I made a taper schedule for her I would want to check in intermittently and do follow up with her in the hospital to see how shes tolerating it.

But if shes this severe off the xanax, the question becomes what will happen once shes completely off the xanax, if shes reportedly as bad as they say she is? Will she be able to care for the baby? Heck, can she care for the baby on the max dose of xanax? Those are questions in itself.

This consult has many hidden questions besides the original consult question, in my opinion

It was the treatment of last resort. She's been on it for ten years no DUIs. The plan would be for her to slowly resume it after delivery, she wants a healthy baby, sounds like her life consisted of panic attacks and staying inside before. She sent a freaking book of notes. EVERY other med was tried. You have to taper REALLY slowly in pregnancy, tapering too fast can cause a miscarriage

In my nearly decade of working with Neurological consults and inpatient stuff, this is the first time I have heard of a "panic induced TIA." And yeah, that is enough Xanax to put down a freakin elephant.

Per the ER reports, it was due to a hypertensive emergency related to the panic attack. Maybe she's a rapid metabolizer? She's been on it for 10 years, works, functions in society.

 

[DJKitty]

Personally, I wouldn't touch this case with a 10-foot pole. Way too much risk involved. Is maternal-fetal medicine involved? Are you near a university hospital that has psychiatry and/or perinatal/women's psychiatry? If so, I would refer her there and call it a day.

 

[deleted1100659]

It was the treatment of last resort. She's been on it for ten years no DUIs. The plan would be for her to slowly resume it after delivery, she wants a healthy baby, sounds like her life consisted of panic attacks and staying inside before. She sent a freaking book of notes. EVERY other med was tried. You have to taper REALLY slowly in pregnancy, tapering too fast can cause a miscarriage

Per the ER reports, it was due to a hypertensive emergency related to the panic attack. Maybe she's a rapid metabolizer? She's been on it for 10 years, works, functions in society.

It was the treatment of last resort. She's been on it for ten years no DUIs. The plan would be for her to slowly resume it after delivery, she wants a healthy baby, sounds like her life consisted of panic attacks and staying inside before. She sent a freaking book of notes. EVERY other med was tried. You have to taper REALLY slowly in pregnancy, tapering too fast can cause a miscarriage

Per the ER reports, it was due to a hypertensive emergency related to the panic attack. Maybe she's a rapid metabolizer? She's been on it for 10 years, works, functions in society.

When patients have insanely detailed daily notes/failed every other medication I start to wonder about personality disorder.

Well, that's why if I was to taper her from the max dose of xanax I would want to continue to follow her to ensure the patient is tolerating it ok. Im going off a general taper schedule and adjusting based upon patient response/signs of withdrawl. Another thing is, is the primary team going to be watching her closely for signs of withdrawl, and what happens if they show, are they going to reconsult you? Unless you plan on keeping her on your list the next few months. This is a pretty complicated scenario.

I havent seen a specific protocol geared towards pregnant women but maybe one of my older colleagues knows of one.

Generally though, being able to monitor for signs of withdrawl and adjusting the taper would be optimal rather than having a rigid taper schedule set and then signing off.

 

[hamstergang]

Per the ER reports, it was due to a hypertensive emergency related to the panic attack.

What is the evidence that it wasn't a somatic symptom related to the panic attack, such as like a conversion disorder, instead of a TIA?

 

[futuredo32]

What is the evidence that it wasn't a somatic symptom related to the panic attack, such as like a conversion disorder, instead of a TIA?

Her BP I don't recall but was extremely high. She said once everything went black and she collapsed and was taken to the ED another time, it was blurry vision, severe headache. She went to the ED a few times and they were all witnessed. ED records all stated TIA. Multiple episodes of vomiting due to anxiety (not self induced). I have spent so much time. I talked to her OB and psychiatrist and neither feels it's safe to taper Xanax, PCP wants nothing to do with patient during the pregnancy (PCP was an NP). She's the only one who wants to taper off of Xanax. I suggested a psychiatrist who specializes in pregnancy and psychiatry and the waitlist was six months. No obvious personality disorder except maybe avoidant which would better be described by GAD and Panic d/o with agorophobia. Maybe her OB and psychiatrist are correct? I don't want to harm.

 

[WisNeuro]

Panic induced TIA to me sounds like it's in the same category as PNEE/PNES. Also, I don't blame the PCP for not wanting anything to do with this very high risk pregnancy.

 

[clausewitz2]

Panic induced TIA to me sounds like it's in the same category as PNEE/PNES.

Yes, I certainly have plenty of very somatically-focused anxious patients who would immediately google the symptoms of a hypertensive emergency the moment their blood pressure was even mildly elevated and definitely report experiencing them. Once again, important to distinguish between verbal behavior and observable findings.


I would also maybe not lean too heavily on the opinion of ED docs about the details of neurological issues beyond those that affect emergent treatment and disposition.

