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Dr. Andrew Rynne
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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Good afternoon doctor - on your advise, reduced mirtaz to

Answered by
Dr.
Dr. Seikhoo Bishnoi

Psychiatrist

Practicing since :2007

Answered : 5171 Questions

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Posted on Mon, 18 Mar 2019 in General Health
Question: Good afternoon doctor - on your advise, reduced mirtaz to 22.5 from 22.5+1/2 of 7.5 about 4 days back.Other medicines remain the same I.e. amitryn 310, quitipin 150 sr in the night and duolextine 60 and betacap tr 20.
Still wake you every two hours but the quality if sleep I think is better and not much change in terms of anxiety. What would your advise be?
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Follow up: Dr. Seikhoo Bishnoi 0 minute later
Good afternoon doctor - on your advise, reduced mirtaz to 22.5 from 22.5+1/2 of 7.5 about 4 days back.Other medicines remain the same I.e. amitryn 310, quitipin 150 sr in the night and duolextine 60 and betacap tr 20.
Still wake you every two hours but the quality if sleep I think is better and not much change in terms of anxiety. What would your advise be?
doctor
Answered by Dr. Seikhoo Bishnoi 22 hours later
Brief Answer:
The dose should be reduced to 15 mg

Detailed Answer:
Hello again

The dose should be reduced further to 15 mg. This will make sleep better. Improved sleep will make anxiety better. This will take time but you will definitely see improvement.

No need to get worried. You can use Betacap on sos basis for exacerbation of anxiety.

Thanks
Above answer was peer-reviewed by : Dr. Nagamani Ng
doctor
doctor
Answered by Dr. Seikhoo Bishnoi 0 minute later
Brief Answer:
The dose should be reduced to 15 mg

Detailed Answer:
Hello again

The dose should be reduced further to 15 mg. This will make sleep better. Improved sleep will make anxiety better. This will take time but you will definitely see improvement.

No need to get worried. You can use Betacap on sos basis for exacerbation of anxiety.

Thanks
Above answer was peer-reviewed by : Dr. Nagamani Ng
doctor
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Follow up: Dr. Seikhoo Bishnoi 29 hours later
Thank you doctor - on your advise, I have reduced amitryn to 15+1/2 of 7.5 from 22.5 mg since Saturday night and I feel better with anxiety. Though I still wake up every 2-3 hours in the night, I can feel that my anxiety is better. If it was 90% better earlier, may be now 95% but full bindaas attitude is still slightly missing. I have not understood how reduction in mirtaz is helping? is it that there is drug interference between amitryn and mirtaz and may be that's the reason of mirtaz reduction helping me? Out of the medicines I am taking (i.e. amitryn 310, quitipin 100 sr, mirtaz 15+1/2 of 7.5 in the night and duolextine 60, betacao tr 20 in the morning) wondering if there is drug interference among other medicines too that I am taking, and if that be the case, it may be a good idea if I gradually reduce/stop other medicines too and give a chance to one or may be two salts to show their full effect. Pls advise
And am sorry if I have been asking too many questions. It is just that I have developed some kind of comfort and trust with you, therefore, I take such liberties with you. Hope you don't mind.
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Follow up: Dr. Seikhoo Bishnoi 0 minute later
Thank you doctor - on your advise, I have reduced amitryn to 15+1/2 of 7.5 from 22.5 mg since Saturday night and I feel better with anxiety. Though I still wake up every 2-3 hours in the night, I can feel that my anxiety is better. If it was 90% better earlier, may be now 95% but full bindaas attitude is still slightly missing. I have not understood how reduction in mirtaz is helping? is it that there is drug interference between amitryn and mirtaz and may be that's the reason of mirtaz reduction helping me? Out of the medicines I am taking (i.e. amitryn 310, quitipin 100 sr, mirtaz 15+1/2 of 7.5 in the night and duolextine 60, betacao tr 20 in the morning) wondering if there is drug interference among other medicines too that I am taking, and if that be the case, it may be a good idea if I gradually reduce/stop other medicines too and give a chance to one or may be two salts to show their full effect. Pls advise
And am sorry if I have been asking too many questions. It is just that I have developed some kind of comfort and trust with you, therefore, I take such liberties with you. Hope you don't mind.
doctor
Answered by Dr. Seikhoo Bishnoi 4 hours later
Brief Answer:
With time you will see better response.

Detailed Answer:
Hello again

Please don’t feel bad about asking questions or clearing the doubts. You can ask me anything that helps in reducing the anxiety.

