Adverse side effects lasting 5 weeks

Treatment and medication
1

I started on 150mg Ven in June for anxiety. 5 weeks ago my GP agreed to increase the dose by another 75mg as I wasn't improving.

I experienced increased anxiety, headaches, and other adverse side effects as expected, but after 5 weeks they haven't abated, in fact, if anything, they're worse. The literature says the adverse effects can last 1-2 weeks, my GP, however, says they can last longer. Anyone else have experience of this? Do I continue or ask my GP about reducing the dose?

Any help/advice welcomed,

Mike

2

Continue for another 3 weeks - if no improvement go and see your GP.

3

Thanks, Ben - i wasn't planning to give it that long - do you have experience of this?

4

Mike, I'm no expert, but one option for you is to try a different med. Obviously need to work this closely with your doc. (he may refer you to a specialist).

Good luck, and hang in there.

5

First of all, what condition is being treated? What did you start off with: anxiety symptoms or depressive symptoms - if both: which was prevalent?

Is this the first time you are taking a psychotropic medication? How long have you been taking it in total now? I want to assume you did not simply start on 150mg?!!

Finally, your GP's call to increase by 75mg increments (I am assuming we are talking about extended release caps) is not the best. This is not how dosage is established at all. 37.5 increments are used after 75mg are established. Some doctors will start you straight on 75 and some will be more conservative and ease you in on 37.5 gor a week or two before introducing 75. But from that point on, there is no jumps. Unless the patient is suicidal AND closely monitored.

At this stage your GP needs to refer you to a psychiatrist for an evaluation. No accepting to 'try other drugs' until you are sure that this one was properly covered. Jerking your brain around on large spikes or cuts or worse, various drugs or combos will destroy the clinical picture and make it difficult to assess further down the line.

In answer to you question, "adverse effects" can last longer. But if treatment is taking root properly the bad waves become weaker and fewer apart steadily after the first 4-6 weeks of total therapy time at a therapeutic dose (75 ER plus)...So yes, something may be off. The only right way to do this is be seen by a good psychiatrist. This is not GP domain. Sorry.

All the best.

6

Hi,

Many thanks for your reply.

Firstly, to answer your questions: -

I have been on psychotropic meds before. In 2000, at the age of 54, I had Hodgkin's Lymphoma, went undiagnosed for over a year, and suffered dreadful symptoms (all over body itching) which drove me into depression. I was on a couple of meds which after time got me over it, amytriptyline then paroxetine, finally venlafaxine. In 2003 I had another bout of anxiety/depression because I thought the Hodgkin's was returning, again Venlafaxine sorted it, side effects weren't notable and I eventually came off it with no problems that I can remember.

In June this year I had a nasty cold virus, which laid me low for over a month. I became over-concerned about my health, and this current bout started - it's most definitely anxiety far more than depression, and rather different from the first two occurrences in many ways. My GP started me on 75mg at the end of June, increasing to 150mg extended release. 5 weeks ago last Monday he increased the dose by 75mg to 225mg per day.

Secondly, a question for you if I may. You speak very authoritatively about this drug, both in your response to me and in other posts. Please don't take this amiss, but may I ask if you are in any way qualified to do so? Most responders on this forum use phrases such as "in my personal experience" or "I'm no expert but" - it's notable that you don't. This is in no way a criticism of your response, merely an attempt to discover on what you base your advice - I have previously trusted my GP on this and am reluctant to press for a psychiatric referral.

Again many thanks for your reply,

Regards,

Mike

7

Hi Mike

First I would like to note that your recurring anxiety, closely linked to your health concerns is predictable and justified. Also, you are likely really good at regrouping once you are given a bit of  a push or buffer by medication and speaks volumes of your capacity (or tenacity). However I would be curious to know how you actually felt between rounds of therapy that you listed above and whether any subtle or obvious symptoms lingered beyond what was deemed successful completion...?

I would like to point out that between 2000 and 2003 there are only 3 years. How long did it take for you to get better starting 2000 and how long were you off medication (and symptom-free) before your relapse? And how long were you on the second round of venlafaxine then (2003 onwards)?

The reason I am asking is because it is impossible to estimate what is 'normal' response to medication if there has been 2 or more cycles (relapses).

This is not GP territory exactly because they are lacking the skills for fine-tuning dosages and combinations. If your GP is realistic and skilled then psychiatrist verdict would not differ from theirs anyway.

On to your queries. I understand your points.

My initial basis for these responses is personal experience with this drug (12 years) and over 10 years of observation and direct research with actual patients undergoing treatment. My academic background is in clinical psychology with accent on biological implications. I have closely collaborated with my final set of doctors, and most notably my neuropsychiatrist during and post-treatment and received much insight and literature to assist in furthering my studies/research.

