What is the protocol for tapering off antipsychotic (psychotropic) medication?

From the Guidelines

Weaning off an antipsychotic medication should always be done under the supervision of a healthcare provider, never independently, with a gradual dose reduction over weeks or months, depending on how long you've been taking the medication and your specific condition. The process typically involves a gradual dose reduction, with the goal of minimizing potential discontinuation effects, such as dyskinesias, parkinsonian symptoms, dystonias, and neuroleptic malignant syndrome 1. For example, if you're on 10mg of olanzapine daily, your doctor might reduce it to 7.5mg for 2-4 weeks, then 5mg for another 2-4 weeks, and so on until discontinuation. Some medications like quetiapine or risperidone may require even slower tapering schedules.

Key Considerations

• The decision to taper antipsychotic medication should be accompanied by a discussion with the patient, their surrogate decision maker, and family members, to review the initial goals, observed benefits and side effects of antipsychotic treatment, and potential risks of continued exposure to antipsychotics 1.
• Nonpharmacological psychosocial interventions, such as redirection and reorientation techniques, environmental interventions, simplifying tasks, participation in activities, optimizing sensorial, ensuring social engagement, and maintaining the sleep-wake cycle, can be effective in reducing antipsychotic medication and mitigating behavioral symptoms in nursing-home residents 1.
• Antipsychotic treatment should be continued for at least 12 months after the beginning of remission, and withdrawal may be considered in individuals stable for several years on antipsychotic treatment, keeping in mind the increased risk of relapse, possible adverse effects of medicines, and individual preferences in consultation with the family 1.

Monitoring and Support

During the tapering process, it is essential to monitor for withdrawal symptoms, such as insomnia, anxiety, agitation, or return of original symptoms. Regular follow-up appointments with your healthcare provider are crucial to assess your response to the dose reductions. Having a support system in place and maintaining other therapeutic interventions like psychotherapy during this transition is vital for maintaining stability. A gradual withdrawal strategy is recommended to minimize potential discontinuation effects, and the tapering schedule should be individualized based on the patient's specific needs and circumstances.

From the FDA Drug Label

2.4 Discontinuation of Treatment Method of treatment discontinuation will vary depending on the patient’s last ANC: ... Reduce the dose gradually over a period of 1 to 2 weeks if termination of clozapine therapy is planned and there is no evidence of moderate to severe neutropenia

To wean off an antipsychotic like clozapine, the dose should be reduced gradually over a period of 1 to 2 weeks if termination of therapy is planned and there is no evidence of moderate to severe neutropenia 2.

• Monitor all patients carefully for the recurrence of psychotic symptoms and symptoms related to cholinergic rebound.
• Key considerations include the patient's last ANC and the presence of moderate to severe neutropenia. It is essential to follow the recommended discontinuation method to minimize potential risks.

From the Research

Weaning Off Antipsychotics

To wean off antipsychotics, it is essential to follow a gradual tapering process to minimize the risk of relapse and withdrawal symptoms. The following steps can be taken:

• Gradually reduce the dose of antipsychotics over months or years, rather than weeks, to allow for adaptations to resolve and reduce the disruption to homeostatic equilibrium 3, 4.
• Reduce the dose by smaller amounts, especially at lower doses, to minimize the risk of psychotic symptoms 3.
• Taper the antipsychotics in a hyperbolic manner, reducing the dose by one quarter or one half of the most recent dose, equivalent to a reduction of 5 or 10 percentage points of D2 blockade, sequentially, at intervals of 3-6 months, titrated to individual tolerance 4.
• Final doses before complete cessation may need to be as small as 1/40th of a therapeutic dose to prevent a large decrease in D2 blockade when stopped 4.

Considerations

When weaning off antipsychotics, the following considerations should be taken into account:

• Specialist advice should be sought when stopping or switching antipsychotics, as withdrawal syndromes, relapse, and rebound can occur if antipsychotics are discontinued abruptly 5.
• The process of reduction is associated with the precipitation or exacerbation of psychotic symptoms, and a slower process of reduction may minimize this effect 3.
• Exacerbation of psychotic symptoms on antipsychotic reduction may not represent evidence of the need for a higher dose of antipsychotic on a long-term basis but may indicate the need for more gradual reduction 3.

Risks and Benefits

The risks and benefits of weaning off antipsychotics should be carefully considered:

• Gradual reduction of antipsychotics may provide time for adaptations made to the presence of the medications to resolve, thus reducing the disruption to homeostatic equilibrium caused by dose reduction, potentially reducing the risk of relapse 3, 4.
• However, the use of high-dose augmentations may be associated with an increased risk of hospitalization due to psychosis 6.
• Clozapine may be more efficacious than other atypical antipsychotics for treatment-resistant schizophrenia, but it entails a significant risk of serious blood disorders and other side effects 7.