Reducing the Mirtazapine is indirectly improving sleep quality and this is helping in relatively better sleep. This is the reason you are seeing reduction in anxiety.

You are still on three different antidepressants in high doses. In near future we will try to reduce the dose of Amitriptyline or Duloxetine. We can start with Duloxetine and will try to bring this under 20 after around 4 weeks. The dose of Mirtazapine will be brought to 15 mg and then we will start with Duloxetine.

Try not to quantify the anxiety and treatment response. You are doing good and will continue to do good with medicines. Just don’t get distressed. Ignore any minor changes totally.

Thanks
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
doctor
Answered by Dr. Seikhoo Bishnoi 0 minute later
Brief Answer:
With time you will see better response.

Detailed Answer:
Hello again

Please don’t feel bad about asking questions or clearing the doubts. You can ask me anything that helps in reducing the anxiety.

Reducing the Mirtazapine is indirectly improving sleep quality and this is helping in relatively better sleep. This is the reason you are seeing reduction in anxiety.

You are still on three different antidepressants in high doses. In near future we will try to reduce the dose of Amitriptyline or Duloxetine. We can start with Duloxetine and will try to bring this under 20 after around 4 weeks. The dose of Mirtazapine will be brought to 15 mg and then we will start with Duloxetine.

Try not to quantify the anxiety and treatment response. You are doing good and will continue to do good with medicines. Just don’t get distressed. Ignore any minor changes totally.

Thanks
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Seikhoo Bishnoi 31 minutes later
When should I bring mirtaz to 15 from 15+ 1/2 of 7.5? I reduced it to 15+1/2 of 7.5 from 22.5 on Saturday night.
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Follow up: Dr. Seikhoo Bishnoi 0 minute later
When should I bring mirtaz to 15 from 15+ 1/2 of 7.5? I reduced it to 15+1/2 of 7.5 from 22.5 on Saturday night.
doctor
Answered by Dr. Seikhoo Bishnoi 1 minute later
Brief Answer:
You can make the dose to 15 from tomorrow

Detailed Answer:
Hello again

You can make Mirtazapine to 15 mg from tomorrow.

Thanks
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
doctor
Answered by Dr. Seikhoo Bishnoi 0 minute later
Brief Answer:
You can make the dose to 15 from tomorrow

Detailed Answer:
Hello again

You can make Mirtazapine to 15 mg from tomorrow.

Thanks
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Seikhoo Bishnoi 48 hours later
Still on 15+1/2 of 7.5 mirtaz. Hope making it 15 does not make it worse. How about 15+1/4 of 7.5?
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Follow up: Dr. Seikhoo Bishnoi 0 minute later
Still on 15+1/2 of 7.5 mirtaz. Hope making it 15 does not make it worse. How about 15+1/4 of 7.5?
doctor
Answered by Dr. Seikhoo Bishnoi 2 minutes later
Brief Answer:
Make the dose to 15 mg.

Detailed Answer:
Hello again

Please reduce to 15 mg, no need to get worried. This will not cause any worsening of symptoms and will improve your anxiety.

Thanks
Above answer was peer-reviewed by : Dr. Prasad
doctor
doctor
Answered by Dr. Seikhoo Bishnoi 0 minute later
Brief Answer:
Make the dose to 15 mg.

Detailed Answer:
Hello again

Please reduce to 15 mg, no need to get worried. This will not cause any worsening of symptoms and will improve your anxiety.

Thanks
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Seikhoo Bishnoi 7 days later
Good morning doctor,
on your advise i made mirtaz 15 from 15+1/7.5 on 8th feburary i.e. last Friday. I must say it has helped me. Initial 2-3 days, i was getting weird dreams and now it has settled. I am almost 90% of my bindaas self. Was wanting to take your advise, if any further tweaking with mirtaz or any other pill will help me with 100% bindaas self of mine. Still wake up in the night 2-3 times but its manageable. My other medicines are : amitryn 310, quitipin 150 sr in the night and duolextine 60, betacap tr 20 in the morning. I am on leave from tomorrow till 19th feb. Was thinking if any other tweaking with the medicines will help me further, and if that be the case, i can try that during my leave.
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Follow up: Dr. Seikhoo Bishnoi 0 minute later
Good morning doctor,
on your advise i made mirtaz 15 from 15+1/7.5 on 8th feburary i.e. last Friday. I must say it has helped me. Initial 2-3 days, i was getting weird dreams and now it has settled. I am almost 90% of my bindaas self. Was wanting to take your advise, if any further tweaking with mirtaz or any other pill will help me with 100% bindaas self of mine. Still wake up in the night 2-3 times but its manageable. My other medicines are : amitryn 310, quitipin 150 sr in the night and duolextine 60, betacap tr 20 in the morning. I am on leave from tomorrow till 19th feb. Was thinking if any other tweaking with the medicines will help me further, and if that be the case, i can try that during my leave.
doctor
Answered by Dr. Seikhoo Bishnoi 9 hours later
Brief Answer:
The dose of Duloxetine can be reduced

