Effexor and miscarriage risk; at odds with pdoc

Hi guys. Some of you have may seen my previous threads about trying to get off my meds so I can get pregnant; I've also talked a bit about it in chat. An issue has come up in this process for me and I was hoping to get some thoughts about it.

When my husband and I first seriously started talking about getting pregnant a few years back, I was on Lamictal, Effexor, Wellbutrin, Abilify, and Klonopin (as needed). This was the cocktail I had left the hospital on in 2010 and as I was relatively stable on it my pdoc (actually a nurse practitioner) was loathe to touch it. She did not think I would handle being off all of my meds well and repeatedly suggested that my husband and I look into adoption.

From my own research I knew that plenty of women take antidepressants while they are pregnant; it is just a matter of knowing the risks as well as knowing which meds to take and in what trimesters. My NP, however, was very cautious and strongly favored the no-meds-at-all approach to pregnancy. I don't think this was based on any of her previous patients' experiences; in fact, I get the impression she doesn't have much experience with pregnant patients, period. She would often crack open her Physician's Desk Reference when I had a question about a med's classification.

She didn't think I would do well on no meds, however. But I was insistent that I wanted to at least try and have a baby. We started slowly weaning me off my meds and it did not go well.

As a result I ended up in a partial hospitalization program. I could not stand the group therapist I was assigned to there but when I discussed my meds with the NP there she said that 1. I was on way too many and should get off some (I was so happy about that) and that 2. Some meds are ok with pregnancy and she had treated plenty of pregnant women on meds.

After the PHP I went back to my regular NP, now just on the Lamictal and Effexor. My regular NP was skeptical of the changes the PHP NP had made. Also, when I told her about the PHP NP's view of being on meds while pregnant, she said something to the effect of, "Well, I don't know why she thinks that's ok, but I am basing my opinion on the most recent literature."

It was getting clearer to me that my NP and I just had different philosophies on psych meds and pregnancies. I tried to get an appointment with a pdoc who specializes with pregnant women but he wasn't taking new patients. So instead I talked to my OB/GYN for a sort of second opinion.

He said 1. Lamictal is only dangerous during the first trimester because of increased cleft lip/palate risk and 2. Effexor is only dangerous during the last trimester because of pulmonary hypertension risk. I took this info back to my NP and said I wanted off the Lamictal; we did a slow two-month taper off. I figured at that point I might as well try to get off the Effexor as well.

Last week was my last dose of Effexor. The next day all hell broke loose and I felt more anxious and depressed than I had in years. The range and types of emotions I was feeling were those that I had not felt since my last hospitalization.

So my husband suggested I go back on the Effexor until I get pregnant and am in my last trimester as according to my OB/GYN that is when it is dangerous. I thought this was a good idea until---and here is my main issue---I found a study online that links Effexor to increased risk of miscarriage.

Here's the link if anyone is actually interested:

Use of antidepressants during pregnancy and the risk of spontaneous abortion

Basically the article says that being on Effexor doubles the risk of miscarriage and the higher dose you are on, the higher the risk is. I have a background in statistics/econometrics and as far as I can tell the study/methods are sound.

So now I just don't know what to do. I'm not sure I can realistically go on feeling like this for nine months or longer. At the same time, I don't want to double my risk of miscarriage by going back on the Effexor. Complicating the issue is the fact that I feel constantly at odds with my NP because she believes no drugs are safe during pregnancy and I feel like it is a balancing of risks. I also do not feel like she has confidence in my ability to get through a pregnancy on no/limited drugs and she also keeps "reminding" me how hard it is to raise a child.

Wow, this is really long; I apologize. Thanks for reading.

A med like an SSRI will probably get rid of a lot of those Effexor withdrawal symptoms. I don't know if you can take an SSRI. Sometimes they will give you Prozac for a month and then stop it.

Another option is to go back on the last dose of Effexor that you were taking and then drop it by 10% every month or so. (That can become difficult to get the correct dose when they get really tiny.)

