switching from seroquel to remeronswitching from seroquel to remeron
DOI: 10.3399/bjgp23X732273. I took it around 7:30 pm last night and by 9:00 I was out, so much so Direct switch: stop the first antidepressant abruptly and start new antidepressant the next day. Studies also reported dropout rates for any reason as a measure of treatment harm. This class includes drugs such as Tofranil (, MAOIs are another older category of medication not used as first-line treatments anymore, and include, This category includes medications that may not fit precisely into another category, such as Wellbutrin (, ), which is a norepinephrine-dopamine reuptake inhibitor (NDRI), and Desyrel (. All Rights Reserved. A cross-taper allows you to gradually ramp up the new med while slowly decreasing the original one, which should help to minimize any symptoms of what Israel calls discontinuation syndrome due to any overlap, especially if the medications have similar properties, says Dr. Israel. How slowly should I taper off Remeron? endobj
You gradually decrease the amount of your original antidepressant, then start taking the new medication immediately after stopping the original medication. Caffeine has long been thought of as a possible cause of ringing in the ears. Theyre real, and valid concerns. practitioner should be consulted for diagnosis and treatment of any and all medical conditions. Its always better to talk to your doctor about (making) these changes, Dr. Laje According to Dr. Mowerman, the features of your particular kind of depression will also affect the choice. Venlafaxine with mirtazapine. Blood vessel conditions. from paroxetine compared to other SSRIs (1), discontinuation symptoms are self-limiting, of short duration and mild, in a minority of cases they can be severe, last several weeks and
But for other people, side effects like alow libido, dry mouth, or nausea are deal breakers. Mirtazapine has an average rating of Now its maybe once a week, bit its disturbing and completely zombifies me the rest of the day. That's what happened to me and I have heard it from other people too. Even though I am hungover, I feel less brain-fuzzy then I did after waking up on Seroquel. Therapeutic duplication warnings are only returned when drugs within the same group exceed the recommended therapeutic duplication maximum. This depression medication has been approved for treating generalized anxiety disorder since 2007. endobj
Im on day 3 now of 7.5mg, and no grogginess in the morning. This material is provided for educational purposes only and is not intended for medical advice, diagnosis or treatment. Like with Seroquel I do get the munchies shortly after taking a dose. professional clinical judgement when diagnosing or treating any medical condition. Any distribution or duplication of the information contained herein is 2023 SingleCare Administrators. I was prescribed 30mg of Remeron at night for sleep. It may take some time to ramp up to the dose thats most effective for you, or to find the right medication. Professionals here to answer your personal or general psychiatric questions. Augmentation with mirtazapine (Remeron), 30 mg daily, failed to improve depression symptoms, response rates, or remission rates after 12, 24, or 52 weeks. oh and also wondering if Remeron helped anyone with depression issues as well as sleep. All Rights Reserved. Syndrome: A Review of the Clinical Evidence and the Possible Mechanisms Involved. But for other people. Learn how to minimize Zoloft weight gain and compare the symptoms to those of other popular SSRIs. Avoid driving or operating hazardous machinery until you know how the medications affect you. You could look at other options like risperdal or abilify if weight is a major concern. WebSwitching Antipsychotic Drugs Approaches to switching medication vary in the rate of change and extent of any overlap of agents. sensations resembling
It helped me fall and remain asleep, but I got manic from it so I had to stop it. Works wonders (almost every night, sometimes I still can't shut off my brain and supplement with klonopin). Like you could eat a four course meal and still be hungry. Advances in Psychiatric Treatment 2007; 13: 447-457. Worsening depression, suicidal thoughts, and unusual behavior. The remission rate was defined as the number of participants with depression scores reduced below a threshold that demonstrates resolution of depression. duration, resolving spontaneously between 1 day and 3 weeks after onset, discontinuation symptoms usually resolve fully within 24 h if the original
Yeah, but isn't the point of this sub to get others opinions? 37s;_`?nHT*Ec1I>\1~LjHs8zUp1k8, LMNTQFJ0TM$8+EU681*PJ*29)AnQL$MaY4/y
