Taper off Effexor XR or keep trying add-ons?
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Glad I found this site. I am 37 and suffer from Major Depressive Disorder (Recurrent), GAD, Panic Disorder and OCD. I was on Paxil for 10 years when it pooped out and now I've been on Effexor XR 225mg for the last 12 years and started having issues in February to the point of panic attacks. They upped my Effexor to 300mg. I have also been on Buspar for two years. They doubled that to 60mg daily. They gave me Ativan to help with the panic and started me on Abilify as an add-on. The Abilify made me too restless, so now they're trying me on Rexulti, but I'm not sure if it will work. My only other options are try other add-ons (Seroquel, Remeron, etc) or start tapering slowly the Effexor for an antidepressant overhaul. I don't feel I'm where I need to be in terms of my anxiety being too much and I feel like a zombie and tired but I'm not sure which med(s) are causing it. Any advice on the best route? I know Effexor can be a bear to come off of but I'd do it very slowly per my Dr and PA. Is it worth fiddling with other add-ons?
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johnkov mook
Posted
Here is what I can suggest – but mind that I am not a psychiatrist and you really need a second opinion on this. You could gradually withdraw venlafaxine by reducing the dose by no more than 37.5 mg per 2 weeks. In the same time, you could ask your pdoc for diazepam script – start with 5 mg tablets. Once you reduce the venlafaxine dose and the anxiety starts increasing, you would need to start taking diazepam and eventually increase the dose to 10 – 30 mg per day (again – this is a huge dose that would certainly result in the development of tolerance and benzodiazepine addiction – this is why it is important that you get diazepam and not any other benzodiazepine (like Ativan) - diazepam dependence is relatively ‘easy’ to overcome).
Once venlafaxine is no longer present in your system, I would start a treatment with MAO inhibitors – either the more sedating phenelzine (Nardil) or the more activating pranylcypromine (Parnate). These drugs belong to an older generation of antidepressants and also increase the levels of all three neurotransmitters. However, they do it in a totally different way that does not turn people into zombies. There would be two drawbacks to this solution: (1) You would need to follow a strict diet with products like cheese, cured meat, beer or yeast extracts being banned forever, and (2) you would eventually need to withdraw diazepam, which is likely to be a painful experience. The total time until the switch is complete could be anywhere between 6 months and a year. But it could be worth it – the majority of patients with underlying anxiety issues who don’t respond to SSRI/SNRI, respond very well to MAO inhibitors.
jane75220 johnkov
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johnkov jane75220
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No, being a benzodiazepine, clobazam binds to the GABA receptor group and controls the polarisation of neurons. This mechanism of action is entirely different to the re-uptake inhibition of neurotransmitters (like in SSRI/SNRI) or preventing their breakdown (like in the case of MAOi).
jane75220 johnkov
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ann55375 johnkov
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johnkov ann55375
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Interactions between warfarin and MAOi have been poorly investigated. I am aware of only one paper reporting that tranylcypromine and warfarin administered in combination caused problems as both of these medications are metabolised by the p450 system (CYP2C19 to be specific). Mind that this is not the kind of interaction that can lead to a hypertensive crisis, but as the metabolism rate of both substances becomes impossible to predict, a pdoc would probably consider starting such therapy only on an in-patient ward (at least during the initial few weeks), where the concentration of both drugs in your system could be quickly determined (if a dangerous interaction occurred).
Regarding the other MAOi that you could consider (phenelzine, selegiline) - I cannot tell. There are no data. It really depends on whether you would be willing to try and whether your pdoc would consider taking the risk / putting his career on the line...
ann55375 johnkov
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johnkov ann55375
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If you decided to go ahead with the antipsychotics route, do your research first. While all modern antipsychotics are equally effective, their side effect profiles are different. Olanzapine is highly sedating and induces some serious weight gain, so I would certainly say no to this one. By weight gain I mean putting up 20 - 30 kg in a few months’ time. It is also known to dramatically increase prolactin levels in women, which can cause further problems. Risperidone is rather activating. While this feature makes it very useful for people suffering from negative symptoms of schizophrenia (or from bipolar depression), it can increase anxiety. Aripiprazole (trade name Abilify) could be a good compromise. It composes well with sertraline – this is probably the most common SSRI + antipsychotic combination, which means that pdocs usually have experience in managing the augmented therapy. You could start with 5 mg of aripiprazole and 100 mg sertraline and eventually increase the antipsychotic dose to 10 mg. Side effects… weight gain (though not as severe as with olanzapine) and very slow development of tardive dyskinesia. Probably you would not notice any involuntary movements after taking aripiprazole for a year, but staying on it for many years would require a careful risk vs benefits evaluation.