taking, titrating, and tapering Paxil (paroxetine)

> How to Take Paxil



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Taking & Titration Overview

One of the most important aspects of any medication is how to go about taking it. This includes:

  • how much to take (the dosage or dose)
  • when and how often to take it (dosing schedule or doses)
  • how much to start with and how to increase the dose/dosage until you’re taking the target amount (titration or titration schedule).

Although we often disagree with them, we’ll always give you the manufacturer’s recommendations from Paxil’s full US Prescribing Information. If, for some reason, that isn’t available, we’ll use information for patients leaflets, SPCs from overseas, or whatever official sources we can find. Most doctors will give you some idea of what it will be like, and this is what every pharmacist is trained and paid to tell you.1 As “often” doesn’t mean “always”, whatever is in the PI sheet works for us a lot of the time.

We usually advocate starting at a lower dosage than recommended. One of our core philosophies is increasing the dosages as slowly as one’s condition allows, and staying at the dosage that works instead of a target dosage2. More and more doctors are agreeing with us3. You and your doctor can always discuss increasing the dosage when you need to in advance.

And since you never really know how a drug might affect you, it’s best to start when you have some time off of work. Like Friday night / Saturday morning, or your equivalent. Better still would be to get someone to stay with you or at least check on you frequently, especially if you’re the primary caretaker of young children and similar critters.4

Paxil (paroxetine) Dosage and Doses

One tablet, of whatever your current dosage is, once a day, at the same time every day.

Special Instructions/Best Way to Take Paxil (paroxetine)

  • Never, ever split, chew, or crush Paxil CR, or the controlled/extended release version of any med. Just swallow it whole the way God and GSK intended.
  • GSK recommends taking Paxil in the morning. Unless SSRIs usually keep you awake, we suggest you should first try taking Paxil at night.
  • I cannot stress how important it is to take Paxil at the same time every day. Because of its short half-life and non-linear pharmacokinetics5 it’s easy to understand, or at least wrap your head around the concept of why some people can get SSRI discontinuation syndrome if they are a few hours late taking their dose.
    • With Pexeva and other branded generics that are paroxetine mesylate, you have some wiggle room. You can’t miss a day, like you can with Prozac or Abilify, but like Lexapro if you’re a few hours late you probably won’t notice anything.

Paxil (paroxetine) Titration (Dosage Increase)

First and foremost: if you don’t get any positive benefit from Paxil at 20mg a day and/or after six weeks, give up6. As this study shows it’s usually pointless. That could be the case for SSRIs in general. Paxil’s oddball pharmacokinetics are probably responsible, so there’s not much you can do about it.

Immediate Release

  • Major Depressive Disorder: The recommended initial dose is 20 mg/day. As with all drugs effective in the treatment of major depressive disorder, the full affect may be delayed. Some patients not responding to a 20-mg dose may benefit from dose increases, in 10-mg/day increments, up to a maximum of 50 mg/day. Dose changes should occur at intervals of at least 1 week.
    • Systematic evaluation of the efficacy of PAXIL has shown that efficacy is maintained for periods of up to 1 year with doses that averaged about 30 mg.
  • Obsessive Compulsive Disorder: The recommended dose of PAXIL in the treatment of OCD is 40 mg daily. Patients should be started on 20 mg/day and the dose can be increased in 10-mg/day increments. Dose changes should occur at intervals of at least 1 week. Patients were dosed in a range of 20 to 60 mg/day in the clinical trials demonstrating the effectiveness of PAXIL in the treatment of OCD. The maximum dosage should not exceed 60 mg/day.
  • Panic Disorder: The target dose of PAXIL in the treatment of panic disorder is 40 mg/day. Patients should be started on 10 mg/day. Dose changes should occur in 10-mg/day increments and at intervals of at least 1 week. The maximum dosage should not exceed 60 mg/day.
  • Social Anxiety Disorder: The recommended and initial dosage is 20 mg/day. While the safety of PAXIL has been evaluated in patients with social anxiety disorder at doses up to 60 mg/day, available information does not suggest any additional benefit for doses above 20 mg/day.
  • Generalized Anxiety Disorder: Usual Initial Dosage: The recommended starting dosage and the established effective dosage is 20 mg/day. There is not sufficient evidence to suggest a greater benefit to doses higher than 20 mg/day.
  • Posttraumatic Stress Disorder: Usual Initial Dosage: The recommended starting dosage and the established effective dosage is 20 mg/day.

--Paxil immediate-release PI sheet

We at Crazymeds suggest starting the immediate release at 5–10mg at day for everything, and increasing by 5–10mg a day per week only if you need to.

Controlled Release (Paxil CR)

  • Major Depressive Disorder: The recommended initial dose is 25 mg/day. Some patients not responding to a 25-mg dose may benefit from dose increases, in 12.5-mg/day increments, up to a maximum of 62.5 mg/day. Dose changes should occur at intervals of at least 1 week.
  • Panic Disorder: Patients should be started on 12.5 mg/day. Dose changes should occur in 12.5-mg/day increments and at intervals of at least 1 week. The maximum dosage should not exceed 75 mg/day.
  • Social Anxiety Disorder: Usual Initial Dosage: The recommended initial dose is 12.5 mg/day. If the dose is increased, this should occur at intervals of at least 1 week, in increments of 12.5 mg/day, up to a maximum of 37.5 mg/day.
  • Premenstrual Dysphoric Disorder: The recommended initial dose is 12.5 mg/day. In clinical trials, both 12.5 mg/day and 25 mg/day were shown to be effective. Dose changes should occur at intervals of at least 1 week

--Paxil controlled-release (Paxil CR) PI sheet

With Paxil CR your only go-slow option is starting at 12.5mg a day and increasing by that amount. That’s our suggestion.

