NEW 2024 ‘DEprescribing guidelines’

[[Gr...]]

I just purchased ‘The Maudsley’-“Deprescribing guidelines” for anti-depressants, benzodiazepines, gabapentin, and Z drugs released just weeks ago, 2024. it seems VERY informative and has exact printed schedules for most antidepressants and benzos ecc tapering at RO receptor occupancy of 5%, 2.5% and 1.3%  instead of a linear taper. They state withdrawals will be lessened with this method. Thoughts -comments?

anyone else read this book or have any input about it?

Edited March 12 by [Gr...]
Fixed layout.

[[Li...]]

Thank you for starting a discussion about The Maudsley Deprescribing Guidelines @[Gr...].  This is an important work.  

We’ve already discussed it briefly on the Benzos in the News forum when it was first released in February (see link below) but now that members have had the opportunity to purchase and read the book, I hope they will share their thoughts.

Might I offer a clarification about the tapering regimens presented by the authors, Mark Horowitz and David Taylor?

Unlike the dose-based regimens commonly used in this community, the ones in The Maudsley Deprescribing Guidelines are derived from the unique receptor occupancy curve (binding curve) for each benzodiazepine.  Consequently, the percentage points of GABA-A occupancy reduced per step in the regimens varies by benzodiazepine.

For example, there are up to 5.2 percentage points of GABA-A occupancy between each step in the ‘fast’ regimen for clonazepam compared to 5.0 in the ‘fast’ regimen for diazepam.

 

[[Gr...]]

Thank you Libertas! for the clarification I’m about to discuss this with my doctor and convert from the Ashton manual to this NEW method, addressing the  RO-receptor occupancy with a 1.3% gabba receptor occupancy between each step. attached Pic is for starting dose of diazepam 60 MG daily. I will be starting at step 21 which begins at 30 MG diazepam daily.Total number of steps will be 86 after converting to liquid at step 52. Each step is recommended every 1-4 weeks and more steps in between if necessary can be added, according to their guidelines. 

 

Edited March 12 by [Gr...]
Correct information

[[Gr...]]

Keep you all posted how it goes. 

Edited March 12 by [Gr...]
Add photo

[[Li...]]

You’re welcome @[Gr...].  In a nutshell, hyperbolic tapering regimens are based on the theory that equal-sized reductions in receptor occupancy may cause less severe withdrawal effects than equal-sized reductions in dose (which cause increasingly large reductions in receptor occupancy as shown in  the graph on the left in Figure 3.13, page 404). 

Please let us know how your doctor responds to your request so we all may learn from your experience!

@[Ka...] and @[Re...]:  If memory serves, both of you have purchased copies of The Maudsley Deprescribing Guidelines.  Do you have any comments you feel comfortable sharing at this time?  For example, what are your major takeaways from the book thus far?  Have you discussed this book with any of your healthcare providers?  How did they respond?

[[Ka...]]

1 hour ago, [[L...] said:

You’re welcome @[Gr...].  In a nutshell, hyperbolic tapering regimens are based on the theory that equal-sized reductions in receptor occupancy may cause less severe withdrawal effects than equal-sized reductions in dose (which cause increasingly large reductions in receptor occupancy as shown in  the graph on the left in Figure 3.13, page 404). 

Please let us know how your doctor responds to your request so we all may learn from your experience!

@[Ka...] and @[Re...]:  If memory serves, both of you have purchased copies of The Maudsley Deprescribing Guidelines.  Do you have any comments you feel comfortable sharing at this time?  For example, what are your major takeaways from the book thus far?  Have you discussed this book with any of your healthcare providers?  How did they respond?

Hello @[Gr...] Yes, thank you @[Li...] in general my takeaway is the book is such a valuable & comprehensive resource. Everything is set out & explained. 

Sadly, I was refused liquid diazepam I think probably due to cost to our NHS. I did my own taper against all the odds. Guidelines will not permit me to say too much on this subject! I haven’t personally discussed with my GP since I’m off diazepam now & doctors involved don’t seem to acknowledge WD, or the recovery phase. 

Gathering feedback to the book & attitude from providers actually would be very good. We are going to be those people with knowledge/the purple book, pointing at relevant pages & starting a collaborative conversation. I am hopeful there will be a positive change that the guidelines can empower. 
 

[[Re...]]

The book does a difficult job very well: merges pharmacology, psychiatry, a bit of psychology, withdrawal methods, references to previous authors, etc. And does this without a "predecessor" . This is a lot of material to organize, and an extreme accomplishment.  It is incredible that the withdrawal experience gave Dr. Horowitz this motivation, but to be honest: I can imagine. 

Do I get lost sometimes looking for something specific from all the different data? Absolutely. But I might have been doing that for the same reason I have just poured two glasses of orange juice and forgot of both.... So... 

To be honest I have not read the whole book, and only have it electronically. It is a whole different experience, I know.

 

[[Li...]]

Thank you for sharing your thoughts @[Ka...]!  I’m sorry you were refused liquid diazepam.  I’ve heard the same thing as you — it’s a cost issue with NHS.  I’ve also heard that advocates in the UK are working to change this.