Detailed Answer:
Hello again

Good that you are feeling better. I don't think there is need to reduce the dose of Mirtazapine, but we can now focus on Duloxetine. The dose of Duloxetine can be reduced to 50 mg (30+20 gastroresistant tabs or capsules), such slow dose reduction would not cause any withdrawal symptoms. In coming days we can think of making its dose to 30 or less. This will reduce the drug load and you will feel better.

Thanks.

So you can make Duloxetine to 50 from tomorrow morning.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Seikhoo Bishnoi 0 minute later
Brief Answer:
The dose of Duloxetine can be reduced

Detailed Answer:
Hello again

Good that you are feeling better. I don't think there is need to reduce the dose of Mirtazapine, but we can now focus on Duloxetine. The dose of Duloxetine can be reduced to 50 mg (30+20 gastroresistant tabs or capsules), such slow dose reduction would not cause any withdrawal symptoms. In coming days we can think of making its dose to 30 or less. This will reduce the drug load and you will feel better.

Thanks.

So you can make Duloxetine to 50 from tomorrow morning.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Seikhoo Bishnoi 4 hours later
Thank you doctor. Little scared if any other tweaking may or may not suit. Also, instead of duolextine, is there a merit in bringing amitryn down to 300? After reading on the Internet, wondering if amitryn beyond 300 offers any help! Just thought of clarifying with you.
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Follow up: Dr. Seikhoo Bishnoi 0 minute later
Thank you doctor. Little scared if any other tweaking may or may not suit. Also, instead of duolextine, is there a merit in bringing amitryn down to 300? After reading on the Internet, wondering if amitryn beyond 300 offers any help! Just thought of clarifying with you.
doctor
Answered by Dr. Seikhoo Bishnoi 11 hours later
Brief Answer:
Right now we should focus on Duloxetine.

Detailed Answer:
Hello again

I was thinking about reducing Amitriptyline too but I didn't ask you to reduce its dose because you are more comfortable with this drug. Reducing Duloxetine will not cause any adverse events and you can reduce its doses without worries. Once you are settle on 30 mg dose then we will reduce the dose to 300 mg of Amitriptyline. This will make smooth dose reduction.

Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Seikhoo Bishnoi 0 minute later
Brief Answer:
Right now we should focus on Duloxetine.

Detailed Answer:
Hello again

I was thinking about reducing Amitriptyline too but I didn't ask you to reduce its dose because you are more comfortable with this drug. Reducing Duloxetine will not cause any adverse events and you can reduce its doses without worries. Once you are settle on 30 mg dose then we will reduce the dose to 300 mg of Amitriptyline. This will make smooth dose reduction.

Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Seikhoo Bishnoi 48 hours later
Dear doctor - i reduced duolextine from 60 to 50 on 15th feburary (last friday) keeping other medicines same ( amitryn 310, quitipin 150 sr, mirtaz 15 in the night and betacap tr20 along with duolextine 50 in the morning). I must tell you that i can clearly see the difference. Also, how long it should be before i reduce it further?
Wondering how reduction in medicines is helping me, first mirtaz from 37.5 to 15 and now duolextine from 60 to 50 whereas the general understanding is that higher the dose, better the effect!
Regards
Rajesh
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Follow up: Dr. Seikhoo Bishnoi 0 minute later
Dear doctor - i reduced duolextine from 60 to 50 on 15th feburary (last friday) keeping other medicines same ( amitryn 310, quitipin 150 sr, mirtaz 15 in the night and betacap tr20 along with duolextine 50 in the morning). I must tell you that i can clearly see the difference. Also, how long it should be before i reduce it further?
Wondering how reduction in medicines is helping me, first mirtaz from 37.5 to 15 and now duolextine from 60 to 50 whereas the general understanding is that higher the dose, better the effect!
Regards
Rajesh
doctor
Answered by Dr. Seikhoo Bishnoi 3 hours later
Brief Answer:
Reduce the dose to 40 after a couple of days.

