Tapering Austedo (Deutetrabenazine)
Austedo should be tapered gradually by reducing the dose by 6 mg per day at weekly intervals until discontinuation, rather than stopping abruptly, to minimize withdrawal symptoms and rebound of chorea or tardive dyskinesia.
Recommended Tapering Protocol
Based on the FDA-approved prescribing information, the tapering approach for Austedo should mirror the titration schedule in reverse 1:
Standard Taper Schedule
- Reduce by 6 mg per day each week until reaching the lowest dose
- For patients on AUSTEDO XR (once-daily): Decrease by 6 mg increments weekly
- For patients on AUSTEDO (twice-daily): Decrease total daily dose by 6 mg weekly, adjusting the divided doses accordingly
- Continue weekly reductions until complete discontinuation
Practical Example for Twice-Daily Formulation
If a patient is taking 12 mg twice daily (24 mg/day total):
- Week 1: Reduce to 9 mg twice daily (18 mg/day)
- Week 2: Reduce to 6 mg twice daily (12 mg/day)
- Week 3: Reduce to 6 mg once daily (6 mg/day)
- Week 4: Discontinue
Clinical Considerations During Tapering
Monitor for Withdrawal Effects
While specific withdrawal symptoms from deutetrabenazine are not extensively documented in the evidence, as a VMAT2 inhibitor affecting dopamine regulation, monitor for:
- Rebound chorea or tardive dyskinesia (worsening of the original movement disorder)
- Psychiatric symptoms (anxiety, depression, agitation)
- Sleep disturbances
- Akathisia or restlessness
Slower Tapers May Be Needed
For patients who have been on Austedo long-term (>6 months) or at higher doses (>36 mg/day), consider:
- Reducing by 6 mg every 2 weeks instead of weekly
- Pausing the taper if withdrawal symptoms emerge
- Temporarily increasing the dose if severe rebound symptoms occur, then resuming a slower taper
This approach aligns with general principles for tapering CNS-active medications 2, 3, 4.
Special Populations
Poor CYP2D6 metabolizers: These patients have higher drug exposure and may require even more gradual tapering to avoid withdrawal effects 1.
Patients switching to alternative therapy: If transitioning to another VMAT2 inhibitor or alternative treatment for chorea/tardive dyskinesia, coordinate the taper with initiation of the new medication to maintain symptom control.
Common Pitfalls to Avoid
- Abrupt discontinuation: Never stop Austedo suddenly, as this will likely cause rapid return of chorea or tardive dyskinesia symptoms 4
- Too-rapid tapering: Reducing faster than 6 mg/week may precipitate withdrawal symptoms
- Inadequate monitoring: Schedule follow-up visits during the taper to assess for symptom recurrence
- Ignoring patient distress: If rebound symptoms cause significant functional impairment, slow or pause the taper
Documentation and Patient Education
Inform patients that:
- Movement symptoms (chorea or tardive dyskinesia) will likely return as the medication is tapered
- The taper process typically takes 3-8 weeks depending on the starting dose
- They should report any worsening psychiatric symptoms immediately
- Abrupt discontinuation increases risk of severe symptom rebound
The gradual weekly reduction approach balances the need to safely discontinue the medication while minimizing withdrawal effects and allowing time to assess symptom recurrence 1, 5.