Have an odd potential consult. Woman has severe GAD panic disorder with a documented history (read all medical records) of Panic Attack induced TIAs. She was taking oral contraceptives and is a few weeks pregnant and on 10 mg Xanax. . Tried and failed everything else (Librium never tried) no other benzo worked. Per psychiatry notes she was reluctant to take any benzo. According to her records before the Xanax she was not able to work, had severe agoraphobia, and lived like a hermit. After titrating up to 10 mg she got a job boyfriend, friends. She wants a second opinion. Her OB said that due to the severity of her panic attacks she should stay on 10 mg Xanax. daily. She's worried about the health of the baby. I would be willing to evaluate her, she sent me multiple envelopes of all of her records, but I have NO idea how to taper a pregnant woman off of Xanax. It has to be slow. I think she should be able to make an informed decision, she doesn't feel other benzos do anything, so she wants to taper off of Xanax, not add Valium or Klonopin to taper off of. I have googled for a few days. Taking her off too fast could cause miscarriage. Leaving her on could lead to multiple adverse outcomes. Thank you.

So the OB, who presumably is the person who has the best grasp of exactly how bad some of these outcomes might be (since you haven't mentioned any special training, expertise, or interest in perinatal psychiatry), a physician from a specialty that tends towards the conservative when it comes to risks during pregnancy, is saying that it's not a good idea for her pregnancy to stop the Xanax.

Out of curiosity, why exactly is she so insistent on tapering off Xanax directly instead of cross-titrating to something longer-acting?

One wonders if she is, mayhaps, somewhat aware that no one is going to want to do this without switching to a longer acting agent and that insisting on the Xanax directly is erecting quite the roadblock against any pressure she may be receiving to do this. "Y'know, I wanted to stop taking my Xanax, but all those useless doctors just refused to help me."

This is a really high dose and I would be large sums of money she is not going to tolerate even very very slow BZD w/d well. On a practical level, it's going to be a huge headache. On the more medical/clinical level...floppy baby syndrome is distressing but temporary. You know what's really bad for a fetus? Seizures.

I get that she is saying she wants to get off of it but why exactly do you feel like it is a good idea to facilitate this?

 

[futuredo32]

Yes, I certainly have plenty of very somatically-focused anxious patients who would immediately google the symptoms of a hypertensive emergency the moment their blood pressure was even mildly elevated and definitely report experiencing them. Once again, important to distinguish between verbal behavior and observable findings.


I would also maybe not lean too heavily on the opinion of ED docs about the details of neurological issues beyond those that affect emergent treatment and disposition.




So the OB, who presumably is the person who has the best grasp of exactly how bad some of these outcomes might be (since you haven't mentioned any special training, expertise, or interest in perinatal psychiatry), a physician from a specialty that tends towards the conservative when it comes to risks during pregnancy, is saying that it's not a good idea for her pregnancy to stop the Xanax.

Out of curiosity, why exactly is she so insistent on tapering off Xanax directly instead of cross-titrating to something longer-acting?

One wonders if she is, mayhaps, somewhat aware that no one is going to want to do this without switching to a longer acting agent and that insisting on the Xanax directly is erecting quite the roadblock against any pressure she may be receiving to do this. "Y'know, I wanted to stop taking my Xanax, but all those useless doctors just refused to help me."

This is a really high dose and I would be large sums of money she is not going to tolerate even very very slow BZD w/d well. On a practical level, it's going to be a huge headache. On the more medical/clinical level...floppy baby syndrome is distressing but temporary. You know what's really bad for a fetus? Seizures.

I get that she is saying she wants to get off of it but why exactly do you feel like it is a good idea to facilitate this?

She tried Klonopin Valium and Ativan prior to Xanax and she felt they were useless which is why she wants to stick with Xanax. Her BP was extremely high, I don't doubt it was a TIA, actually she's lucky it wasnt a stroke. The risks of staying on are floppy baby syndrome, mental ******ation, motor and speech delay, , SEIZURES, etc. . I'd love to send her to someone who specializes in this but the wait list is huge. The ONLY purpose of the post was to ask if anyone had a specific sheet of how to taper a pregnant woman off of Xanax. The end.

 

[tr]

Where are you located that there is a six month waiting list for reproductive psychiatry? I know what I would do in this case (start SSRI depending on what "everything" is and taper Xanax very slowly, maybe with gabapentin support) but if this isn't your area I would not try to manage it on your own without formal assistance from repro psych.

If you are having trouble locating reproductive psychiatry in your area you could submit this for MGH repro psych interactive grand rounds or call the PSI provider consult line.

Resource: Join us for Virtual Rounds at the Center for Women’s Mental Health on Wednesday, April 15th - MGH Center for Women's Mental Health

As our faculty at the Center for Women’s Mental Health (CWMH) have gone fully remote with respect to clinical and research activity, we have managed to stay connected these last three weeks with “virtual rounds”. For over 25 years, our group has met on Wednesdays at midday to discuss clinical...

womensmentalhealth.org

Perinatal Psychiatric Consult Line | Postpartum Support International (PSI)

Our free consult line is available to medical professionals with mental health care questions for pregnant or postpartum patients and preconception planning.

www.postpartum.net

 

[aim-agm]

If it's TIA secondary to Hypertensive Emergency tertiary to Panic in setting of predisposing vascular condition I could see that. Although it's pretty unlikely in the patient's age range at the time. But weird things happen...a neurologist told me about a patient of his that had postprandial blindness due to the blood supply to the pertinent area of the brain being so tenuous that the dip in blood pressure after eating caused ischemia.