Detailed Answer:
Hello again

Most likely reducing the doses are resulting in reduction of drugs load and thus this is helping you. After a couple of days reduce the dose to 40 and then again after a week to 30. Stay on this dose then we will reduce the dose of Amitriptyline.

Most of SSRI and SNRI drugs have ceiling and based upon pharmacokinetics the efficacy doesn't increase beyond the ceiling but risk of side effects increases.

Though you are not on very high dose of Duloxetine but reducing dose will reduce the side effects because of a number of drugs you're taking.

Thanks.
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
doctor
Answered by Dr. Seikhoo Bishnoi 0 minute later
Brief Answer:
Reduce the dose to 40 after a couple of days.

Detailed Answer:
Hello again

Most likely reducing the doses are resulting in reduction of drugs load and thus this is helping you. After a couple of days reduce the dose to 40 and then again after a week to 30. Stay on this dose then we will reduce the dose of Amitriptyline.

Most of SSRI and SNRI drugs have ceiling and based upon pharmacokinetics the efficacy doesn't increase beyond the ceiling but risk of side effects increases.

Though you are not on very high dose of Duloxetine but reducing dose will reduce the side effects because of a number of drugs you're taking.

Thanks.
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Seikhoo Bishnoi 23 hours later
Thank you doctor. It’s been 4 days since I made duolextine 50 ( started last Friday). When do you think I make it 40 precisely?
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Follow up: Dr. Seikhoo Bishnoi 0 minute later
Thank you doctor. It’s been 4 days since I made duolextine 50 ( started last Friday). When do you think I make it 40 precisely?
doctor
Answered by Dr. Seikhoo Bishnoi 47 minutes later
Brief Answer:
From tomorrow morning you should take 40 mg.

Detailed Answer:
Hello again

From tomorrow morning you should take 40 mg. Try not to think that reducing dose will result in any issues.

Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Seikhoo Bishnoi 0 minute later
Brief Answer:
From tomorrow morning you should take 40 mg.

Detailed Answer:
Hello again

From tomorrow morning you should take 40 mg. Try not to think that reducing dose will result in any issues.

Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Seikhoo Bishnoi 2 days later
Good evening doctor - I have reduced duolextine to 40 mg from 50 from tomorrow morning and feeling much much better and thank you for that. Yesterday and today i was feeling very sleepy. In fact, i took a small nap in the office today as i was finding it difficult to keep my eyes open. After the nap, i felt fresh though. Is it because of reducing duolextine to 40? My other medicines are : quitipin 150 sr, amitryn 310, mirtaz 15 in the night and duolextine 40 and betacap tr 20
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Follow up: Dr. Seikhoo Bishnoi 0 minute later
Good evening doctor - I have reduced duolextine to 40 mg from 50 from tomorrow morning and feeling much much better and thank you for that. Yesterday and today i was feeling very sleepy. In fact, i took a small nap in the office today as i was finding it difficult to keep my eyes open. After the nap, i felt fresh though. Is it because of reducing duolextine to 40? My other medicines are : quitipin 150 sr, amitryn 310, mirtaz 15 in the night and duolextine 40 and betacap tr 20
doctor
Answered by Dr. Seikhoo Bishnoi 8 hours later
Brief Answer:
This was not due to reduction of dose of Duloxetine.

Detailed Answer:
Hello again

No this was not due to reduction of dose of Duloxetine. The sleepiness probably occurred because you were feeling somewhat better and the anxiety was relatively less.

Remain relaxed, in coming days we will reduce the dose of Duloxetine to 30.

Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Seikhoo Bishnoi 0 minute later
Brief Answer:
This was not due to reduction of dose of Duloxetine.

Detailed Answer:
Hello again

No this was not due to reduction of dose of Duloxetine. The sleepiness probably occurred because you were feeling somewhat better and the anxiety was relatively less.

Remain relaxed, in coming days we will reduce the dose of Duloxetine to 30.

Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Seikhoo Bishnoi 39 hours later
Good evening doctor - I reduced duolextine to 40 from 50 on Tuesday (19th Feb) and I am almost there in terms of my natural self and I think reducing 40 to 30 should do the trick? When should I make it 30? Pls advise
I will be grateful to you for the rest of my life as if it was not for you, I would have never reached this winning combination of my medicines! Thank you so so very much
My other medicines are : mirtaz 15, amitryn 310, quitipin 150 sr in the night
Duolextine 40 and betacap tr 20 in the morning
Also wanted to have your advise regarding betacap, should I continue taking it?
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Follow up: Dr. Seikhoo Bishnoi 0 minute later
Good evening doctor - I reduced duolextine to 40 from 50 on Tuesday (19th Feb) and I am almost there in terms of my natural self and I think reducing 40 to 30 should do the trick? When should I make it 30? Pls advise
I will be grateful to you for the rest of my life as if it was not for you, I would have never reached this winning combination of my medicines! Thank you so so very much
My other medicines are : mirtaz 15, amitryn 310, quitipin 150 sr in the night
Duolextine 40 and betacap tr 20 in the morning
Also wanted to have your advise regarding betacap, should I continue taking it?
doctor
Answered by Dr. Seikhoo Bishnoi 12 hours later
Brief Answer:
After 3 days reduce the dose to 30

Detailed Answer:
Hello again

Please reduce the dose to 30 mg after 3 more days. We will keep you on this dose for some more days and I am planning to focus on Amitriptyline after that.

Try to remain relaxed, avoid anticipating anything. You are healthy and nothing wrong is happening.

For some time continue to take Betacap as advised.

Thanks
Above answer was peer-reviewed by : Dr. Nagamani Ng
doctor
doctor
Answered by Dr. Seikhoo Bishnoi 0 minute later
Brief Answer:
After 3 days reduce the dose to 30

Detailed Answer:
Hello again

Please reduce the dose to 30 mg after 3 more days. We will keep you on this dose for some more days and I am planning to focus on Amitriptyline after that.

Try to remain relaxed, avoid anticipating anything. You are healthy and nothing wrong is happening.

For some time continue to take Betacap as advised.

Thanks
Above answer was peer-reviewed by : Dr. Nagamani Ng
doctor
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Follow up: Dr. Seikhoo Bishnoi 4 hours later
Was feeling better and thinking that if I can make duolextine 30 from tomorrow because of the weekend.
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Follow up: Dr. Seikhoo Bishnoi 0 minute later
Was feeling better and thinking that if I can make duolextine 30 from tomorrow because of the weekend.
doctor
Answered by Dr. Seikhoo Bishnoi 6 hours later
Brief Answer:
Yes you can make

Detailed Answer:
Hello again

Yes you can make, no need to get worried.

Thanks
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Seikhoo Bishnoi 0 minute later
Brief Answer:
Yes you can make

Detailed Answer:
Hello again

Yes you can make, no need to get worried.

Thanks
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Seikhoo Bishnoi 48 hours later
Thank you doctor. Made duolextine 30 from yesterday morning and feeling much better. Wanted to check with you if reducing it further to 20 will work better instead of reducing amitryn. I feel reducing duolextine to 20 might work better. Pls advise.
My current medication is :
Amitryn 310, quitipin 150 sr and mirtaz 15 in the night
Duolextine 30 and betacap tr 20 in the morning
I need to consult you for some of the issues that have bothering me of late. Can’t put them here as they are a bit confidential in nature. Will book
an appointment with you at icliniq. Thank you
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Follow up: Dr. Seikhoo Bishnoi 0 minute later
Thank you doctor. Made duolextine 30 from yesterday morning and feeling much better. Wanted to check with you if reducing it further to 20 will work better instead of reducing amitryn. I feel reducing duolextine to 20 might work better. Pls advise.
My current medication is :
Amitryn 310, quitipin 150 sr and mirtaz 15 in the night
Duolextine 30 and betacap tr 20 in the morning
I need to consult you for some of the issues that have bothering me of late. Can’t put them here as they are a bit confidential in nature. Will book
an appointment with you at icliniq. Thank you
doctor
Answered by Dr. Seikhoo Bishnoi 7 minutes later
Brief Answer:
First we will reduce Amitriptyline to 300.

Detailed Answer:
Hello again

No, please remain on 30 mg dose for some more days. We will try to reduce the dose of Amitriptyline to 300 mg and once you are stable on 300 mg then we will again reduce the dose of Duloxetine. Duloxetine can even be stopped completely but before that its better to bring Amitriptyline dose in therapeutic range. Reducing the dose of Amitriptyline will not cause much issues.

Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Seikhoo Bishnoi 0 minute later
Brief Answer:
First we will reduce Amitriptyline to 300.

Detailed Answer:
Hello again

No, please remain on 30 mg dose for some more days. We will try to reduce the dose of Amitriptyline to 300 mg and once you are stable on 300 mg then we will again reduce the dose of Duloxetine. Duloxetine can even be stopped completely but before that its better to bring Amitriptyline dose in therapeutic range. Reducing the dose of Amitriptyline will not cause much issues.

Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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