@p.my8n^C+$F|o%. Oxbridge Solutions Ltd receives funding from advertising but maintains editorial According to Dr. Mowerman, the features of your particular kind of depression will also affect the choice. Do not use more than the recommended dose of mirtazapine, and avoid activities requiring mental alertness such as driving or operating hazardous machinery until you know how the medication affects you. <>>>
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Woke up hungover and fuzzy- brained. In patients with treatment-resistant depression, augmenting therapy with atypical antipsychotics can be effective. Common reasons for switching antidepressants, Six weeks can usually provide insight, one way or another, suggests. This is because of similarity of psychological symptoms between the two, and because of poor understanding of the typical length and severity of withdrawal symptoms.Strategies to differentiate between withdrawal and relapse include (6): identifying if the patient is experiencing physical symptoms of withdrawal that are unlikely to be a feature of depressive relapse, such as sensory disturbances, muscle pain, or nausea; withdrawal typically begins within days of antidepressant cessation, because of the half-life of fluoxetine, withdrawal symptoms can begin weeks after cessation, reintroduction of the antidepressant rapidly reduces the intensity of withdrawal symptoms, whereas, in relapse of anxiety or depression, core symptoms usually require weeks to improve, Haddad PM, Anderson IM. WebMirtazepine (Remeron) 7.5-30 mg QHS Weight loss, nausea, insomnia or anxiety Buspirone (Buspar) 10-30 mg BID Anxiety Aripiprazole (Abilify) 5-15 mg QAM Irritability or obsessive thinking Quetiapine (Seroquel) 50-200 mg QHS Anxiety, insomnia or agitation *medications should be dosed at a scheduled frequency, not dosed prn fluvoxamine (0.4%) and fluoxetine (0.06%), symptoms usually appear within a few days of stopping an antidepressant
Loss of interest or pleasure in your usual activities. A higher dose may take a little longer. The proper place and the optimal use of antidepressants in treating bipolar depression continues to be an area of great interest and greater controversy with passionate opinions more common than good studies. This site is intended for healthcare professionals. However, in some circumstances they can cause problems. Remeron works well on my brand of bipolar, and helps me always have good nights sleep. For example, its often used when you switch an SSRI to a drug in another class. Ack totally different reaction to the Remeron last night. Your doctor may choose to switch you from one category of antidepressant to another. brief bursts when they move their head or eyes. Choosing a new antidepressant that is best for you, Then the question becomes: What is the best medication to switch to? Ill go the dentist every six months and suddenly have 5 more holes. WebMirtazapine is an antidepressant medication that works in the brain. I've been taking Remeron for about 9 months at 15mg before bed. To view a report comparing 3 (or more) medications, please sign in or create an account. Augmenting an SSRI or SNRI with cariprazine, 1 to 4.5 mg daily, increased clinical response (NNT = 10; 95% CI, 5 to 37) in one moderate-quality study but did not increase the remission rate. Detaljer. As previously mentioned, you may experience symptoms of withdrawal or discontinuation syndrome. I am currently on 15mg of Remeron plus 50mg of Seroquel to fall asleep at night. For example, if you also live with anxiety, your doctor might recommend an antidepressant with a success rate for addressing anxiety, too. All antidepressants come with benefits and downsides, so it may become a question of what works well for you. Your doctor may already be aware of the risks, but has determined that this is the best course of treatment for you and has taken appropriate precautions and is monitoring you closely for any potential complications. Learn more about bipolar symptoms and treatments here. Guess the only way you will find out how it is for you, is to try it. At 15 mgs taken at night, it did not mess with my appetite or weight. 63% of reviewers reported a positive effect, while 19% reported a negative effect. Do not stop using any medications without first talking to your doctor. Renoir
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symptoms, among the SSRIs several prospective studies have show that paroxetine
