Should I start Ven?

[23fish]

I have had a couple of bad experiences (with Mirtazapine and Valdoxan) over the last few weeks after many years on Citalopram and have now been prescribed Venlafaxine. Citalopram stopped working, probably due to the menopause.

My problem is, I am so scared of a repeat performance of side effects that every day I have a long debate with myself over whether to take it. I try not to get hooked in to the horror stories and focus on the positives, but I can't find many of those, and there is a huge amount about withdrawal being awful.
I have been prescribed 37.5 immediate release 2 x per day.

If anyone can answer any of the following I would be so grateful:
1. Do you have to take them 12 hours apart or is morning and evening at approximately the same time OK?
2. Could I start with one a day (in which case which would be best, am or pm) and build up slowly?

Any thoughts, tips or successes?
Thank you

[23fish]

Any thoughts?

[ian6989]

don't feel any different to be honest feel worse :(

[Lan69]

Hi I started ven 7 weeks ago. First 5 weeks I was taking 37.5mg 12 hours apart ( that is what I was advised to do) then switched to 75mg extended release 2 weeks ago. Maybe you could cut the 37.5mg in half and take that 12 hours apart if you want to start slowly.
I take mine with a combo of mirt so I'm on 'california rocket fuel' and the side effects were ok just a bit dizziness, dilated pupils and a bit constipation but that has all settled now. I noticed a calming effect almost straight away and my mornings which were absolutely horrendous have eased, still bad but much improved. If this combo works for me I shall be staying on it for life as I realise I need medication to stabilise me I have been on and off ADs too many times so withdrawl is not an issue with me
Hope this helps

[23fish]

Thank you for taking the time to respond x

[MyNameIsTerry]

It is the withdrawal more than anything that worries me, especially as I've been prescribed immediate release. I know that the extended release comes in capsules and you can gradually reduce by removing the beads inside.

You posted this on Carolin's thread, 23fish, and I just wanted to raise this so thought it better on here.

If you break the capsules to reduce the beads you will need to insert them back in again. Capsules can be because the med can aggravate the throat (like my Duloxetine does) and if the capsule is "enteric coated" it must be replaced in the same type as it needs to get past your stomach.

I think the Ven beads are coated too but would have to check, so handling will need to be researched first. I know the big tablets inside capsules come out the other end and the coating is the med itself and I think I may have read the same about beads with this med but I can't se sure it was the XR.

There is some concern over whether counting beads is accurate, it's the same with mine as non generic Duloxetine only comes in beads (great for withdrawal there!). What I wonder is whether you could do what I do with my supplements which I encapsulate? I bought a jewellery scale and it goes from 0.01-200g. This helps me work out an average of what I can pack into my capsules since all powders are different in terms of density (talk about teaching to suck eggs, I've just remembered you are a teacher! :doh:). I wonder if this could help to get the dose closer to what it should be rather than counting beads, and potentially quicker too?

If you do weigh them though, remember that the overall weight includes everything, not just the active drug. So, if you reduced the weight by 10%, the active drug wouldn't be 10%, it would likely be a lower %. Do you see what I mean? (I'm not sure if I'm explaining this well enough) If you use your own new capsules rather than the Ven ones, the weight may differ in that too.

It may seem less than accurate but it's far more measured than a GP blurting out "50%".

(why has the Ven forum gone so quiet these days? :shrug:)

---------- Post added at 05:16 ---------- Previous post was at 05:04 ----------


I have had a couple of bad experiences (with Mirtazapine and Valdoxan) over the last few weeks after many years on Citalopram and have now been prescribed Venlafaxine. Citalopram stopped working, probably due to the menopause.

My problem is, I am so scared of a repeat performance of side effects that every day I have a long debate with myself over whether to take it. I try not to get hooked in to the horror stories and focus on the positives, but I can't find many of those, and there is a huge amount about withdrawal being awful.
I have been prescribed 37.5 immediate release 2 x per day.

