Paxil (Paroxetine)

General Information:

Paxil (paroxetine) belongs to an antidepressant drugs called selective serotonin reuptake inhibitors (SSRIs). It affects chemicals in the brain which have become unbalanced. This remdy is prescribed to cure anxiety disorders, depression, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, and premenstrual dysphoric disorder (PMDD).

Paxil may be recommended by your physician for some other purposes, which are not listed here. Ask your physician to get more detailed information concerning Paxil.

You should follow all recommendations of your physician strictly. Before stopping drug therapy with Paxil consult your physician. Do it even if you have noticed the improvements of your condition. Please be informed that stopping cure too early may result in worsening of your condition. Be careful about driving, doing dangerous tasks, climbing or operating machinery till you know how this remedy affects you. Alcohol may interact with this medication; we would recommend you not to drink alcohol during treatment. It is necessary to contact your health care provider every time you are going to give Paxil to a child.

What Paxil is and what it is used for

Paxil is a treatment for adults with depression and/or anxiety disorders. The anxiety disorders that Paxil is used to treat are:

• obsessive compulsive disorder (repetitive, obsessive thoughts with uncontrollable behaviour)
• panic disorder (panic attacks, including those caused by agoraphobia, which is a fear of open spaces)
• social anxiety disorder (fear or avoidance of social situations)
• post-traumatic stress disorder (anxiety caused by a traumatic event)
• generalised anxiety disorder (generally feeling very anxious or nervous).

Paxil is one of a group of medicines called SSRIs (selective serotonin re-uptake inhibitors). Everyone has a substance called serotonin in their brain. It is not fully understood how Paxil and other SSRIs work but they may help by increasing the level of serotonin in the brain, Treating depression or anxiety disorders properly is important to help you get better.

Before you take Paxil

Do NOT take Paxil

• If you are taking medicines called monoamine oxidase inhibitors (MAOIs, including moclobemide), or have taken them at any time within the last two weeks. Your doctor will advise you how you should begin taking Paxil once you have stopped taking the MAOI.
• If you are taking an anti-psychotic called thioridazine or an anti-psychotic called pimozide.
• If you are allergic (hypersensitive) to paroxetine or any of the other ingredients of this medicine (listed below).
• If any of these apply to you, tell your doctor without taking Paxil.

Take special care with Paxil

Check with your doctor.

• Are you taking any other medicines (see ‘Taking other medicines’)
• Do you have kidney, liver or heart trouble?
• Do you have epilepsy or have a history of fits or seizures?
• Have you ever had episodes of mania (overactive behaviour or thoughts)?
• Are you having electro-convulsive therapy (ECT)?
• Do you have a history of bleeding disorders, or are you taking other medicines that may increase the risk of bleeding (these include medicines used to thin the blood, such as warfarin, anti-psychotics such as perphenazine or clozapine, tricyclic antidepressants, medicines used for pain and inflammation called non-steroidal anti-inflammatory drugs or NSAIDs, such as acetylsalicylic acid, ibuprofen, celecoxib, etodolac, diclofenac, meloxicam)?
• Do you have diabetes?
• Are you on a low sodium diet?
• Do you have glaucoma (pressure in the eye)?
• Are you pregnant or planning to get pregnant (see ‘Pregnancy and breast-feeding’)?
• Are you under 18 years old (see ‘Use in children and adolescents under 18 years of age’)?
  

If you answer YES to any of these questions, and you have not already discussed them with your doctor, go back to your doctor and ask what to do about taking Paxil.

Use in children and adolescents under 18 years of age Paxil should normally not be used for children and adolescents under 18 years. Also, you should know that patients under 18 have an increased risk of side effects such as suicide attempt, suicidal thoughts and hostility (predominantly aggression, oppositional behaviour and anger) when they take this class of medicines. Despite this, you r doctor may prescribe Paxil for patients under 18 because he/she decides that this is in their best interests. If your doctor has prescribed Paxil for a patient under 13 and you want to discuss this, please go back to your doctor. You should inform your doctor if any of the symptoms listed above develop or worsen when patients under 18 are taking Paxil. Also, the long-term safety effects concerning growth, maturation and cognitive and behavioural development of Paxil in this age group have not yet been demonstrated.