I have taken Effexor twice and I did a Cymbalta taper last year from 120 mg/day to 60 mg/day. It took 5 months and I still had lots of anxiety.

It's a shame that the pdoc who sees lots of pregnant patients isn't taking new ones. Maybe there's a waiting list? Maybe they would recommend someone else to you?

There is a lot of info online about people tapering off Effexor and how they did it if you want to look into it.

You can also probably switch to Cymbalta or Pristiq or Fetzima (all SNRIs) at a low dose to get completely away from the Effexor if you want to do that. I think they are easier to taper because they don't act so strongly on serotonin receptors.

When I was taking Effexor, I switched straight from Effexor to Cymbalta and couldn't really even feel any side effects.

So jo, do you think (obviously you can't know) that this is more of a withdrawal issue and less of a "krminnj can't survive without Effexor ever" issue?

I feel like if I knew it was more of a withdrawal thing I could focus on alternatives and coping skills more instead of freaking out about the whole thing.

If you just stopped Effexor and you were taking some whole-pill sized dose and you didn't go to another SNRI or to an SSRI, then you are almost certainly in withdrawal.

I don't know what dose of Effexor you were taking before you started tapering or what the last dose was before you stopped.

But yes, if you just stopped the Effexor, it sounds more likely that it's withdrawal.

This is a change of topic, but do you know what antidepressants are safe to take during pregnancy? I think Prozac and Zoloft are? I don't know about others like Wellbutrin or older ones, like the tricyclics.

I was at 225 mg of Effexor and the NP told me to do 50 percent for three days; 50 percent of that for three days. Because of the size capsules I had I did 150 for three days and then 75 for three days. Then nothing.

I know Wellbutrin is supposed to be a good one for pregnancy but the NP at the PHP took me off of it. She said she was surprised anyone had prescribed that for me because of my problems with anxiety/panic, which I guess it can make worse.

I'm honestly confused about the risks of SSRIs/SNRIs. My OB/GYN said they were all pretty much the same in terms of pregnancy risk except for Paxil, which is supposed to be somewhat worse. But then I found this study that says Effexor is worst in terms of miscarriage risk.

I read that tricyclics are ok for pregnancy and I've actually thought about asking to be put on one--back when I was first diagnosed as a kid I took Imiprimine and I tolerated it well.

I was disappointed about the specialist not being available :-( They didn't have a waiting list or anything (in fact it took me almost a month to get a person and not a recording as they ignored my messages). I have thought about trying to find just another pdoc (there isn't another "pregnancy pdoc" in the area) but it just seems like such a gamble.

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Holy cow, that's not much of a taper! That's not a low Effexor dose, either. I was taking 375 mg/day, but that was because it takes that much for it to help fibromyalgia pain. I went straight from that to 60 mg/day Cymbalta and didn't really notice the difference. (Which doesn't exactly make sense to me, but that's what happened.)

Some people (a few) don't react so severely to Effexor withdrawal. How have you been feeling the last few days? You can PM me if you want. Or ignore all my questions.

Have you ever gone off Effexor before, like run out of it for 2-3 days? I have. By the 3rd day I would be crying and shaking, my vision and balance would be affected to the point where I couldn't drive and I would be so agitated that I felt like I was going to crawl out of my skin.

I did once miss about 3 days of my Effexor last year because of a NP's office/pharmacy snafu. I was a basket case. Physical and emotional symptoms all over the place.

Hmmm, I think you are right about withdrawal being a problem here.

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Could you try something else to substitute for the Effexor? There's a lot of studies out there showing wellbutrin appears to be safe in pregnancy and latuda, which is actually a second gen antipsychotic is being used a lot for major depression because it's actually a pregnancy class B.
Just something to think about.

Hi pinkflower! Thanks for the suggestions.

The nurse practitioner at the partial hospitalization program I was at back in October took me off Wellbutrin because she said it was bad for my anxiety/panic.

