Antidepressants - Venlafaxine Withdrawal
by Malcolm Hulatt
Successful Venlafaxine Reduction Programmes
4.1 Reducing from 2 x 75 mg XL capsules per day
The Prozac decay model was used to calculate a drug reduction programme. The schedule used was faster than the one given below but it did occasionally give difficulties so the reduction plan below has been adjusted to avoid these situations.
As always the doctor should be consulted when making these reductions. Having said that, the psychiatry consultant wanted the levels to be held for 6 months after each stage of reduction and he never accepted that the medication was part of the problem. We just ignored him as we clearly saw a correlation between improved health and reduced medication. Clearly the drug did not initiate the depression but it did appear to contribute to the ongoing problems.
The dosage had been 2 x 75 mg capsules twice daily (300 mg per day) although the recommended maximum was 225 mg once daily. Reduction to 2 x 75 mg once daily allowed much more clarity of thought although the patient’s faculties were still affected. If a level of 4 x 75 mg is being taken, the programme below can still be used but maintain an extra 150 mg per day as prescribed (either once or twice per day). After elimination of the one 75 mg capsule repeat again to eliminate the other. At this higher level (4 x 75 mg) the reduction may possibly be done more quickly as the reductions are much smaller in percentage terms.
A separate sheet is attached which could be copied and given to a patient to give day by day guidance on the following reduction programme starting with 2 x 75 mg capsules of XL.
Capsules have the disadvantage that they cannot be broken up in any way so the full dose has to be taken. Smaller capsule sizes need to be used until the smallest available are being taken. Only capsule size and frequency can be used to ease the level down if no tablets are available. Change over to venlafaxine tablets was delayed as long as possible to keep the amount of drug being taken to a minimum. The tablets do have the advantage of being able to be broken up into quarters or even smaller to facilitate gentle reduction.
If as a result of a reduction, the patient feels unwell at any time they should hold the medication at the level achieved until they feel well again. A period of consolidation of a new drug level can be done at any time to make an assessment of progress. The following describe the steps which could be taken to reduce the venlafaxine medication.
4.1.1 Replace one 75 mg capsule every third day with 2 x 37.5 mg tablets. The tablet will have a similar effect to the capsule on the day of taking it but it will have the effect of reducing the body drug levels slightly over the few days because it leaves the body quickly. Repeat this for 2 cycles or 6 days.
4.1.2 Reduce the frequency of substitution so that the 2 x 37.5 mg tablets are being taken every 2 days and repeat for 6 days.
4.1.3 Reduce the frequency of substitution so that the 2 x 37.5 mg tablets are being taken every day and a half and repeat for 6 days.
4.1.4 Reduce the frequency of substitution so that the daily dose is one 75 mg capsule a.m. and 2 x 37.5 mg of tablets p.m. and continue for 6 days.
4.1.5 Reduce the level of tablets being taken in stages by ¼ of a 37.5 mg tablet each cycle and holding for 3 days each time until the tablet intake is zero and the total level is at one 75 mg capsule per day.
This overall programme will take about 7 weeks as described above. An accelerated reduction in 4 weeks was actually employed but a couple of periods were encountered when the reduction had been too fast so this looks a trouble free programme unless the patient needs the drug to maintain their health. At a level of one 75 mg capsule per day most of the visible side effects seemed to have been eliminated but there was still some suppression of personality which lifted when the drug was eliminated completely.
The drug intake can be consolidated at this level for a period of assessment. We held it for one week but a longer period may be better if in any doubt.