In studies of paroxetine in under 18s, common side effects that affected less than 1 in 10 children / adolescents were an increase in suicidal thoughts and suicide attempts, deliberately harming themselves, being hostile, aggressive or unfriendly, lack of appetite, shaking, abnormal sweating, hyperactivity (having too much energy), agitation, changing emotions (including crying and changes in mood).These studies also showed that the same symptoms affected children and adolescents taking sugar pills (placebo) instead of paroxetine, although these were seen less often.

Some patients in these studies of under 18s had withdrawal effects when they stopped taking paroxetine, These effects were mostly similar to those seen in adults after stopping paroxetine (see section 3, ‘How to take Paxil’), In addition, patients under 18 also commonly (affecting less than 1 in 10) experienced stomach ache, feeling nervous and changing emotions (including crying, changes in mood, trying to hurt themselves, thoughts of suicide and attempting suicide).

Thoughts of harming yourself and worsening of your condition

People who are depressed and/or suffer from anxiety disorders can sometimes have thoughts of harming or killing themselves. These may be increased when you first start taking antidepressants, since these medicines all take time to work,

Certain groups of patients may be more likely to think like this:

• If you have previously had thoughts about killing or harming yourself.
• If you are a young adult, Information from clinical trials has shown an increased risk of suicidal behaviour in young adults (less than 25 years old) with psychiatric conditions who were treated with an antidepressant.

If you get thoughts of harming or killing yourself at any time, contact your doctor or go to a hospital straight away.

Yon may find it helpful to tell a relative or close friend that you are depressed or suffering from an anxiety disorder, and ask them to read this leaflet. You might ask them to tell you if they think your depression or anxiety is getting worse, or if they are worried about changes in your behaviour.

Important side effects seen with Paxil

Some patients who take Paxil develop something called akathisia, where they feel restless and feel like they can’t sit or stand still. Other patients develop something called serotonin syndrome, where they have some or all of the following symptoms: feeling confused, feeling restless, sweating, shaking, shivering, hallucinations (strange visions or sounds), sudden jerks of the muscles or a fast heartbeat. If you notice any of these symptoms, contact your doctor. For more information on these or other side effects of Paxil, see section 4, ‘Possible side effects’.

Taking other medicines

Some medicines can affect the way that Paxil works, or make it more likely that you’ll have side effects. Paxil can also affect the way some other medicines work. These include:

• Medicines called monoamine oxidase inhibitors (MAOIs, including moclobemide) – see ‘Do NOT take Paxil’
• Thioridazine or pimozide, which are anti-psychotics – see ‘Do NOT take Paxil’
• Acetylsalicylaic acid, ibuprofen or other medicines called NSAIDs (non-steroidal anti-inflammatory drugs) like celecoxib, etodolac, diclofenac and mebxicam that are used for pain and inflammation
• Tramadol, a painkiller
• Medicines called triptans, such as sumatriptan, used to treat migraine
• Other antidepressants including other SSRIs and tricyclic antidepressants like clomipramine, nortriptyline and desipramine
• A dietary supplement called tryptophan
• Medicines such as lithium, risperidone, perphenazine, clozapine (called anti-psychotics) used to treat some psychiatric conditions
• A combination of fosamprenavir and ritonavir, which is used to treat Human Immunodeficiency Virus (HIV) infection
• St John’s Wort, a herbal remedy for depression
• Phenobarbital, phenytoin, sodium valproate or carbamazepine used to treat fits or epilepsy
• Atomoxetine which is used to treat attention deficit hyperactivity disorder (ADHD)
• Procyclidine, used to relieve tremor, especially in Parkinson’s disease
• Warfarin or other medicines (called anticoagulants) used to thin the blood
• Propafenone, flecainide and medicines used to treat an irregular heartbeat
• Metoprolol, a beta-blocker used to treat high blood pressure and heart problems
• Rifampicin, used to treat tuberculosis (TB) and leprosy
• Linezolid, an antibiotic.