If anyone can answer any of the following I would be so grateful:
1. Do you have to take them 12 hours apart or is morning and evening at approximately the same time OK?
2. Could I start with one a day (in which case which would be best, am or pm) and build up slowly?

Any thoughts, tips or successes?
Thank you

What have you been advised in terms of times? And was it a psychiatrist or GP? If a GP, are they a good one who knows their stuff about meds?

Don't miss doses of these, SADNoMore (Marie) said the withdrawal would hit her the same day. This isn't surprising because the half life is so short that you can reduce the % quite low by missing a single dose and waiting for the next scheduled on. The way around this is the XR version which has a longer half life. Others I have seen on here switch to XR and find less issues with it.

I don't know about one a day, like I said, you would reduce very quickly. Because the half life is 5 hours (+2), if you said 7 hours by the end of a 24 hour period after taking one you would be at potentially 6.75% of the active drug left, if we use the standard pharmacokinetic calculation for elimination. I know with Ven that it reaches it's steady-state in about 3 days, which is longer than the standard pharmacokinetic calculation for steady-state, so I'm less sure of how fast it will eliminate as compared to ones like Cit or Sert which are close to that standard model in steady-state recording found in studies.

If you went by 5 hours, then you are very close to <5% which is considered "clinically insignificant".

However, if the dose is so low that it won't do much, any withdrawal you fall into each day could be minor. BUT I just don't know there, it would be a gamble. The point of twice a day is to keep your blood plasma levels topped up a bit more so this doesn't happen.

Can you see how if you took your dose 6 hours late, it could cause some problems?

If you were on a higher dose, taking once a day would be a very bad move for obvious reasons. I only wonder about starting at 37.5mg once a day because it might have little effect, kind of like chopping up a 10mg Cit to start very carefully. But it would be a gamble unless you can find people doing it.

And because of this half life issue, be wary or squashing doses too close together.

Because of this half life issue, I often wonder about how these reductions impact on people. My med, Duloxetine, has a shortish half life and I've been wondering whether the reductions over that 24 hours are a problem for me but with my med I can't find any advice to take it twice a day other than when starting to lessen the side effects. Ven is a bit different.

Until you hit 150mg a day, it will only be acting as a SSRI. Once you hit that threshold, it will start interacting with adrenaline. I don't know about others but I know with the Duloxetine, where the threshold is 60mg, I found that hard to crossover and the symptoms were more those of anxiety e.g. agitation.

[23fish]

Thank you Terry for such a detailed response. It was my GP who prescribed, and she said nothing about timings. One of the reasons I am reluctant to start Ven is because I think I'm still suffering from the after effects of Valdoxan. I lasted a month but had awful stomach pains and diarrhoea every day which just didn't get any better. Since I stopped the pains have gone but I still have a dodgy stomach every day. It might be better to wait until this settles down. At the moment I am working on Paul David's approach and trying to work alongside the symptoms. We shall see!
Thanks again x

[MyNameIsTerry]

I've just looked it up out of interest on Drugs.com, where I tend to check meds on as it is aimed at professionals as well as consumers, and I noticed in the dosages section that anxiety and panic both show as XR version only whereas depression can be immediate or extended release. That is very interesting given how some users on here have said the immediate release gave them more issues:

http://www.drugs.com/dosage/venlafaxine.html

Usual Adult Dose for Depression

Immediate release:
Initial dose: 37.5 mg orally twice a day or 25 mg orally 3 times a day
Maintenance dose: May increase in daily increments of up to 75 mg orally at intervals of no less than 4 days
Maximum dose: (moderately depressed outpatients): 225 mg orally per day
Maximum dose (severely depressed inpatients): 375 mg orally per day
Comments:
-Daily dosage may be divided in 2 or 3 doses/day

Extended release:
Initial dose: 75 mg orally once a day
Maintenance dose: May increase in daily increments of up to 75 mg orally at intervals of no less than 4 days
Maximum dose (moderately depressed outpatients): 225 mg orally per day
Maximum dose (severely depressed inpatients): 375 mg orally per day

Use: Treatment of major depressive disorder (MDD)

