What is the recommended protocol for tapering paroxetine (selective serotonin reuptake inhibitor, SSRI)?

From the Guidelines

Paroxetine should be tapered slowly over several weeks to months to minimize withdrawal symptoms, with typical reductions of 5-10% of the dose every 2-4 weeks. This approach is supported by the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders, which notes that a discontinuation syndrome has been reported following missed doses or acute discontinuation of shorter-acting SSRIs, notably paroxetine 1. For patients on standard doses (20-40mg daily), it is recommended to begin by reducing the dose by 5mg every 2-4 weeks, with smaller reductions of 2.5mg as the dose gets lower (below 20mg).

Some key considerations when tapering paroxetine include:

• The taper should be even more gradual in the final stages, potentially using liquid formulations (2mg/ml) to allow for tiny decrements of 1mg or less
• Patients should be monitored for withdrawal symptoms including dizziness, electric shock-like sensations, anxiety, irritability, insomnia, and flu-like symptoms
• If withdrawal symptoms occur, the taper should be slowed or the previous dose temporarily reinstated until symptoms stabilize
• Paroxetine requires particularly careful tapering compared to other SSRIs due to its short half-life (21 hours) and high potency for serotonin reuptake inhibition, which increases the risk of discontinuation syndrome, as noted in the guideline 1

It is also important to note that some patients may need 6 months or longer to completely discontinue the medication, especially those who have been on long-term treatment. Medical education, training, and experience are necessary to safely and effectively prescribe and taper antidepressant medications, including paroxetine 1.

From the FDA Drug Label

A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose but at a more gradual rate The taper-phase regimen used in GAD and PTSD clinical trials involved an incremental decrease in the daily dose by 10 mg/day at weekly intervals When a daily dose of 20 mg/day was reached, patients were continued on this dose for 1 week before treatment was stopped.

The recommended protocol for tapering paroxetine is a gradual reduction in dose. The dose should be decreased by 10 mg/day at weekly intervals. When a daily dose of 20 mg/day is reached, the patient should be continued on this dose for 1 week before treatment is stopped. If intolerable symptoms occur, the previously prescribed dose may be resumed, and the dose decreased at a more gradual rate 2.

From the Research

Tapering Paroxetine: Recommended Protocol

To minimize symptoms of antidepressant discontinuation, gradual tapering is necessary for paroxetine, a selective serotonin reuptake inhibitor (SSRI) with a shorter half-life 3. The recommended protocol for tapering paroxetine involves:

• Gradual tapering to minimize discontinuation symptoms, which can be somatic or psychological 3
• Tapering over a period of months, rather than weeks, to reduce withdrawal symptoms 4
• Hyperbolic reduction of doses to minimize the effect on serotonin transporter inhibition in a linear manner 4
• Using tapering strips to facilitate personalized titration of discontinuation and reduce withdrawal symptoms 5

Key Considerations

When tapering paroxetine, consider the following:

• The optimal therapeutic dose for most patients is 20 mg/day, with a maximum dose of 50 mg/day 6, 7
• The therapeutic dose range in the elderly is 20 mg to 40 mg of paroxetine 7
• Females and individuals with more severe experience of withdrawal, longer use of antidepressant medication, and more previous attempts at discontinuation may be less likely to successfully discontinue paroxetine using tapering strips 5

Tapering Strategies

Different tapering strategies can be used, including:

• Short tapers of 2-4 weeks, which may not be effective in reducing withdrawal symptoms 4
• Longer tapers of several months, which can be more effective in reducing withdrawal symptoms 4
• Hyperbolic tapering, which involves reducing doses in a non-linear fashion to minimize the effect on serotonin transporter inhibition 4
• Using tapering strips, which can facilitate personalized titration of discontinuation and reduce withdrawal symptoms 5