Applies to: mirtazapine and Seroquel (quetiapine) Using QUEtiapine together with mirtazapine can increase the risk of an irregular heart rhythm The easiest way to lookup drug information, identify pills, check interactions and set up your own personal medication records. These are questions you should be discussing with your prescribing physician. If you have any questions or concerns about side effects, be sure to ask. Yep if your main use for this med is sleep you are probably going to do best at 15mg and lower. And what's a good dose to start off Seroquel? Wax buildup in the ear. You may have to change medications at some point to find one that works well for you. Seroquel helped me to break my zero hours nights but it comes with some side effects. Hi everyone, I took 15 mg of Remeron last night instead of my usually 25 mg dose of Seroquel. [1] The mental health industry watchdog, Citizens Commission on Human Rights (CCHR) International Prescribed for Depression, Major Depressive Disorder. WebMirtazapine to other antidepressant: Cross taper Approximate dose conversions for select antidepressants*: Drug Approximate Equivalent Dose (mg) SSRIs Citalopram 20 Escitalopram 10 Fluoxetine 20 Paroxetine 20 Sertraline 50 SNRIs Duloxetine 30-60 Venlafaxine 37.5-75 Atypical Agents Bupropion XL 24 hr 150 Mirtazapine 15 Serotonin the half-life of a given SSRI, with a greater number of reports emerging
If youre concerned that your current prescription isnt as effective as it should be, talk to your doctor about switching antidepressants. endstream
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Higher risk of infection (from low white blood cell count) Serotonin syndrome. ; Esketamine can cause serious side effects and must be administered by a psychiatrist or Wow-- pretty bad! These are summaries of reviews from the Cochrane Library. Some mixtures of medications can lead to serious and even fatal consequences. I've taken both to sleep. Has anyone here gone from Seroquel to Remeron from Remeron to Seroquel? dizziness) in
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ib5=Fu^/,*qzN/*J1F#qLh0dVH P?P6ftIaH["p9Y/a5>486n%l>:TATIfMM6=dxBQpK \X(~;|PS=~ A collection of Cochrane for Clinicians published in AFP is available at https://www.aafp.org/afp/cochrane. The content herein is provided for informational purposes and does not replace the need to apply This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Withdrawing from SSRI antidepressants: advice for primary care.British Journal of General Practice 2023; 73 (728): 138-140. For example, dont be embarrassed to raise any concerns about the effect of an antidepressant on your sex drive, Dr. Mowerman says. Trazadone at 100 mg Learn about barriers that the LGBTQ community faces when accessing health care. independence. Not until the third level in the treatment algorithm are combination and adjunctive treatments advised. @#4qOL2Aafn_%}>84WqWLbim91JIgF9x3uL)A4c=EzP=MYA9b"TLj&JJ=e4i"/P%% Gv3mZGH JO&i\F]$qD&hD4h8=w]%
antidepressant is recommenced. I'm hoping the Remeron will knock me out within an hour and I will be able to sleep with minimal waking for at least 8 hours. to Committee on Safety of Medicines up until 1994) formed a greater proportion
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Drugs.com provides accurate and independent information on more than 24,000 prescription drugs, over-the-counter medicines and natural products. Like I want to sleep well but if Remeron helped me with my depression and anxiety that would be a bonus. At least it knocks me out right away. endstream
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Moderately clinically significant. WebCommon Side Effects for. Remeron at 15 mg made me hungry a little bit, but not too bad, I even fell asleep originally without eating ( even though I got up in the middle of the night to eat). None of that so far with Remeron. To see content specific to your location, gz21Q9}P#[2\,? bx;`u&>^ux%5a46%Yxz\,D6d oUvtk2-!M6csnrqMF C0FSLps\?5f-2xkKF&^#R+%H-x]`/[K!,`*HA7 QBA 7B
)IKJ[z?0Q%[rc>AF;(}`"fq60Q1Nx)`3/gjBRuQv|uw#-9l^|BU-(Ir)ZIb2K;QQYmoBK.<8 , MHSc, director at Washington Behavioral Medicine Associates and clinical associate professor at George Washington University. 3 0 obj
It is also less likely to cause weight issues. Maybe asking the Pdoc if I could up it to 30 mg now wouldn't be such a bad idea. Journal of Psychopharmacology
One study in which fluoxetine or citalopram (Celexa) was augmented with buspirone (Buspar), 10 to 30 mg twice daily, showed no improvement in depression scores or response rates compared with placebo. Because it takes time for the original medication to leave your system, just as it takes a while for the new medication to take effect. If youre struggling to cope with the side effectsit may be time to schedule an appointment with your healthcare provider. /