I like your idea of us becoming the experts on The Purple Book!  I also hope we’ll become the experts on how best to use the book with providers via discussion on this thread.

[[Li...]]

Well said, @[Re...]. I agree wholeheartedly that this book is an incredible accomplishment.  The time and effort required to produce a work of this nature is considerable.  I hope our community will express its gratitude to Dr. Horowitz and Dr. Taylor by purchasing the book!

Your comment about pouring two glasses of orange juice and then forgetting about both of them resonates with me. (I have had similar experiences.)

I also get lost in the book but am coping by using sticky notes to flag key sections.  (My copy is beginning to look like a Christmas tree with too many colored lights! )

[[Nu...]]

15 hours ago, [[G...] said:

Thank you Libertas! for the clarification I’m about to discuss this with my doctor and convert from the Ashton manual to this NEW method, addressing the  RO-receptor occupancy with a 1.3% gabba receptor occupancy between each step. attached Pic is for starting dose of diazepam 60 MG daily. I will be starting at step 21 which begins at 30 MG diazepam daily.Total number of steps will be 86 after converting to liquid at step 52. Each step is recommended every 1-4 weeks and more steps in between if necessary can be added, according to their guidelines. 

I/We look forward to following your collaboration with your doc...

[[...]]

How is the recommended taper for Zolpiclone/Lunesta? 

[[Li...]]

[[...]]

I included "Lunesta" because Zolpiclone isn't a available in USA, which I know a lot of members come from. But yes, it was imprecise.

It makes sense that the linear is not too different from the hyperbolic. I have interdose withdrawal every single day because of the short half-life. 🤥

I am sort of trying to taper slowly in a fast way with it. I have only been taking them for two months, and started tapering as soon as I could. I am balancing between not stopping too suddenly, and not continuing longer, causing tolerance.

[[Li...]]

[[...]]

15 hours ago, [[L...] said:

Thank you for clearing that up, @[...].

For the benefit of other readers of this thread, it’s important to note that although the linear and hyperbolic tapering regimens are not substantially different for the z-drug zopiclone, they are for the benzodiazepines.  

Also, a point of clarification, interdose withdrawal is not related GABA-A receptor occupancy, which is what informs hyperbolic tapering regimens.  Interdose withdrawal is related to the pharmacokinetics of the drug (e.g. short half-life) and may also be a sign of physical dependence via neuroadaptation to the continued presence of the drug.

Per The Maudsley Deprescribing Guidelines (MDG):

”Normally the duration of the taper should not be longer than the period that the patient has been on the drug for people who have only taken it for a few weeks.  For example, if zopiclone is taken for 3 weeks the taper should be less than 3 weeks.”  (p. 492)

So less time on the drug = a shorter taper with the caveat that the patient’s experience of withdrawal should guide the rate of taper.  The goal of a taper is to keep withdrawal symptoms in the tolerable range.  Again, per MDG:

”Withdrawal symptoms should not be too unpleasant: a rate of reduction should be aimed for that produces tolerable withdrawal symptoms [note: not zero withdrawal symptoms] … If withdrawal symptoms are moderately severe or take longer than a couple of weeks to resolve, dose reductions should be postponed until symptoms resolve, and then made more gradually by choosing a slower tapering rate.” (pp. 491-492)

Thank you. I am learning a lot.

I have taken them for two months, but sort of tapered from a week in, because they felt too strong. I wonder what I should count as taper. 

My issue is that I got them for nerve stings and muscle movements preventing me from sleeping, and I still have those. I am testing how low I can go and still get the muscle relaxant/anti-convulsive  effect. 

Edited March 17 by [...]

[[Li...]]

[[...]]

6 hours ago, [[L...] said:

Your welcome @[...]. 

Is your intent to stay on the zopiclone long term?  If so, I hope you have thoroughly researched risks versus benefits.

I really don't want to! I hope I will be able to get something else, that is not a benzo, which will help with the nerve stings long enough for me to sleep. Or that the stings eventually go away (because they might have been caused by tapering to near zero of Citalopram. Not sure though).

For reference I was completely unable to sleep for several days, even on quetiapine/Seroquel, because the stings and muscle movements kept me awake. Everyone says "the body's need for sleep will override everything eventually", but my nerves didn't care.

I have a consultation with a phyciatrist this Thursday and hope that we will be able to figure out something else to help me. But stuff that helps with neuropathic pain has its own disadvantages.

As we say in my language it seems I have to choose between the plague and cholera...

(It is also possible that it is neurological, but I have been evaluated for ALS/MS earlier, and at least it is not that. And now there is a 1/2 year waiting time to see the neurologist again).

I have never had problems with the *sleep* part, it is the nerve stuff that is the issue. So it never seemed like the right choice (but my GP didn't know what to do other than dish out Zol, and of some reason quetiapine). And they do help with that too.

So I hope that I will be able to get something else. I *HATE* how the Zol makes me feel, and at least on this lower dose it is less pronounced.

 

Edited March 17 by [...]