If you are taking or have recently taken any of the medicines in this list, and you have not already discussed these with your doctor, go back to your doctor and ask what to do. The dose may need to be changed or you may need to be given another medicine.

Please tell your doctor or pharmacist if you are taking or have recently taken any other medicines, including medicines obtained without a prescription,

Taking Paxil with food and drink

Do not drink alcohol while you are taking Paxil. Alcohol may make you r symptoms or side effects worse. Taking Paxil in the morning with food will reduce the likelihood of you feeling sick (nausea).

Pregnancy and breast-feeding

If you are already taking Paxil and have just found out that you are pregnant, you should talk to your doctor immediately. Also if you are planning to get pregnant, talk to your doctor. This is because some studies have suggested an increase in the risk of heart defects in babies whose mothers received Paxil in the first few months of pregnancy. These studies found that less than 2 in 100 babies (2%) whose mothers received paroxetine in early pregnancy had a heart defect, compared with the normal rate of 1 in 100 babies (1%) seen in the general population.

When all types of birth defects are taken into account, there is no difference in the number of babies born with birth defects after their mothers took paroxetine while they were pregnant compared Do the overall number of birth defects that occur in the general population. You and your doctor may decide that it is better for you to change to another treatment or to gradually stop taking Paxil while you are pregnant. However, depending on your circumstances, your doctor may suggest that it is better for you to keep taking Paxil,

If you are taking Paxil in the last 3 months of pregnancy, let your midwife know as your baby might have some symptoms when it is born. These symptoms usually begin du ring the first 24 hours after the baby is born. They include not being able to sleep or feed properly, trouble with breathing, a blue-ish skin or being too hot or cold, being sick, crying a lot, stiff or floppy muscles, lethargy, tremors, jitters or fits. If your baby has any of these symptoms when it is born and you are concerned, contact your doctor or midwife who will be able to advise you.

Paxil may get into breast milk in very small amounts. If you are taking Paxil, go back and talk to your doctor before you start breast-fee ding. You and your doctor may decide that you can breast-feed while you’re taking Paxil.

Ask your doctor or pharmacist for advice before taking any medicine,

Driving and using machines

Possible side effects of Paxil include dizziness, confusion, feeling sleepy or blurred vision. If you do get these side effects, do not drive or use machinery.

How to take paroxetine

Always take Paxil exactly as your doctor has told you. You should check with your doctor or pharmacist if you are not sure.

Sometimes you may need to take more than one tablet or half a tablet. This table will show you how many tablets to take.

Dose	Number of tablets to take
10 mg	Half a 20 mg tablet
20 mg	One 20 mg tablet
30 mg	One 30 mg tablet or one and a half 20 mg tablets
40 mg	Two 20 mg tablets
50 mg	One 20 mg tablet + one 30 mg tablet or two and a half 20 mg tablets
60 mg	Three 20 mg tablets or two 30 mg tablets

The usual doses for different conditions are set out in the table below:

	Starting dose	Recommended daily dose	Maximum daily dose
Depression	20 mg	20 mg	50 mg
Obsessive compulsive disorder	20 mg	40 mg	60 mg
Panic disorder	10 mg	40 mg	60 mg
Social anxiety disorder	20 mg	20 mg	50 mg
Post-traumatic stress disorder	20 mg	20 mg	50 mg
Generalised anxiety disorder	20 mg	20 mg	50 mg

Your doctor will advise you what dose to take when you first start taking Paxil. Most people start to feel better after a couple of weeks. If you don’t start to feel better after this time, talk to your doctor, who will advise you. He or she may decide to increase the dose gradually, 10 mg a time. Lip to a maximum daily dose.

Oral use.

Take your tablets in the morning with food.

Swallow them with a drink of water.

Do not chew.

Your doctor will talk to you about how long you will need to keep taking your tablets. This may be for many months or even longer.

Older people

The maximum dose for people over 65 is 40 mg per day.

Patients with liver or kidney disease

If you have trouble with your liver or severe kidney disease, your doctor may decide that you should have a lower dose of Paxil than usual.