I tend to respond to posts (in the way I do) where I am certain I can contribute correctly. I use politer prefixes such as "in my experience" or "I believe" when I do not feel I have enough resources/base to feel fully comfortable with a suggestion. These kinds of sentences usually end with please consult your doctor.

With issues such as yours I am certain there is something off and in conclusion would say: please consult your doctor and an expert for a second opinion. Both.

My own treatment was roughly 3-fold with failures setting me back considerably. But proving very fruitful in making me get to know various phases of treatment face-to-face.

Venlafaxine is a potent drug that needs to be handled rather gently (and patiently).

I would again advise that at the level of 150mg ER it is not best practice to up by 75mg but 37.5mg increments. Not "in my experience". I would state this as a fact.

When the drug is working for you no new symptoms come after the adjustment (approximately 2 weeks...give or take some depending on several factors). I would state this as a fact too.

Yet you mention: "I experienced increased anxiety, headaches, and other adverse side effects as expected, but after 5 weeks they haven't abated, in fact, if anything, they're worse. " This is a sign that you are either overmedicated or require reassessment. The danger is that GP may try to swap drugs or introduce a second agent which would not be a great idea unless more than one experts agree...

Your options are actually limited to the following: 1. reduce by 37.5 and re-evaluate in 2 weeks; 2. Up by another 37.5 mg and re-evaluate after 2 weeks (I would not but THAT is a personal opinion on a hunch 3. introduce an additional buffering agent in the form of sedatives for a couple of weeks and watch for patterns of steady improvement; 4. Introduce a second drug to counter venlafaxine fallout (from what I have seen around here this tends to be Mirtazapine more often than not - my own doctor tends to work with one agent unless absolutely impossible to do so - but approaches vary); finally...5. get a second opinion by a qualified psychiatrist. In fact your GP can consult a psychiatrist themselves for advice. Maybe he already did. But I doubt it (from personal experience with GPs)

Among the listed options you will note that they do not include "wait for another couple of weeks and do nothing". The only reason this is not included is because you feel like you are getting worse. You should be feeling the same or better by now. Not worse.

I hope this helps cut your struggle a little shorter. It sounds like you had a lot on your plate and are left reeling. From a psychological perspective I would like to suggest that coming to grips with uncertainties of life gets easier the more we experience. It is good to remind yourself that you do what you can to keep yourself well and safe. But there is a limit to how much you can 'control' or 'prevent'. Time to look for ways to put your health fears in perspective. You do what you can. Let the rest be what it will. 

Is your sleep/diet adequate at this stage? Are you meeting people/going out etc?

All the best.

8

I would like first to express my gratitude to you for taking the time to respond to me, you have helped me a lot.

Secondly, an apology for the delay in responding – I typed pretty much the whole of what follows into the web site yesterday, but the page froze and I was unable to send or even copy what I had written. My only recourse was to photograph the screen and then retype today – into Word first as a precaution!

I can’t answer your questions fully regarding my previous episodes I’m afraid, the memory of such events tends (thankfully) to fade.

What I can tell you is the following: -

My first episode was depression, no panic attacks, just despair at the failure of my GP and several consultants (dermatologists) to find any reason for my itching. I couldn’t sleep, lost weight, and had the usual “fight or flight” response which I responded to by walking, miles every day. Amitryptiline did little to help for a long time (months) but did eventually help me to recover well enough such that I’d actually started back to work before I was diagnosed with Hodgkin’s in September of 2000. My consultant haematologist switched me to Paroxetine; either that, or the fact that when I started chemotherapy and responded well the itching disappeared, rapidly helped and I was soon quite well again.

I should mention that the above may differ from what I may have said previously, I have reassessed my memories of the course of events with regard to the different drugs I’ve “sampled”

All went well until 2003, when I started to get a tingling in my arms, which is where the itching had started previously. I fairly rapidly went back into depression/anxiety (panic attacks this time) and was put for the first time onto Venlafaxine, building up to 225mg per day. I don’t remember how long this lasted, several months certainly, but I was able to continue working and eventually the meds and reassurance from MRI (or was it CT) scans that the Hodgkin’s wasn’t back I eventually recovered fully, though it did take a long time after I’d had the reassurance. I don’t remember any problems with side effects from the Venlafaxine, either whilst on it or when coming off.

I have never thought that I was particularly prone to depression/anxiety, my belief was that the two episodes were very explicable given what I’d been through. My wife (whom I love and depend on totally, we have had a wonderful married life for almost 50 years now) developed a particularly aggressive breast cancer in 2008, and whilst of course extremely concerned I didn’t go into any anxious or depressive state, remained positive and saw her through to her current state of good health.