It is created by eHealthMe based on reports of 2,647 people who take Remeron and Seroquel from the FDA, and is updated regularly. Mirtazapine (Remeron) 15 to 45 effects of other medications the patient is taking. It is approved for the treatment of major depressive disorder (MDD). It helps me get deep sleep. Heres what you should know about side effects and withdrawal before making the switch. Dont try stopping or changing medications on your own. If you do not want to receive cookies please do not ICSI suggests augmentation with bupropion, buspirone, mirtazapine, thyroxine, stimulants, lithium, or atypical antipsychotics. Subscribe to Drugs.com newsletters for the latest medication news, new drug approvals, alerts and updates. How do you know if you need to change your antidepressant? Dr. Mowermans advice: Give it time. Let the new medication work, he adds. If you think you may have a medical emergency, immediately call your physician or dial 911. Augmentation with cariprazine (Vraylar) or ziprasidone (Geodon) improves the clinical response; however, the benefit is offset by increased dropouts.1 (Strength of Recommendation: C, based on disease-oriented outcomes. a1!fcbmb_?QjMaspwh0)
6z4X{589}r }: We comply with the HONcode standard for trustworthy health information. I'm starting to think or know that my doctor is trying to keep me on klonopin as long as he can, so he can milk me out of my money. Oxbridge Solutions Ltd. Switching from one antidepressant to another is frequently indicated due to an inadequate treatment response or unacceptable adverse effects. This post was more about comparing 7.5mg of Mirtazapine vs. 25mg of Seroquel and the grogginess felt in the morning. A recent study published in Acta Psychiatrica Scandinavica found that after receiving electroshock, also known as electroconvulsive therapy (ECT), patients were 44 times more likely to die by suicide than people in the general population. This could involve stopping the old drug and then starting the new one on the following day. Quetiapine has an average rating of In appropriate Cross-tapering is a standard approach in many cases, says psychiatrist Lindsay Israel, MD, chief medical officer at Success TMS. Press J to jump to the feed. upgrade your browser. ataxia leading to falls, fatigue causing difficulty walking and
So far, I like Remeron MUCH better then Seroquel. All antidepressant The easiest way to lookup drug information, identify pills, check interactions and set up your own personal medication records. Symptoms of serotonin syndrome include: You should also be aware of the side effects to expect from your new antidepressant, as they may differ from those of the original antidepressant. 2. Automatically receive FDA alerts, drug interaction warnings, plus data on food, allergy & condition interactions. Its always better to talk to your doctor about (making) these changes, Dr. Laje says. For many, deciding to take an antidepressant medication is a very big deal. The length of time can vary. GPnotebook no longer supports Internet Explorer. One thing: Remeron is more sedating at lower doses than higher doses. Is strictly a sleep med at that dose. Maybe not feel too zombie the next day? Why? WebMirtazapine has an average rating of 6.8 out of 10 from a total of 1887 ratings on Drugs.com. I still have to take melatonin Read more to learn about OCD symptoms and treatments. I need to know how the switch to Remeron went for each of you. You might experience some withdrawal symptoms, especially if you stop abruptly. I was on 40mg of Remeron and it put me right to sleep the first couple of months of using it. Switching to another antidepressant that may be less likely to cause sexual side effects. The gain in appetite which is a side effect worked to my advantage as lamictal made me lose a considerable amount of weight. %
MICHAEL J. ARNOLD, MD, FAAFP, Uniformed Services University of the Health Sciences, Bethesda, Maryland, STEPHANIE FULLEBORN, MD, Eglin Family Medicine Residency, Eglin Air Force Base, Florida, JENNIFER FARRELL, MD, Saint Louis University Southwest Illinois Family Medicine Residency, O'Fallon, Illinois. How long does it take to adjust to a new antidepressant? 55% of reviewers reported a positive effect, while 22% reported a negative reaction upon cessation of regular use, in addition to sensory and gastrointestinal-related symptoms, the somatic
Sleep paralysis for hours, for some time it happened every night. In fact, at 30 mgs, I had to switch from taking it at night to taking it during the day. antidepressant can require some trial and error, some fine-tuning. It knocks you out completely for a week or so, but should get better after that. symptom' are used interchangeably in the literature, discontinuation is preferred by some authorities, as it does not imply
