Beginning cross taper from citalopram to fluxotine tomorrow.

[kain]

Hey I've been on citalopram for 4 year and believe It has pooped out on me as my anxiety came back and I'm on the max dose.

I tried to treat it as a "blip" which I don't really buy into I'm in the first place maybe one or two days but not weeks.

So tomorrow my doctor wants me to cross taper onto fluxotine. Not sure how fast or how long a cross taper but we'll figure it out.

I have 2 questions I guess.

1. Is there a huge risk of serotonin syndrome when cross tapering ssris?

2. And has 1 ssri ever stopped working and found switching to another ssri worked?

Doctor thinks fluxotine will help with my "OCD" symptoms would she attributes to my racing thoughts and constantly seeking reassurance lol. Has anybody found fluxotine helpful in this aspect.

[panic_down_under]

1. Is there a huge risk of serotonin syndrome when cross tapering ssris?

No. At least not to the extent that it will do any harm. Serotonin syndrome is a much rarer beast than Dr Google would have us believe.


2. And has 1 ssri ever stopped working and found switching to another ssri worked?

If citalopram is the first SSRI you've taken then switching to another SSRI is worth trying as it is the easiest, and likely quickest acting option available. OTOH, if you've had other SSRIs fail previously then either a SNRI, or TCA should be considered instead, with a preference for TCAs.


Doctor thinks fluxotine will help with my "OCD" symptoms would she attributes to my racing thoughts and constantly seeking reassurance lol. Has anybody found fluxotine helpful in this aspect.

Fluoxetine seems to be reasonably effective for OCD, however, this is the hardest of the *anxiety disorders to control, so there are no guarantees.


* OCD has recently been reclassified and is technically no longer an anxiety disorder, but anxiety remains a major component of it.

[kain]

Yes citalopram is the first ssri I tried...ive been stable enough to work so I'm thinking of asking her if I can start the cross taper during April vacation since I work at a school and theres no school that week so I don't have any pressure to do anything but I might as well start getting it over with.

[panic_down_under]

Yes citalopram is the first ssri I tried...ive been stable enough to work so I'm thinking of asking her if I can start the cross taper during April vacation since I work at a school and theres no school that week so I don't have any pressure to do anything but I might as well start getting it over with.

Sounds like a plan. There are usually few serious issues when switching from one SSRI to another, however, switching to fluoxetine is a little more complicated because it has a very long half-life so it can take several weeks for plasma levels to build and stabilize. But a slow and steady cross-taper should minimize any side-effects.

[MyNameIsTerry]

No. At least not to the extent that it will do any harm. Serotonin syndrome is a much rarer beast than Dr Google would have us believe.



If citalopram is the first SSRI you've taken then switching to another SSRI is worth trying as it is the easiest, and likely quickest acting option available. OTOH, if you've had other SSRIs fail previously then either a SNRI, or TCA should be considered instead, with a preference for TCAs.



Fluoxetine seems to be reasonably effective for OCD, however, this is the hardest of the *anxiety disorders to control, so there are no guarantees.


* OCD has recently been reclassified and is technically no longer an anxiety disorder, but anxiety remains a major component of it.

Who has reclassified it? It's due to stay where it is in the latest ICD release last I looked. If you mean the OCD Spectrum Disorders group in the DSM-V, we use the WHO ICD so it won't be relevant to us.

The sooner they stop this two manual approach though, the better. And the ASA seem to be moving more & more towards creating disorders for normal human behaviour, something they have been criticised for.

[panic_down_under]

Who has reclassified it?

...If you mean the OCD Spectrum Disorders group in the DSM-V

Yes, I was referring to the DSM-V change.


The sooner they stop this two manual approach though, the better. And the ASA seem to be moving more & more towards creating disorders for normal human behaviour, something they have been criticised for.

True, but I tend to agree that OCD should be in a category of its own together with the other disorders in the spectrum as anxiety is only one component of OCD and for some is only a minor one.

[MyNameIsTerry]

Yes, I was referring to the DSM-V change.



True, but I tend to agree that OCD should be in a category of its own together with the other disorders in the spectrum as anxiety is only one component of OCD and for some is only a minor one.

I had a feeling it might be the DSM. There are some categorisations that completely disagree with each other between WHO and the ASA, Somatoform Disorders and certain impulse disorders spring to mind. It just seems bizarre that the two major manuals can't agree.