Seconding above of trying to stay away from the case. I've gathered that juries are very sympathetic to plaintiffs when a baby is harmed.

But if you are going to be involved in the case, some thoughts:
- It sounds like another physician with more specific expertise diagnosed a medical condition (TIA 2/2 panic attack) so you might be safe to rely on their expertise. In that case, does the risk of neurologic harm outweigh the risk of adverse effect from alprazolam?
- At the very least her panic attacks cause severe hypertension, which can complicate pregnancy. What are OB's thoughts on how important it is to avoid that situation? Again, risks vs. benefits of downtitration
- How dose-dependent are the significant effects on the baby? If the risk of the dose you could realistically (or optimistically) get her down to has about the same risk of 10 mg, what benefit would downtitration have at this time?

 

[futuredo32]

Where are you located that there is a six month waiting list for reproductive psychiatry? I know what I would do in this case (start SSRI depending on what "everything" is and taper Xanax very slowly) but if this isn't your area I would not try to manage it on your own without formal assistance from repro psych.

If you are having trouble locating reproductive psychiatry in your area you could submit this for MGH repro psych interactive grand rounds or call the PSI provider consult line.

Resource: Join us for Virtual Rounds at the Center for Women’s Mental Health on Wednesday, April 15th - MGH Center for Women's Mental Health

As our faculty at the Center for Women’s Mental Health (CWMH) have gone fully remote with respect to clinical and research activity, we have managed to stay connected these last three weeks with “virtual rounds”. For over 25 years, our group has met on Wednesdays at midday to discuss clinical...

womensmentalhealth.org

Perinatal Psychiatric Consult Line | Postpartum Support International (PSI)

Our free consult line is available to medical professionals with mental health care questions for pregnant or postpartum patients and preconception planning.

www.postpartum.net

She's been on every SSRI, SNRI Topomax, Neurontin, Lyrica, Tiagabine, Vistaril, Mirtazapine, Buspar, Trazodone, Seroquel, Risperdal, MAOIs, TCAs Propanolol (which her OB said to stop) There aren't a lot of reproductive psychiatrists here and are university related. I didn't know there was a number to call. Thank you so much. I think my best bet is to give her current psychiatrist the number. Thank you so much!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

 

[futuredo32]

If it's TIA secondary to Hypertensive Emergency tertiary to Panic in setting of predisposing vascular condition I could see that. Although it's pretty unlikely in the patient's age range at the time. But weird things happen...a neurologist told me about a patient of his that had postprandial blindness due to the blood supply to the pertinent area of the brain being so tenuous that the dip in blood pressure after eating caused ischemia.

Seconding above of trying to stay away from the case. I've gathered that juries are very sympathetic to plaintiffs when a baby is harmed.

But if you are going to be involved in the case, some thoughts:
- It sounds like another physician with more specific expertise diagnosed a medical condition (TIA 2/2 panic attack) so you might be safe to rely on their expertise. In that case, does the risk of neurologic harm outweigh the risk of adverse effect from alprazolam?
- At the very least her panic attacks cause severe hypertension, which can complicate pregnancy. What are OB's thoughts on how important it is to avoid that situation? Again, risks vs. benefits of downtitration
- How dose-dependent are the significant effects on the baby? If the risk of the dose you could realistically (or optimistically) get her down to has about the same risk of 10 mg, what benefit would downtitration have at this time?

From an EXTENSIVE google search, cleft lip and palate are low and first trimester. The preventable side effects (given the timetable) are 2nd-3rd trimester and are simply listed as "increased risk with increased dose" I'm seriously going to give her current psychiatrist the number listed above. I'm not afraid of a lawsuit, not that I am looking to be sued, but I really would like her to have a healthy baby.

 

[birchswing]

You have to taper REALLY slowly in pregnancy, tapering too fast can cause a miscarriage

<Not a doctor or medical student>

Given that you have to do it that slowly, and starting at 10 mg, and that a pregnancy is ca 9 months, what would be the point? A slower taper would not be over by the end of the pregnancy, and you already indicated she would go back on after.

 

[Celexa]

I see no way this patient could be tapered off Xanax and zero point in doing so, given the risks of withdrawal in pregnancy.

If she was genuinely committed to being off the Xanax (or even to a lower dose)--not just for the pregnancy--I would start tapering conservatively, with a plan to pause the taper prior to birth and in the immediate first few postpartum months.

You mentioned med trials but not therapy trials. I know it can be hard to find good therapy but this woman has been incredibly poorly served if she went through all those med trials, including multiple benzos, without getting proper Cbt for anxiety. And now of course her ability to benefit from therapy will be compromised by the benzo.

Just an absolute disaster and I agree she should be under the care of a specialized perinatal psychiatrist. The reason no one can point you to a 'taper schedule for pregnant patients' is because there isn't one. Too much art of medicine in a case like this.

 

[futuredo32]

She's been in therapy for 15 years. I'm going to call the number listed or probably give it to her current psychiatrist. Thank you so much.