If you take more Paxil than you should

Never take more tablets than your doctor recommends. If you take too many Paxil tablets (or someone else does), tell your doctor or a hospital straight away. Show them the pack of tablets.

Someone who has taken an overdose of Paxil may have any one of the symptoms listed in section 4 ‘Possible side effects’, or the following symptoms: being sick, fever, headache, uncontrollable tightening of the muscles.

If you forget to take Paxil

Take your medicine at the same time every day. If you do forget a dose, and you remember before you go to bed, take it straight away. Carry on as usual the next day. If you only remember during the night, or the next day, leave out the missed dose. You may possibly get withdrawal effects, but these should go away after you take your next dose at the usual time.

What to do if you’re feeling no better

Paxil will not relieve your symptoms straight away – all antidepressants take time to work. Some people will start to feel better within a couple of weeks, but for others it may take a little longer. Some people taking antidepressants feel worse before feeling better. If you don’t start to feel better after a couple of weeks, go back to your doctor who will advise you. Your doctor should ask to see you again a couple of weeks after you first start treatment. Tell your doctor if you haven’t started to feel better.

If you stop taking Paxil

Do not stop taking Paxil until your doctor tells you to. When stopping Paxil, your doctor will help you to reduce your dose slowly over a number of weeks or months – this should help reduce the chance of withdrawal effects. One way of doing this is to gradually reduce the dose of Paxil you take by 10 mg a week. Most people find that any symptoms on stopping Paxil are mild and go away on their own within two weeks. For some people, these symptoms may be most severe, or go on for longer.

If you get withdrawal effects when you are coming off your tablets your doctor may decide that you should come off them more slowly, If you get severe withdrawal effects when you stop taking Paxil, please see your doctor, He or she may ask you to start taking your tablets again and come off them more slowly. If you do get withdrawal effects, you will still be able to stop Paxil.

Possible withdrawal effects when stopping treatment

Studies show that 3 in 10 patients notice one or more symptoms on stopping paroxetine. Some withdrawal effects on stopping occur more frequently than others.

Common side effects, likely to affect up to 1 in 10 people:

• Feeling dizzy, unsteady or off-balance
• Feelings like pins and needles, burning sensations and (less commonly) electric shock sensations, including in the head, and buzzing, hissing, whistling, ringing or other persistent noise in the ears (tinnitus)
• Sleep disturbances (vivid dreams, nightmares, inability to sleep)
• Feeling anxious
• Headaches.

Uncommon side effects, likely to affect up to 1 in every 100 people:

• Feeling sick (nausea)
• Sweating (including night sweats)
• Feeling restless or agitated
• Tremor (shakiness)
• Feeling confused or disorientated
• Diarrhoea (loose stools)
• Feeling emotional or irritable
• Visual disturbances
• Fluttering or pounding heartbeat (palpitations).

Please see your doctor if you are worried about withdrawal effects when stopping Paxil.

If you have any further questions on the use of this product, ask your doctor or pharmacist.

Possible side effects

Like all medicines, Paxil can cause side effects, although not everybody gets them. Side effects are more likely to happen in the first few weeks of taking Paxil.

See the doctor if you get any of the following side effects during treatment.

You may need to contact your doctor or go to a hospital straight away.

Uncommon side effects, likely to affect up to 1 in every 100 people:

• If you have unusual bruising or bleeding, including vomiting blood or passing blood in your stools, contact your doctor or go to a hospital straight away.
• If you find that you are not able to pass water, contact your doctor or go to a hospital straight away.

Rare side effects, likely to affect up to 1 in every 1,000 people:

• If you experience seizures (fits), contact your doctor or go to a hospital straight away.
• If you feel restless and feel like you can’t sit or stand still, you may have something called akathisia. Increasing your dose of Paxil may make these feelings worse. If you feel like this, contact your doctor.
• If you feel tired, weak or confused and have achy, stiff or unco-ordinated muscles, this may be because your blood is low in sodium. If you have these symptoms, contact your doctor.

