Paroxetine (Paxil) taper protocol?

From the Guidelines

Paroxetine should be tapered gradually over several weeks to minimize withdrawal symptoms, with a recommended reduction of 10mg every 2-4 weeks until reaching 20mg, then reducing by 5mg every 2-4 weeks until discontinuation, as supported by the most recent and highest quality study available 1.

Taper Protocol

When tapering paroxetine, it is essential to consider the patient's individual needs and medical history. The taper protocol should be tailored to minimize withdrawal symptoms, which can include dizziness, nausea, headache, electric shock-like sensations, anxiety, and insomnia.

• For patients on 20mg daily, consider decreasing to 10mg for 2-4 weeks, then 5mg for 2-4 weeks before stopping.
• Those on higher doses should follow more gradual reductions.
• Liquid formulations of paroxetine (10mg/5mL) can help with smaller dose reductions, especially in the final stages of discontinuation.

Monitoring and Adjustments

During the taper, monitor for withdrawal symptoms and adjust the taper rate as needed. If withdrawal symptoms occur, slow the taper rate to minimize discomfort and prevent severe symptoms.

• Patients should maintain regular contact with their healthcare provider throughout the tapering process.
• Paroxetine has a relatively short half-life (21 hours) compared to other SSRIs, making it more likely to cause withdrawal symptoms, which is why a slow taper is particularly important.

Key Considerations

• Never stop paroxetine abruptly unless medically necessary.
• Patients should be aware of the potential for increased risk of overdose on abrupt return to a previously prescribed higher dose.
• Clinicians should access appropriate expertise if considering tapering paroxetine during pregnancy or in patients with a history of substance abuse.
• The goal of the taper is to minimize withdrawal symptoms and ensure a safe and successful discontinuation of paroxetine, as recommended by the American College of Physicians 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 paroxetine taper protocol is a gradual reduction in dose, with a suggested regimen of:

• Decreasing the daily dose by 10 mg/day at weekly intervals
• When a daily dose of 20 mg/day is reached, continue for 1 week before stopping treatment If intolerable symptoms occur, consider resuming the previous dose and then decreasing it at a more gradual rate 2

From the Research

Paroxetine Taper Protocol

To minimize the symptoms of antidepressant discontinuation, gradual tapering is necessary for all serotonin reuptake inhibitors (SRIs) except fluoxetine, which has an extended half-life 3. Agents with shorter half-lives such as paroxetine should be tapered gradually.

Tapering Recommendations

• Guidelines recommend short tapers, of between 2 weeks and 4 weeks, down to therapeutic minimum doses, or half-minimum doses, before complete cessation 4.
• However, studies have shown that these tapers show minimal benefits over abrupt discontinuation, and are often not tolerated by patients 4.
• Tapers over a period of months and down to doses much lower than minimum therapeutic doses have shown greater success in reducing withdrawal symptoms 4.
• A hyperbolic tapering program, which reduces doses of SSRIs to minimize their effect on serotonin transporter inhibition in a linear manner, may be effective for paroxetine 4.

Paroxetine Dosage

• The starting dose of paroxetine is 20 mg/day, and the optimal dose is usually 20 mg/day, but can be increased in 10-mg increments to a maximum of 50 mg/day 5.
• The therapeutic dose range in the elderly is 20 mg to 40 mg of paroxetine 5.

Withdrawal Symptoms

• Discontinuation symptoms of paroxetine can be somatic (e.g., dizziness and light-headedness; nausea and vomiting; fatigue, lethargy, myalgia, chills, and other flu-like symptoms; sensory and sleep disturbances) or psychological (anxiety and/or agitation, crying spells, irritability) 3.
• Mild symptoms can often be treated by simply reassuring the patient that they are usually transient, but for more severe symptoms, it may be necessary to reinstitute the dosage of the original antidepressant and slow the rate of taper 3.