In the ICD OCD is in it's own category with other anxiety disorders clearly separated.

When anxiety reduces, obsessive compulsive behaviours tend to decrease naturally. I would regard them as closely correlated. But it can be that anxiety symptoms appear controlled by compulsions but take them away and the anxiety will become more prominent.

I'm interested that you mention it can be a more minor symptom as I've never found that in mine or others. Always interested to learn about variance though do if there is anything found in research, I would be interested to read it.

[kain]

So my doctor has decided I'm going to 30mg citalopram and 10 mg fluxotine for a month? Seems like a long time.

[panic_down_under]

So my doctor has decided I'm going to 30mg citalopram and 10 mg fluxotine for a month? Seems like a long time.

It is probably longer than it needs to be. I would have suggested 2 weeks on 10mg fluoxetine then 20mg with a drop in the citalopram. But your doctor is in a better position to make that call.

[kain]

Your right I just don't always know what to think with doctors. They all have different opinions on everything....i heard your body metabolizes fluxotine diffrent then citalopram.

[MyNameIsTerry]

It is probably longer than it needs to be. I would have suggested 2 weeks on 10mg fluoxetine then 20mg with a drop in the citalopram. But your doctor is in a better position to make that call.

It sounds like the doctor is considering the steady-state issue, which is more than many seem to, but I do question that in a cross taper since it's the same class. It's sensible to consider not dropping too low before the new med is propping things up more.

The funny thing is, Ian, I've read the guidelines for this in the UK and cross tapering seems widely open to interpretation, which is not ideal with GP's. At least the OP has a plan that can be easily modified based on response unlike a full stop & start regime.

[panic_down_under]

It sounds like the doctor is considering the steady-state issue, which is more than many seem to, but I do question that in a cross taper since it's the same class.

Yes, switching to fluoxetine has its difficulties because of the long half-life. The problem is that for most plasma levels don't stabilize for 3-4 weeks so it probably won't make that much difference to side-effects severity if the dose is ramped up at one or two week intervals so, imho, you may as well take the quicker option to get onto an effective dose asap and hope the side-effects don't go through the roof. This may be a case of there being not only no good option, but no least worst one either.


I've read the guidelines for this in the UK and cross tapering seems widely open to interpretation, which is not ideal with GP's.

Interesting. I'd be wary about setting hard and fast rules as every patient reacts differently, and not always because of a direct physical response to the meds being switched to and from. Psychology can be just as important. So guidelines should allow for considerable latitude, though I can see they then may not be much help to those GPs that need them the most. To quote a former Australian PM, "life wasn't meant to be easy"! :ohmy:

[Bike Rider]

Hi Kain.

I was on 40mg of Cit for 12 months, helped with anxiety but not mood, so my GP had a chat with a friend of his who is a Psychiatrist and they decided Fluoxetine would help with the mood lift. This appears to be happening, fingers crossed.

All he told me to do was stop the Cit for 3 days and then start the Fluox at 20mg, no problems at all, we have increased to 30mg now and this seems fine.

[kain]

Thanks for the advice guys I havnt taken the Prozac yet I'm just so worried about serotonin syndrome. Maybe I'm being irrational but I'm terrified.

[panic_down_under]

Thanks for the advice guys I havnt taken the Prozac yet I'm just so worried about serotonin syndrome. Maybe I'm being irrational but I'm terrified.

Dr Google has much to answer for. :weep:

Most of the stuff online about SS is male bovine excreta, heck, most of the stuff in medical journals is. Almost all the serious SS injuries and deaths have occurred when MAOI class antidepressants have been combined with either SSRIs, some SNRIs and TCAs, or serotonin releasing drugs.

SSRIs, individually or in combination, rarely cause issues on their own even in massive overdose, thousands of milligrams. To quote Ken Gillman (http://www.psychotropical.com/1-introduction-to-st), arguably the leading authority on serotonin syndrome/toxicity:

The bodies capacity to break down serotonin is so rapid that it seems to be difficult to raise levels sufficiently high to cause death (from serotonin toxicity) by taking only one type of drug (e.g. MDMA, ecstasy (3,4-methylenedioxymethamphetamine)). It is almost always the case that serious toxicity and death is associated with combining two different types of drug with a different mechanisms of action. The great majority of human fatalities have been associated with a combination of MAOIs and (S)SRIs. So far, just about the only other combination capable of causing fatalities is MAOIs with serotonin releasers (‘indirect agonists’) e.g. MDMA (but not methylphenidate)

[kain]

Ya doctor Google doesn't help. It just repeatedly keeps telling me not to take two Ssris at the same time.

