the timing of when to stop antidepressant treatment is discussed in menu item below (length of antidepressant treatment)
patients should be advised not to stop treatment suddenly or omit doses - patients should also be forewarned about possible symptoms that may occur when treatment is discontinued
Drug and Therapeutics Bulletin (1) advises:
after a 'standard' 6-8 months treatment it is recommended that treatment should be tapered off over a 6-8 week period
if the patient has been on maintenance therapy then an even more gradual tapering e.g. by 1/4 of the treatment dose every 4-6 weeks, is advised
if a treatment course has lasted less than 8 weeks then discontinuation over 1-2 weeks is considered safe
this contrasts with the Maudsley prescribing guidelines (2) which recommend that antidepressants should be withdrawn slowly, preferably over four weeks, by weekly increments for example,
Drug
maintenance dose (mg/day)
dose after 1st week (mg/day)
dose after 2nd week (mg/day)
dose after 3rd week (mg/day)
dose after 4th week (mg/day)
amitriptyline
150
100
50
25
Nil
paroxetine
30
20
10
5 (liquid)
Nil
trazadone
450
300
150
75
Nil
If withdrawal symptoms occur then the rate of drug withdrawal should be slowed or (if the drug has been stopped) the patient should be given reassurance that symptoms rarely last more than 1-2 weeks (2).
NICE also suggest a four week period for withdrawal of antidepressant treatment (4):
stopping or reducing antidepressants
advise people that discontinuation symptoms may occur on stopping, missing doses or, occasionally, reducing the dose of the drug. Explain that these are usually mild and self-limiting over about 1 week, but can be severe, particularly if the drug is stopped abruptly
normally, gradually reduce the dose over 4 weeks (this is not necessary with fluoxetine). Reduce the dose over longer periods for drugs with a shorter half-life (for example, paroxetine and venlafaxine)
advise the person to see their practitioner if they experience significant discontinuation symptoms. If symptoms occur:
monitor them and reassure the person if symptoms are mild
consider reintroducing the original antidepressant at the dose that was effective (or another antidepressant with a longer half-life from the same class) if symptoms are severe, and reduce the dose gradually while monitoring symptoms
for detailed guidance then consult the full guideline (4)
Swapping antidepressant treatment (2):
week 1
week 2
week 3
week 4
withdrawing dosulepin
150 mg od
100mg od
50 mg od
25 mg od
Nil
introducing citalopram
Nil
10 mg od
10mg od
20 mg od
20 mg od
Vortioxetine switching (3)
vortioxetine is a new antidepressant and there is limited experience when switching, therefore extra caution is required, particularly when switching to or from inhibitors of CYP2D6, such as fluoxetine and paroxetine
when switching to another antidepressant, doses above 10mg should be reduced to 10mg over a period of 7 days before stopping and starting the new antidepressant
Antidepressant use: swapping and stopping
The tables below have been adapted from the Maudsley prescribing guidelines (2,3). However it is recommended that local prescribing guidelines and/or specialist psychiatric advice must be consulted when swapping antidepressant medication. Also the specific summary of product characteristics for each of the antidepressants involved should be consulted. It has been noted that there are no clear guidelines on switching antidepressants, so caution is required (2).
Table showing switching from either:
fluoxetine 20mg per day, or
a tricyclic antidepressant, or
clomipramine, or
venlfaxine
to an alternative antidepressant
Table showing switching from either:
citalopram, escitalopram, paroxetine or sertraline; OR
fluvoxamine
to an alternative antidepressant
Table showing switching from either:
duloextine, OR,
mirtazapine, OR,
reboxetine, OR,
agomelatne, OR,
vortioxetine
to an alternative antidepressant
NICE guidance regarding switching antidepressants is less detailed (4):
do not switch to, or start, dosulepin
because evidence supporting its tolerability relative to other antidepressants is outweighed by the increased cardiac risk and toxicity in overdose
when switching to another antidepressant, which can normally be achieved within 1 week when switching from drugs with a short half life, consider the potential for interactions in determining the choice of new drug and the nature and duration of the transition. Exercise particular caution when switching:
from fluoxetine to other antidepressants, because fluoxetine has a long half-life (approximately 1 week)
from fluoxetine or paroxetine to a TCA, because both of these drugs inhibit the metabolism of TCAs; a lower starting dose of the TCA will be required, particularly if switching from fluoxetine because of its long half-life
to a new serotonergic antidepressant or MAOI, because of the risk of serotonin syndrome
from a non-reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed routinely during this period).
Notes:
do not co-administer clomipramine and SSRIs or venlafaxine
when switching between one SSRI and another, some consider cross-tapering the doses generally not to be necessary (6,7)
selective serotonin reuptake inhibitors (SSRIs) overlap in their mechanism of action, and the new SSRI will usually prevent discontinuation symptoms that may occur when the first SSRI is stopped. Substituting a new SSRI at the relatively equivalent dose of the former SSRI is typically well-tolerated , though starting the new SSRI at a lower dose may also be considered since patients occasionally have idiosyncratic side effects to particular SSRIs (5)
the New Zealand formularly guidance (6) supports no need for cross-tapering for switching between short acting SSRIs (citalopram, escitalopram, paroxetine, sertraline) - but for switches from fluoxetine then it supports the Maudsley guidance and states
the effects of the first SSRI are likely to be so similar to that of the second one, that the second SSRI will reduce the discontinuation effects of the first (2). The abrupt switch between SSRIs may still produce discontinuation symptoms, and vigilance is still advised. In cases where discontinuation symptoms arise a short period of dose tapering is recommended before starting a different SSRI
* withdrawal effects may be more pronounced. Slow withdrawal over 1-2 months may be necessary
Reference:
Drug and Therapeutics Bulletin (1999); 37 (7):49-52.
The Maudsley Prescribing Guidelines 2001; 6th Ed, p64 - 65.
UKMi (NHS). How do you switch between tricyclic, SSRI and related antidepressants? (November 2015)
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