This time around it started with a simple cold virus – it wasn’t even a particularly bad cold, but I felt very tired and out of sorts for what to me felt like a long time, probably a month or five weeks. I started to worry about my health, especially lung cancer (I’m a smoker I’m afraid) and rapidly descended into my current state – I’m told it’s health anxiety and it’s not uncommon.. I should mention that I’ve recently lost several very close friends, one from a heart failure, three to prostate cancer and another from pancreatic cancer. I feel this has probably affected me more than somewhat.

I am having problems sleeping – I take one quarter of a7.5mg  Zopiclone every night, this sees me through for about 5 – 6 hours, at the moment I’m up about 5:00 every morning, in a fairly desperate state which does abate during the day. I’m eating well, in fact I get quite hungry on an evening, and always eat a good dinner, though not such a good breakfast and often no lunch. I’ve always been a heavy drinker, but at the moment I’m off alcohol virtually altogether – two glasses of 8% alcohol wine on one night in the last week. I am meeting people and going out, but not so much as previously. I am an ardent snooker player, and used to have at least one night a week at the club I belong to, but haven’t been in the last three weeks. I have no fear of social situations.

So, that’s my history in regard to depression/anxiety. Whether that helps you to advise me further regarding any future treatment I may undergo I don’t know. You will be glad to hear, I hope, that I have followed your advice to a degree – I’ve been back to my GP and he has agreed to reduce my dose by 37.5mg to 187.5mg per day extended release – this is day three, and too early  I’m sure to expect any change. I do wonder if it will succeed, and how long before I may see any improvement if I’m going to – anything you can offer on those lines would help immensely.

I haven’t asked for psychiatric referral – frankly that would be a waste of breath, it’s not likely to happen until my GP is sure the Venlafaxine isn’t going to be effective. I have a review appointment in one month, if no better I’ll ask then.

Again my profound thanks for your kind help and advice – you must have helped many such as I on this forum, and it is appreciated.

Regards,

Mike

9

Many thanks for filling in some of the gaps.

It is much clearer now.

"This time around it started with a simple cold virus" Yes this is common - you remain vulnerable due to the initial trauma (feeling something is wrong but not getting it diagnosed and treated for a while and then finding out it is cancer). That trauma makes your mind sensitive to anything that goes wrong in the body because it is striving to preserve you/protect the body/keep alert...

 "I should mention that I’ve recently lost several very close friends, one from a heart failure, three to prostate cancer and another from pancreatic cancer. I feel this has probably affected me more than somewhat." Yes, very stressful. Hits close to home. Reminder of how people tend to get sick and die and there is nothing anyone can do about it. Plus the grief. Very exhausting. Further, while you managed to remain 'with it' to see your wife through her health ordeal, this was very likely another factor leading to this last crash. So glad to hear she is well. You have both been through a lot indeed.

"I’ve always been a heavy drinker, but at the moment I’m off alcohol virtually altogether – two glasses of 8% alcohol wine on one night in the last week"

This is probably the most important point.

How long has it been since you reduced consumption rate and quantity and type of alcoholic beverages consumed?

This is where chemistry gets specific. Alcohol is an awesome CNS depressant. Remove its numbing effects, during times of extreme stress in particular and you get increased anxiety (not only are you relapsing you are also in alcohol withdrawal of sorts. It is a good indication that you will likely get better once your gut rebalances.

Some suggestions: Top up your diet with some quality fermented foods. (Other than just wine . Soured cabbage can help and only small amounts are needed. You can ferment cabbage at home over about one week at room temperature. Search online for methods.

Kefir drinks are good. Live pure yoghurts are less potent but better than nothing.

Dried fruits will help especially those that readily ferment like cherries and apricots.

Fresh pomegranade will keep the colonizing bacteria fed and strong (it is in season right now where I am - see if you can get any where you are) You can juice them or eat raw if the seeds do not bother you. Pomegranate is extremely helpful - purifying and a natural tonic. The above should help rebalance your gut and hopefully kick-start your recovery too over about 2-3 months.

Meanwhile: Get good quality chamomile for tea and drink it strong (a dash of honey for taste is great), at least once per day, preferably about 20 minutes before sleep or with your sedatives for double effect.

If you take coffee/black tea or any other sources of caffeine, slash consumption in half. Coffee should be real and not instant. Actual ground coffee has antioxidants and cancer-fighting substances too. Good for your heart and overall health. Instant coffee – virtually opposite effect.

This last part is for easing the adrenal over-secretion.

It is anyone’s guess whether reducing dosage will help or not. It is worth a try though. If it does work, you should feel like anxiety is sort of losing momentum pretty soon after hitting the correct dosage. About 2 weeks. This will include no new symptoms cropping up and a sense of stabilizing. After the first 2 weeks (I see from your comments your system takes a while to respond though) you should be able to note a sense that it does not feel 'as bad as it was'. Once this occurs, progress begins gradually.

Please let us know how it goes.