Very rare side effects, likely to affect up to 1 in every 10,000 people:

• Allergic reactions to paroxetine. If you develop a red and lumpy ski n rash, swelling of the eyelids, face, lips, mouth or tongue, start to itch or have difficulty breathing or swallowing, contact your doctor or go to a hospital straight away.
• If you have some or all of the following symptoms you may have something called serotonin syndrome. The symptoms include feeling confused, feeling restless, sweating, shaking, shivering, hallucinations (strange visions or sounds), sudden Jerks of the muscles or a fast heartbeat. If you feel like this contact your doctor.
• Acute glaucoma. If your eyes become painful and you develop blurred vision, contact your doctor.

Other possible side effects during treatment

Very common side effects,

likely to affect more than 1 in 10 people:

• Feeling sick (nausea).Taking your medicine in the morning with food will reduce the chance of this happening.
• Change in sex drive or sexual function, for example, lack of orgasm and, in men, abnormal erection and ejaculation.

Common side effects,

likely to affect up to 1 in 10 people:

• Increases in the level of cholesterol in the blood
• Lack of appetite
• Not sleeping well (insomnia) or feeling sleepy
• Feeling dizzy or shaky (tremors)
• Headache
• Feeling agitated
• Feeling unusually weak
• Blurred vision
• Yawning, dry mouth
• Diarrhoea or constipation
• Weight gain
• Sweating.

Uncommon side effects,

likely to affect up to 1 in every 100 people:

• A brief increase in blood pressure, or a brief decrease that may make you feel dizzy or faint when you stand up suddenly
• A faster than normal heartbeat
• Lack of movement, stiffness, shaking or abnormal movements in the mouth and tongue
• Dilated pupils
• Skin rash
• Feeling confused
• Having hallucinations (strange visions or sounds’:
• An inability to urinate (urinary retention) or an uncontrollable, involuntary passing of urine (urinary incontinence).

Rare side effects,

likely to affect up to 1 in every 1,000 people:

• Abnormal production of breast milk in men and women
• A slow heartbeat
• Effects on the liver showing up in blood tests of your liver function
• Panic attacks
• Overactive behaviour or thoughts (mania)
• Feeling detached from yourself (depersonalisation)
• Feeling anxious
• Pain in the joints or muscles.

Very rare side effects,

likely to affect up to 1 in every 10,000 people:

• Liver problems that make the skin or whites of the eyes go yellow
• Fluid or water retention which may cause swelling of the arms or legs
• Sensitivity to sunlight
• Painful erection of the penis that won’t go away
• Low blood platelet count.

Some patients may develop buzzing, hissing, whistling, ringing or other persistent noise in the ears (tinnitus) when they take Paxil.

If you have any concerns while you are taking Paxil, talk to your doctor who will be able to advise you. If any of the side effects gets serious, or if you notice any side effects not listed in this leaflet, please tell your doctor or pharmacist.

Further information

What Paxil contains

The active substance is paroxetine. Each film-coated tablet contains 20 or 30 mg paroxetine (as hydrochloride hemihydrate).

The other ingredients are calcium phosphate dibasic anhydrous, povidone K30, sodium starch glycolate (type A), magnesium stearate, titanium dioxide (E171), methylcellulose, macrogol 400 and polysorbate 80.

What Paxil looks like and contents of the pack

Film-coated tablet.

Paxil 20 mg Film-coated Tablets are white to off-white, round biconvex film-coated tablets, embossed with “20″ and scored on one side and with “PX” on the other side. The tablet can be divided into equal halves.

Paxil 30 mg Film-coated Tablets are white to off-white, round biconvex film-coated tablets, embossed with “30″ and scored on one side and with “PX” on the other side. The score line is only to facilitate breaking for ease of swallowing and not to divide into equal doses,

The 20 mg tablets are available in pack sizes of 14, 20, 23, 30, 50, 56, 60, 34 and 100 tablets.

The 30 mg tablets are available in pack sizes of 28, 30, 50, 56, 60 and 84 tablets.

Not all pack sizes may be marketed.

Question 1

Two years ago, I was diagnosed with borderline clinical atypical depression. I’ve been on 20 mg/day of Paxil ever since. Six months ago, I discontinued the treatment to see the results. Going cold turkey, I experienced severe withdraw symptoms such as intense fatigue, spaceyness, and hangover-like symptoms for three days. My physician says that lifetime treatment may be a reality. What other long-term effects might I experience?