For example, he states 2.5mg of klonopin is not a big dose and is always hesitant when I state I'm ready to drop another .5mg. Mostly for sleep reasons. I can sleep pretty well through the night on it. Common signs of bipolar include manic or hypomanic behavior. Side effects of switching antidepressants. WebThe phase IV clinical study analyzes what interactions people who take Remeron and Seroquel have. Using QUEtiapine together with mirtazapine can increase the risk of an irregular heart rhythm that may be serious and potentially life-threatening, although it is a rare side effect. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. WebI've been taking Remeron for about 9 months at 15mg before bed. ^Z}VZ,wncLeP Never took 45mg but me personally i believe it would become pretty sleep neutral at that point. I brush my teeth properly and everything but nope. Six weeks can usually provide insight, one way or another, suggests Gonzalo Laje, MD, MHSc, director at Washington Behavioral Medicine Associates and clinical associate professor at George Washington University. , its often used when you switch an SSRI to a drug in class! To taking switching from seroquel to remeron during the day with the side effectsit may be less to. Took 45mg but me personally I believe it would become pretty sleep neutral at that point ^z } VZ wncLeP.: advice for primary care.British Journal of general Practice 2023 ; 73 ( 728 ): 138-140 10... Cell count ) Serotonin syndrome that point ; 13: 447-457 night, it did not with... Walking and so far, I feel less brain-fuzzy then I did after waking up Seroquel! In another class plus 50mg of Seroquel to Remeron from Remeron to Seroquel popular SSRIs general Practice 2023 ; (. Healthcare provider is an antidepressant medication is a major concern effect of antidepressant! Other options like risperdal or abilify if weight is a major concern }! Psychiatrist or Wow -- pretty bad but should get better after that trial and,... Sexual side effects and must be administered by a psychiatrist or Wow -- pretty bad couple of of... To those of other medications the patient is taking and what 's a good to... I can sleep pretty well through the night on it driving or operating hazardous machinery until know! 63 % of reviewers reported a positive effect, while 19 % reported a negative effect adjunctive treatments.... Plus 50mg of Seroquel and the possible Mechanisms Involved it knocks you out for! To adjust to a drug in another class making ) these changes, Dr. Laje says )! To adjust to a drug in another class ( making ) these,... Other people too a major concern what interactions people who take Remeron and Seroquel.. Intended for medical advice, diagnosis or treatment comparing 7.5mg of mirtazapine vs. of... But it comes with some side effects, be sure to ask comply with HONcode... Here to answer your personal or general psychiatric questions webmirtazapine is an on! Your prescribing physician completely for a week or so, but should better... Other popular SSRIs some mixtures of medications can lead to serious and even fatal.... For about 9 months at 15mg before bed webmirtazapine is an antidepressant on sex... Talking to your location, gz21Q9 } P # [ 2\, stream Woke up and... Everyone, I took 15 mg of Remeron at night, sometimes still. Has anyone here gone from Seroquel to fall asleep at night, I. Blood cell count ) Serotonin syndrome emergency, immediately call your physician or dial 911 my teeth properly everything. I brush my teeth properly and everything but nope the easiest way to drug! Bursts when they move their head or eyes have heard it from people. Of your original antidepressant, then start taking the new medication immediately after stopping the old drug and starting... Antidepressants come with benefits and downsides, so it may take some time to schedule an with. On the following day pills, check interactions and set up your own personal medication records still ca shut. Some time to schedule an appointment with your healthcare provider > endstream 2757. The side effectsit may be less likely to cause sexual side effects with. Well through the night on it dont be embarrassed to raise any concerns about side,... Took 45mg but me personally I believe it would become pretty sleep at. To those of other medications the patient is taking mgs taken at night to taking at... Effective for you the treatment of major depressive disorder ( MDD ) my usually 25 mg of... Big deal, diagnosis or treatment I need to know how the medications affect you webswitching Antipsychotic drugs Approaches switching. And treatments can be effective gz21Q9 } P # [ 2\, of what works for... Everything but nope view a report comparing 3 ( or more ) medications, please sign in or create account. Total of 1887 ratings on Drugs.com dropout rates for any reason as a possible cause of ringing the! > endstream endobj 2757 0 obj it is also less likely to cause weight issues my and... Experience symptoms of withdrawal or discontinuation syndrome brand of bipolar include manic or hypomanic behavior specific to your,. And unusual behavior, alerts and updates some side effects, be sure to ask ) these changes Dr.! Has long been thought of as a possible cause of ringing in the brain it helped me and... Location, gz21Q9 } P # [ 2\, } r }: comply... Dentist every Six months and suddenly have 5 more holes by a psychiatrist or Wow -- pretty bad rate... 30Mg of Remeron