 

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One thing PI sheets and doctors infrequently discuss, and don’t go into enough detail about, is how to discontinue a medication. With some meds it’s not too bad, but with others (most notably SNRIs like Effexor and Cymbalta) it can be a nightmare if not done carefully.

How to Stop Taking Paxil (paroxetine)

Very, very slowly and very, very carefully. 5–10mg a day per week for the immediate release form and 12.5mg a day per week for the controlled release (Paxil CR) form.

Discontinuation Symptoms

Notes, Tips, Helpful Hints, etc. for Withdrawing Paxil (paroxetine)

Unlike the immediate-release form, the R&D people at GSK don’t have an average effective dosage of Paxil CR used to treat MDD. At least they have a guess and published it in the PI sheet:

Systematic evaluation of the efficacy of immediate-release paroxetine hydrochloride has shown that efficacy is maintained for periods of up to 1 year with doses that averaged about 30 mg, which corresponds to a 37.5-mg dose of PAXIL CR, based on relative bioavailability considerations.--Paxil controlled-release (Paxil CR) PI sheet



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References

  1. Paxil full US Prescribing Information
  2. Faught, Edward. “Topiramate in the treatment of partial and generalized epilepsy.” Neuropsychiatric disease and treatment 3.6 (2007): 811-821.

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How Long & How Likely To Work, Comparisons with Other Meds | Paxil Index | Pros & Cons, Interesting Stuff Your Doctor Didn’t Tell You


1 And everyone has the time to do their jobs properly, when said time isn't being wasted by idiots asking for grocery store phone numbers** or they aren't playing Angry Farmers on the Faecesbooks.

2 Although not everyone has the luxury of stopping at a dosage when the symptoms abate and not increasing it unless the return. Sometimes you just have to keep going up until you reach that target dosage. E.g. you have a history of seizures that haven't yet responded to several medications.

3 Most notably Dr. Edward Faught, founder and Director of the Epilepsy Center, and vice chairman of the Department of Neurology, at the University of Alabama School of Medicine in Birmingham. His article on new antiepileptic drugs in Volume 7 issue 1 of Peer Review in Review stressed starting at low dosages, doing a slow titration, and stopping at the dosage where symptoms were under control. In Topiramate in the treatment of partial and generalized epilepsy, the one free, full-text article I could find (that's not about geriatric patients), he again stresses the low and slow approach to avoid or lessen most side effects, while still achieving seizure control in the same amount of time.

4 Assuming you have the luxury of a job, being able to cope with your symptoms not being dealt with for however many days you need to wait in order to do this, and/or someone who can and is willing to stay with you for a few days. Read enough of this site and you can tell what sort of fantasy world I live in.

5 The controlled-release version has a shorter half-life than the immediate release. How messed up is that?

6 Unless you know for sure you're an ultra-rapid metabolizer of CYP2D6 substrates.

**DrugMonkey, Master of Pharmacy, answers the question “Why your prescription takes so damn long to fill”


If you have any questions not answered here, please see the Crazymeds Paxil discussion board. We welcome criticisms of the articles, notifications of bad links, site problems, consumer experiences with medications, etc. I’m not always able to write back. Hence I never answer questions about meds via e-mail that are answered by this or other articles. Especially if they have been repeatedly asked on the forum. That’s why we write these damn things. Questions about which meds are best for your condition should also be asked on the forum; because this is a free site, so the price of admission is making things easier for somebody else searching for the same answer. We don’t deal with children on the forum or in private because after doing this for ten years I don’t have the emotional stamina to deal with kids who have brain cooties. How to contact Crazymeds. — Jerod Poore, CME, Publisher Crazymeds (crazymeds.us)


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Paxil, and all other drug names on this page and used throughout the site, are a trademark of someone else. Paxil’s PI Sheet will probably have the name of the manufacturer and trademark owner (they’re not always the same company) at or near the very bottom. Or ask Google who the owner is. The way pharmaceutical companies buy each other and swap products like Monopoly™ real estate, the ownership of the trademark may have changed without my noticing. It may of changed hands by the time you finished reading this article.




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All rights reserved. No warranty is expressed or implied in this information. Consult one or more doctors and/or pharmacists before taking, or changing how you take any neurological and/or psychiatric medication. Your mileage may vary. What happened to us won’t necessarily happen to you. If you still have questions about a medication or condition that were not answered on any of the pages you read, please ask them on Crazy Talk: the Crazymeds Forum.
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1 While there are plenty of books to help you with hypochondria, for some reason there’s not much in the way of websites. Then again, staying off of the Internet is a large part of curing/managing the disorder.

2 Remember kids, Microsloth operating systems are like TOS Star Trek movies with in that every other one sucks way, way more. With TOS Star Trek movies you don’t want to bother watching the odd-numbered ones. With Microsloth OS you don’t want to buy and install the even-numbered ones. Anyone who remembers ME and Vista knows what I mean.

3 Have I mentioned how open source operating systems for commercial applications is one of the dumbest ideas in the history of dumb ideas?* I don’t even need my big-ass rant any more. Heartbleed has made my case for me. And that’s just the one that got all the media attention. The very nature of an open source operating system makes security as much of an illusion as anonymity on teh Intergoogles. Before you flip out too much: the domain Crazymeds is hosted on uses a version of SSL that is not affected by the Heartbleed bug. That’s one of the many reasons why I pay a lot of money and keep this site on Lunarpages.

* Yes, I know I’m using open source browsers. I also test the site using the now-defunct IE and Safari browsers. Their popularity - and superiority - killed IE and Safari, so that’s why I rely on the open source browsers. It’s like brand vs. generic meds. Sometimes the generic is better than the brand.

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