Answer

First of all, I think it’s important to separate the issue of “withdrawal symptoms” from “long-term effects” of a medication. Many medications – including many used outside of psychiatry – lead to long-term adaptations by the body, on a cellular level. For example, beta blockers – used in the treatment of angina and hypertension – can lead to gradual adaptation of the nervous system, such that suddenly stopping the medicine (“going cold turkey”) can lead to serious withdrawal symptoms (rebound angina, or hypertension).

This does not imply that beta blockers cause long-term injurious effects – it simply means that your body/nervous system does not like sudden “shocks” of any kind. The withdrawal symptoms that you experienced after suddenly stopping Paxil are well-described in the literature, and would not surprise most psychiatrists. This does not necessarily mean that Paxil would cause any long-term harmful effects. It does mean that patients take a big risk whenever they stop a psychotropic medication suddenly.

Having said that, it must be conceded that we do not yet know the long-term effects of Paxil or related agents (called SSRIs, and include Prozac and Zoloft), if by long-term, you mean, “after 10 or more years of use.” These agents are still too “new” to generate that kind of data. So far as I am aware, there are no convincing studies showing any serious long-term effects from the chronic use of Prozac, which is a closely related medication used since about 1988.

There have been reports of some abnormal movements resulting from SSRIs; e.g., muscle twitches or stiffness. In theory, long-term use of these agents might – I emphasize might – predispose some individuals to such abnormal movements. But this theoretical risk, in my opinion, must be weighed against the debilitating effects of severe (major) depression – which has a 15% mortality rate.

Of course, there are other classes of antidepressants that have been around much longer, and which do not seem to pose these theoretical risks – i.e., tricyclic antidepressants. But these are also much more potentially toxic than the SSRIs, and have their own side effects. So, all in all, I think the risks of taking Paxil indefinitely are probably quite small, but the jury is still out. You may want to write to the company that manufactures Paxil (Smith-Kline-Beecham, 1 Franklin Plaza, Box 7929, Phil PA 19101) and pose the question to them.

Question 2

I am taking Paxil for social phobia and panic attacks. After the first 20mg dose, I felt quite high and nauseous. My partner noted an almost immediate positive change in my mood, despite my feeling physically awful. My anxiety has disappeared, but was replaced by anxiety over side effects. I have also experienced insomnia, headaches, fuzziness, lower back pain, chills, sensitivity to touch, sore eyes, mild hallucinations (changes in light perception mainly), extreme thirst and teeth clenching. I am still looking for something that can “cure” my social phobia without severe side effects. I’ve tried beta blockers and they make me feel faint. Is there anything else? I have no nasty side effects from my occasional recreational drug use, only from prescribed medications.

Answer

I am not sure how extreme your reaction to the Paxil was, but it is possible that you suffered a form of the serotonin syndrome? This may follow use of medications (like Paxil) that boost levels of serotonin (a chemical found in the brain, as well as in the GI tract). This may indicate that you are extremely sensitive to serotonin. Unfortunately, many of the medications used for social phobia do elevate serotonin. However, it is possible that a very cautious retrial on very small doses of Paxil or a similar agent might be tolerable (e.g., 5 mg/day of Paxil or 2 mg/day of Prozac, liquid).

Other medications that could be tried include alprazolam (Xanax) and clonazepam (Klonopin), neither of which boost serotonin markedly; the MAOIs, which require a special diet and do boost serotonin; and buspirone, an antianxiety agent that has some effects on serotonin. I think you should seriously consider getting involved in cognitive-behavioral therapy (CBT), which can be quite effective either instead of or in conjunction with, medication. In the long term, CBT may provide you with more enduring benefits than medication.

However, I think that your search for a cure may lead to unmet expectations and disappointment. It would be wiser to aim for improvement in specific areas, such as 50% less anxiety when making a speech. By the way, I’d take another look at your use of recreational drugs. Even when used sporadically, they can interact with prescribed medications.