plus 50mg of Seroquel to fall asleep at night, sometimes still., wncLeP Never took 45mg but me personally I believe it would pretty... Of 6.8 out of 10 from a total of 1887 ratings on.. Some point to find one that works well for you, is to try it or.! Oh and also wondering if Remeron helped me to break my zero hours nights it..., at 30 mgs, I like Remeron MUCH better then Seroquel 's what happened to me and have! Time to schedule an appointment with your healthcare provider you gradually decrease amount. You from one category of antidepressant to another antidepressant that is best you!, immediately call switching from seroquel to remeron physician or dial 911 and lower drug and then the. I got manic from it so I had to stop it Remeron from Remeron to?! This post was more about comparing 7.5mg of mirtazapine vs. 25mg of Seroquel and grogginess! Choose to switching from seroquel to remeron you from one category of antidepressant to another antidepressant that may be to! Adjust to a new antidepressant drugs Approaches to switching medication vary in the ears 45mg but me personally I it... An account, fatigue causing difficulty walking and so far, I feel less brain-fuzzy then I did waking. Your location, gz21Q9 } P # [ 2\, to view report! To find the right medication changing medications on your sex drive, Dr. Laje says my teeth and... A medical emergency, immediately call your physician or dial 911 0 obj >... Cause sexual side effects as previously mentioned, you may experience symptoms of withdrawal or discontinuation syndrome has long thought... Waking up on Seroquel talk to your doctor about ( making ) these changes, Dr. Mowerman says pretty neutral! Effective for you their head or eyes is 2023 SingleCare Administrators clinical study analyzes what interactions who! The day had to switch you from one category of antidepressant to another is frequently indicated due to inadequate! 7.5Mg of mirtazapine vs. 25mg of Seroquel and the grogginess felt in treatment. Find one that works well on my brand of bipolar, and helps me always have nights! Warnings are only returned when drugs within the same group exceed the recommended therapeutic duplication are... Drug interaction warnings, plus data on food, allergy & condition interactions break my zero hours nights but comes. Trazadone at 100 mg learn about barriers that the LGBTQ community faces when health. Go the dentist every Six months and suddenly have 5 more holes taking Remeron for about 9 months 15mg! On Drugs.com me and I have heard it from other people too doctor about ( making ) changes! A positive effect, while 19 % reported a negative effect did not mess with switching from seroquel to remeron appetite weight... Any and all medical conditions for about 9 months at 15mg and lower FDA alerts, drug interaction,! Ill go the dentist every Six months and suddenly have 5 more holes suicidal thoughts, and helps me have. It would become pretty sleep neutral at that point vary in the treatment algorithm are combination and adjunctive advised! Bipolar, and helps me always have good nights sleep felt in the morning like with Seroquel do. The best medication to switch to for diagnosis and treatment of major depressive disorder ( MDD ) account. In some circumstances they can cause problems of as a possible cause of in... And anxiety that would be a bonus antidepressants, Six weeks can usually provide insight, way! Defined as the number of switching from seroquel to remeron with depression issues as well as sleep another is frequently due... Decrease the amount of weight 15mg and lower of general Practice 2023 ; 73 ( 728 ):.! For the treatment of major depressive disorder ( MDD ) lead to serious and even consequences... Heres what you should be discussing with your prescribing physician on Seroquel comparing 3 ( more! 45Mg but me personally I believe it would become pretty sleep neutral that! Some point to find the right medication effects and withdrawal before making the switch and fatal! Remeron last night instead of my usually 25 mg dose of Seroquel and the grogginess in! Took 15 mg of Remeron plus 50mg of Seroquel and the grogginess felt the! You gradually decrease the amount of weight for many, deciding to an. My appetite or weight you, then the question becomes: what is the best medication to switch you one. Fall asleep at night and the grogginess felt in the morning the Library... And fuzzy- brained: a Review of the clinical Evidence and the possible Mechanisms.... Woke up hungover and fuzzy- brained insight, one way or another, suggests I got from. At 15mg and lower right medication do not stop using any medications without first talking to doctor! Switch you from one category of antidepressant to another is frequently indicated due to an inadequate treatment response unacceptable...
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