I was actually on Latuda briefly. My regular NP wanted to replace the Abilify I was on at the time with it because, as you said, it is Class B. It was one of the few meds she thought was okay to take during pregnancy. It didn't help me much and that is when I ended up in the PHP. The NP there, interestingly enough, said she would never prescribe it for pregnancy because even though it is Class B, it is so new she didn't believe it had stood the test of time as far as being safe for pregnant women. I wish I could get consistent answers from healthcare providers about these things--but I guess it's just one of those issues where there aren't clear answers.

I see my NP this morning. I am going to ask her to prescribe me some Prozac to help with the Effexor withdrawal. I am scared she is going to say that my reaction to coming off the Effexor shows that I am not ready for pregnancy or a baby. Sometimes because of my self-doubt I believe her. I need to stay strong and assertive and let her know what I need from her.

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Good luck.
The Prozac should help with the withdrawals. There's a lot of conflicting data, but most of the studies show the typical SSRIs (with the exception of paxil) are fairly safe. Sorry the Latuda didn't do anything. That sucks. There actually is a fair amount of data on it in pregnancy bc it is class B, even though it is new. It does appear to be safe.
I think you have to really weigh the risks of being mentally unstable vs. the risks of meds bc both have significant risks to the unborn child. It's kind of a what's worse scenario.
There's a lot less studies regarding the second gen antipsychotics. One Swedish birth registry study showed a small increase in cardiac malformations with use of any second gen antipsychotic, not one in particular, but that studies been the main one so far. There's also been some empirical data showing an increased risk of neonatal withdrawal syndrome and extrapyramidal symptoms initially after birth, but all eventually did fine and it was a very small percentage effected.
Good luck. I'm excited about your impending pregnancy. I hope it goes well. Just an idea regarding your NP, a good maternal fetal medicine doc will probably be just as educated regarding this issue as a psychiatrist, if you can't get into a psych with experience with pregnant patients...

You think she's not going to believe that you're having withdrawal symptoms? There are whole web sites for people tapering off Effexor and Cymbalta, and in most cases they're talking about how many MONTHS it took them to get off. They're pleased that they've gotten off it successfully in say, ten months. If you decide you want to do a taper like that, you'll need the extended release capsules with the beads in them.

So she did give me a prescription for Prozac. Yay, mission accomplished!

Yeah, I was worried she wouldn't believe it was withdrawal. Honestly, when I told her about the stuff I had found out about Effexor withdrawal and using an SSRI to help come off of it, she did say it had a short half-life, but I didn't get the impression she was knowledgable about how widespread a problem it was.

She said I should get off the Prozac before I get pregnant. I know there are risks, but honestly based on my own research and what my OB/GYN said I feel like it would be relatively safe at least until the third trimester.

I don't really have a lot of confidence in her anymore based on the experiences I've had with her over the past year or so, but I am worried about switching providers at such a crucial time. Perhaps that's a topic for another thread.

Anyway, thanks guys for the awesome help.

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I hope the Prozac makes you feel better and stops the withdrawal.

I got pregnant while taking Prozac. Stopped it cold turkey with no problems. I went back on in my fifth month and took it right thru to delivery and beyond. My daughter was healthy. She is now 18. Good luck

I was on Paxil when I got pregnant with my 8 year old- I stayed on it until my 4th month of pregnancy- I did a quick taper with no issues - seriously I sometimes think pregnancy protects your emotional brain lol - krminnj one of the ways you can usually tell the difference between withdrawals and rebound is the patterns- with withdrawal you will have overwhelming waves of negative emotions followed by feeling relatively normal - and they( the overwhelming emotions) happen quickly 20 min or so - I am still on Paxil 8 years later and really want to get off and have been thinking of using Prozac to do so- please please keep us posted! Would love to know if this works for you!!

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Thanks so much for sharing your experiences, guys, I really appreciate it!

Right now I'm down to just 20 mg Prozac. I've been having a pretty rough time with it but honestly I've been worse before. I'm going to stay on it a bit longer and see how it goes.

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