Usual Adult Dose for Anxiety

Extended release:
Initial dose: 75 mg orally once a day
Maintenance dose: May increase in daily increments of 75 mg orally at intervals of no less than 4 days
Maximum dose: 225 mg orally per day

Uses:
-Treatment of Generalized Anxiety Disorder (GAD)
-Treatment of Social Anxiety Disorder (SAD)

Usual Adult Dose for Panic Disorder

Extended release:
Initial dose: 37.5 mg orally once a day
Maintenance dose: May increase dose in daily increments of 75 mg orally at intervals of no less than 7 days
Maximum dose: 225 mg orally per day

Use: Treatment of Panic Disorder (PD), with or without agoraphobia


That link will contain all the side effects and clinical trial stuff so I've posted the section in.

Something interesting is that the XR has been noted to cause less nausea. It's more expensive hence why GP's will always dish out the immediate release until they get a patient who has found out their options. The trusts tell them to do that anyway so save money.

That's really annoying how doctors just leave people to work out things on there own! Pulisa knows about Ven, I seem to recall her daughter was on it so I'm sure she could help you with the timings. Nicola1980 has used both forms from what I remember too. Perhaps they can advise on that? If not, a pharmacist might be worth asking.

[23fish]

Good advice as always. Thank you x

[23fish]

Just looked at your last post again. I wonder why the GP prescribed the immediate release. Probably the cheapest option! I do wonder if any of them really know what they are prescribing!

[MyNameIsTerry]

This will explain the motivation for it:

http://www.devonpartnership.nhs.uk/fileadmin/user_upload/MedsMan/InternetDocs/MedicineCostComparisonChart.pdf

Ven 75mg MR (that's Modified Release, so the XL version) = £22.08 (caps) or £10.45 (tabs) for 28 days.

The immediate release comes in at £2.45 for 28 days.

There is a detailed breakdown by one trust here but it's a bit older:

http://www.coventrywarksapc.nhs.uk/mf.ashx?ID=e1ba5e4f-335a-49e5-be52-0d554e481900

So, the motivation is saving money. Even in this NICE guidance it shows that they are expected to weigh up the costs in using Ven against other meds:

http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1375338426

NICE also suggest that, before prescribing venlafaxine, practitioners should take into account the increased likelihood of patients stopping treatment because of side effects, and its higher cost, compared with equally effective SSRIs

Notice in that doc what else NICE tell our doctors to be checking, like our blood pressure, but does that happen?

Page 10 of this NHS doc is interesting:

http://www.sept.nhs.uk/wp-content/uploads/2014/03/Section-1-Treatment-of-Depression.pdf

In the table it shows both SA & GAD showing as Ven only in XL form. Yet pretty much everyone you see posting on here seems to start with standard release. GP's saving money? Technically that is "off labelling" but then so is prescribing Citalopram for anxiety as it's not licenced for it, which is common and seems to be accepted. Another one of the double standards employed by our GP's who refuse to off label other meds but will do it with these without hesitation, possibly because they can fall back on guidance that says "use a SSRI"?

This shows evidence that NHS trusts were looking to move away from licencing (I've seen others) to put all XL patients on immediate release to ensure savings unless they couldn't tolerate it:

http://www.swlstg-tr.nhs.uk/_uploads/documents/healthcare-professionals/venlafaxine_qipp_guidance_20101014_2.doc

That's the NHS for you. It's a pity they aren't put on these meds when ill to feel how disruptive the side effects would be, they would be asking for the XL too.

NHS Scotland was at it as well:

http://www.dgprescribingmatters.co.uk/documents/Venlafaxine%20MR%20audit.pdf

Basically, an example of when cost savings are driving patient care and not patient need.

[23fish]

After a lot of thought I decided against Ven. I've now been taking Sertraline 25mg for 11 days in the hopes that the side effects will be easier to deal with at that dose. So far I've had nausea for a couple of hours in for the first few days, and increased anxiety and panic attacks for the last week. Can't wait for them to pass!