stopping and/or swapping antidepressant treatment

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stopping and/or swapping antidepressant treatment

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Stopping antidepressant treatment

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recommend that antidepressants should be withdrawn slowly,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 (3):

normally gradually reduce the doses of the drug over a 4-week

period, although some people may require longer periods. Fluoxetine

can usually be stopped over a shorter period

if discontinuation/withdrawal symptoms are mild, practitioners

should reassure the patient and monitor symptoms. If symptoms are

severe, the practitioner should consider reintroducin the original

antidepressant at the dose that was effective (or another

antidepressant with a longer half-life from the same class) and

reduce gradually while monitoring symptoms

for detailed guidance then consult the full guideline (3)

Swapping antidepressant treatment (2):

when swapping from one antidepressant to another, abrupt withdrawal

should usually be avoided. Cross-tapering is preferred, where the

dose of the ineffective or poorly tolerated drug is slowly reduced

while the new drug is slowly introduced for example, week 1 week

2 week 3 week 4

withdrawing dothiepin 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

Antidepressant use: swapping and stopping

The table below has been adapted from the Maudsley prescribing

guidelines (2). 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).

changing from to tricyclics to citalopram to fluoxetine to

paroxetine to sertraline to venlafaxine

tricyclics (TCA) cross taper cautiously halve dose and add

citalopram then slow withdrawal halve dose and add fluoxetine then

slow withdrawal halve dose and add paroxetine then slow withdrawal

halve dose and add sertraline then slow withdrawal cross taper

cautiously starting with 37.5 mg per day

citalopram cross taper cautiously withdraw citalopram then start

fluoxetine withdraw citalopram and then start paroxetine at 10 mg

per day withdraw citalopram and then start sertraline at 25 mg per

day withdraw and then start venlafaxine at 37.5 mg per day. Increase

very slowly

fluoxetine stop fluoxetine. Start tricyclic at very low dose and

increase very slowly stop fluoxetine. Wait 4-7 days; start

citalopram at 10mg per day and increase slowly stop fluoxetine.

Wait 4-7 days; start paroxetine at 10mg per day and increase slowly

stop fluoxetine. Wait 4-7 days; start sertraline at 25 mg per day

and increase slowly stop fluoxetine. Waite 4-7 days; start

venlafaxine at 37.5 mg per day. Increase very slowly

paroxetine cross taper cautiously with very low dose of tricyclic

withdraw paroxetine then start citalopram withdraw paroxetine then

start fluoxetine withdraw paroxetine then start sertraline at 25

mg per day withdraw paroxetine. Start venlafaxine at 37.5 mg per

day. Increase very slowly

sertraline cross taper cautiously with very low dose of tricyclic

withdraw sertraline then start citalopram withdraw sertraline then

start fluoxetine withdraw sertraline then start paroxetine

withdraw sertraline then start venlafaxine at 37.5 mg per day

venlafaxine cross taper cautiously with very low dose of tricycli

cross taper cautiously. Start with citalopram 10 mg per day crosss

taper cautiously. Start with 20 mg every other day cross taper

cautiously. Start with 10 mg per day. cross taper cautiously. Start

with 25 mg per day

stopping reduce over four weeks reduce over four weeks at 20mg per

day - just stop

at 40 mg per day, reduce over four weeks

reduce over four weeks, or longer if necessary * reduce over four

weeks reduce over four weeks or longer if necessary

Notes:

Do not co-administer clomipramine and SSRIs or venlafaxine

When switching between one SSRI and another, cross-tapering the

doses is generally not considered necessary. 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

were 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.

NICE (December 2004). Management of depression in primary and

secondary care.

[Guest guest]

***** What the GP is told from his/her on-line note book !!!! *****

stopping and/or swapping antidepressant treatment

Medical search

http://www.gpnotebook.co.uk/simplepage.cfm?

ID=1630863432 & linkID=12579 & cook=yes

Stopping antidepressant treatment

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 (3):

normally gradually reduce the doses of the drug over a 4-week

period, although some people may require longer periods. Fluoxetine

can usually be stopped over a shorter period

if discontinuation/withdrawal symptoms are mild, practitioners

should reassure the patient and monitor symptoms. If symptoms are

severe, the practitioner should consider reintroducin the original

antidepressant at the dose that was effective (or another

antidepressant with a longer half-life from the same class) and

reduce gradually while monitoring symptoms

for detailed guidance then consult the full guideline (3)

Swapping antidepressant treatment (2):

when swapping from one antidepressant to another, abrupt withdrawal

should usually be avoided. Cross-tapering is preferred, where the

dose of the ineffective or poorly tolerated drug is slowly reduced

while the new drug is slowly introduced for example, week 1 week

2 week 3 week 4

withdrawing dothiepin 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

Antidepressant use: swapping and stopping

The table below has been adapted from the Maudsley prescribing

guidelines (2). 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).

changing from to tricyclics to citalopram to fluoxetine to

paroxetine to sertraline to venlafaxine

tricyclics (TCA) cross taper cautiously halve dose and add

citalopram then slow withdrawal halve dose and add fluoxetine then

slow withdrawal halve dose and add paroxetine then slow withdrawal

halve dose and add sertraline then slow withdrawal cross taper

cautiously starting with 37.5 mg per day

citalopram cross taper cautiously withdraw citalopram then start

fluoxetine withdraw citalopram and then start paroxetine at 10 mg

per day withdraw citalopram and then start sertraline at 25 mg per

day withdraw and then start venlafaxine at 37.5 mg per day. Increase

very slowly

fluoxetine stop fluoxetine. Start tricyclic at very low dose and

increase very slowly stop fluoxetine. Wait 4-7 days; start

citalopram at 10mg per day and increase slowly stop fluoxetine.

Wait 4-7 days; start paroxetine at 10mg per day and increase slowly

stop fluoxetine. Wait 4-7 days; start sertraline at 25 mg per day

and increase slowly stop fluoxetine. Waite 4-7 days; start

venlafaxine at 37.5 mg per day. Increase very slowly

paroxetine cross taper cautiously with very low dose of tricyclic

withdraw paroxetine then start citalopram withdraw paroxetine then

start fluoxetine withdraw paroxetine then start sertraline at 25

mg per day withdraw paroxetine. Start venlafaxine at 37.5 mg per

day. Increase very slowly

sertraline cross taper cautiously with very low dose of tricyclic

withdraw sertraline then start citalopram withdraw sertraline then

start fluoxetine withdraw sertraline then start paroxetine

withdraw sertraline then start venlafaxine at 37.5 mg per day

venlafaxine cross taper cautiously with very low dose of tricycli

cross taper cautiously. Start with citalopram 10 mg per day crosss

taper cautiously. Start with 20 mg every other day cross taper

cautiously. Start with 10 mg per day. cross taper cautiously. Start

with 25 mg per day

stopping reduce over four weeks reduce over four weeks at 20mg per

day - just stop

at 40 mg per day, reduce over four weeks

reduce over four weeks, or longer if necessary * reduce over four

weeks reduce over four weeks or longer if necessary

Notes:

Do not co-administer clomipramine and SSRIs or venlafaxine

When switching between one SSRI and another, cross-tapering the

doses is generally not considered necessary. 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

were 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.

NICE (December 2004). Management of depression in primary and

secondary care.