You sound like you know what your talking about and the pharmacist says they don't think I'll devolp serotonin syndrome though they couldn't say i wouldn't so I'll do it tomorrow.

[panic_down_under]

You sound like you know what your talking about

The bloke that does know what he's talking about if Ken Gillman. He's written over 70 papers (https://scholar.google.com.au/citations?user=ea6KeD0AAAAJ&hl=en) on serotonin syndrome. I'm just passing on the message.

[kain]

I read the entire article you referred to above. Good stuff. I took the fluxotine and citalopram about 10 minutes ago so if I'm going to get sick I'll know I'm the next 24 hours lol.

[panic_down_under]

I took the fluxotine and citalopram about 10 minutes ago so if I'm going to get sick I'll know I'm the next 24 hours lol.

You'll be fine. You may experience some side-effects, but they won't be serotonin syndrome, just the usual initial SSRI 'fun and games'. :ohmy:

[kain]

Thanks for all of your reassurance.

I had real bad side affects when I started citalopram but at the time they had me keep mixing it with other stuff like mirtazapam and gabapentin then amitriptyline and propranol then buspar...but ever since I settled on citalopram alone I've only had minor side effects when increasing doses like loss of appetite for a few days.

[panic_down_under]

I had real bad side affects when I started citalopram but at the time they had me keep mixing it with other stuff like mirtazapam and gabapentin then amitriptyline and propranol then buspar..

That's crazy. There should never be changes to more than one med at a time because if problems arise it can be difficult working out which is causing the problem. This is #$%^&* basic doctoring 101. :mad:

[kain]

Yes that's why I switched doctors. It's also why I was so apprehensive about the fluxotine and citalopram combo lol.

---------- Post added at 10:26 ---------- Previous post was at 07:15 ----------

So I made it through the night and today I felt fine just some stomach cramps so panic down under I think it's safe to say I'm clear of serotonin syndrome.

People keep telling me I'll get all these side effects but they were very mild when I increased before and so I have a feeling this won't bother me all that much.

[panic_down_under]

So I made it through the night and today I felt fine

Oh, bummer. :weep: I had such high hopes for collecting on the 24 hour $1 million life insurance policy I took out on you. :roflmao:


just some stomach cramps so panic down under I think it's safe to say I'm clear of serotonin syndrome.

Yep. Gut issues are fairly common as the enteric nervous system (http://www.scientificamerican.com/article/gut-second-brain/), the mini brain which controls the gut, makes and uses about 50 times more serotonin than the brain as so can be more affected by SSRIs than any other organ.

The serotonin syndrome symptoms to be concerned about are clonus (https://en.wikipedia.org/wiki/Clonus) - involuntary muscle movements, usually mostly of the lower limbs, followed by a large increase in body temperature. It is the temperature spike which does the damage.


People keep telling me I'll get all these side effects but they were very mild when I increased before and so I have a feeling this won't bother me all that much.

Support groups such as this one can give a distorted impression. Most people do not have severe side-effects when taking antidepressants. It is the relatively few who do that come here.

[kain]

Well I definitely appreciate all your reassurance and yes I can say I 100% don't feel anything like i did after my first dose of citalopram and amitriptyline that's for sure.

[kain]

Day 3 no side effects really so far so good. Whoohoo

[kain]

Day 4 no upset stomach or anything actually feel pretty good I know Prozac doesnt work that fast maybe a placebo effect but I feel better today.

[panic_down_under]

I know Prozac doesnt work that fast maybe a placebo effect but I feel better today.

Yes, it is the placebo-effect, but a good day is a good day irrespective of the reason. Enjoy it while it lasts. :)

[kain]

Ya I hear ya a good day is a good day.

---------- Post added at 17:26 ---------- Previous post was at 17:16 ----------

It's weird I always seem to bounce back weather they increase or switch my meds it's kind of like I just have 4 awful weeks then i can function again who knows though.

[kain]

I'm still alive with no unbearable side effects to report.