Antidepressant tapering advice

Transcription

1 Antidepressant tapering advice Professor Tony Kendrick et al, NIHR REDUCE Programme in the UK has kindly made this available to New Zealand prescribers as there is little empirical evidence on how to taper antidepressant medication. Disclaimer: the schedules are subject to potential changes in light of experience gathered during the six-year REDUCE programme. It has also originally been designed for the UK prescribers. Modified by Bruce Arroll for New Zealand The sheet has been modified by Professor Bruce Arroll from the Goodfellow Unit at the University of Auckland to apply to currently funded medications in New Zealand. The REDUCE programme advises the use of liquid fluoxetine which is not available in NZ. If a liquid version is required prescribers could consider the dispersible version of fluoxetine which is available and funded. If there is an issue of blinding the patient to the dose then a capable family member could be asked to reduce the dose over the required period of the tapering. It would be prudent for the family member to have this explained to them by a Pharmacist. There are three plans below for plan A, B and C. Antidepressant Reduction Schedules Plan A: Patients on antidepressants with fewer withdrawal problems (sertraline, citalopram, fluoxetine, mirtazapine, escitalopram), with no past history of distressing withdrawal, and no particular fear of undergoing withdrawal over 4-6 weeks Plan B: Patients taking antidepressants associated with more withdrawal symptoms due to particularly short half-lives (paroxetine or venlafaxine) Plan C: Patients who have a history of difficult or distressing withdrawal, or have a particular fear of withdrawing over six weeks or less For each plan, withdrawal can be slowed up if distressing withdrawal symptoms occur. If symptoms are severe, return to the previous dose until symptoms subside then change to a slower taper for future steps. If symptoms are tolerable, continue taking the current dose until the symptoms subside, and then follow then consider changing to a slower taper. All schedules outlined in this section can be achieved without a need for pill cutters or liquids. If a slower taper is needed, in exceptional case you may wish to suggest the patient uses pill cutters or liquid formulations, after discussion with the pharmacist.

2 Plan A Plan A: For patients on antidepressants with fewer withdrawal problems, with no past history of distressing withdrawal, and no particular fear of undergoing withdrawal over 4-6 weeks A.1 Reduce dose by ¼ to ½ every 2-4 weeks, reviewing the patient at intervals as necessary Select an antidepressant from the list below to see the suggested tapering schedule. A.2 For those who have been on antidepressants for >2 years or who are particularly anxious about withdrawal, reductions could be made at longer intervals. Plan B Plan B: For patients taking antidepressants associated with more withdrawal symptoms due to particularly short halflives e.g. paroxetine, and venlafaxine B.1 Convert to an equivalent dose of fluoxetine tablets, stabilise on fluoxetine for at least four weeks, and then taper as in Plan A for fluoxetine. Fluoxetine 20mg is equivalent to: Paroxetine 20mg; Venlafaxine 75mg; Duloxetine 30mg Reduce the dose of the drug, while introducing equivalent doses of fluoxetine E.g. Paroxetine 20mg Fluoxetine 10 mg plus Paroxetine 10mg Fluoxetine 20 mg Fluoxetine 10mg stop

3 B.2 For those who have been on antidepressants for >2 years or who are particularly anxious about withdrawal, reductions could be made at longer intervals. Plan C Plan C: For patients who have a history of difficult or distressing withdrawal, or have a fear of withdrawing over six weeks or less Convert to an equivalent dose of fluoxetine in liquid form (20mg in 5 ml- In New Zealand there are dispersible tablets- a family member may be able to assist by down-titrating the medication) stabilise on fluoxetine for at least four weeks and then reduce by 10% at each step by diluting the liquid, after consulting your local pharmacist about obtaining liquid fluoxetine. Fluoxetine 20mg is equivalent to: Sertraline 50mg; Citalopram 20mg; Mirtazapine 15mg; Escitalopram 10mg; Sertraline Sertraline *Use either half a scored tablet or higher/lower doses on alternate days to achieve daily equivalent.

4 Citalopram Citalopram Use either half a scored tablet or higher/lower doses on alternate days to achieve daily equivalent. Fluoxetine Fluoxetine

5 *Use either half a scored tablet or higher/lower doses on alternate days to achieve daily equivalent. Mirtazapine Mirtazapine Escitalopram Escitalopram

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