Do you have to taper off mirtazapine (Remeron) when discontinuing it?

Tapering Off Mirtazapine: Recommendations for Safe Discontinuation

Yes, mirtazapine should be tapered when discontinuing rather than stopped abruptly to avoid withdrawal symptoms. According to the FDA drug label, mirtazapine should be gradually reduced rather than stopped abruptly whenever possible to prevent adverse reactions upon discontinuation 1.

Why Tapering is Necessary

Abrupt discontinuation of mirtazapine can lead to several withdrawal symptoms:

• Panic attacks occurring within 48 hours of discontinuation 2
• Anxiousness, nausea, tremor, loss of appetite 3
• Sleep disturbances and irritability 4

These withdrawal symptoms can be mistaken for recurrence of the original condition, potentially leading to unnecessary long-term medication continuation 5.

Recommended Tapering Protocol

Based on the available evidence, here's a structured approach to tapering mirtazapine:

1. Initial Reduction: Reduce the dose by approximately 25% of the current dose
2. Timing Between Reductions: Wait 1-2 weeks between dose reductions 1
3. Continued Reduction: Continue reducing by 25% increments until reaching the lowest available dose (typically 7.5mg)
4. Final Discontinuation: After 1-2 weeks at the lowest dose, discontinue completely

This gradual approach is similar to what's recommended for other psychotropic medications that require tapering 4.

Special Considerations

• Duration of Treatment: Patients who have been on mirtazapine for longer periods (months to years) generally require slower tapers than those on short-term treatment 4
• Higher Starting Doses: Patients on higher doses (30-45mg) may benefit from more gradual reductions
• Previous Discontinuation Attempts: If a patient has previously experienced withdrawal symptoms, a more gradual taper is warranted

Managing Withdrawal Symptoms

If withdrawal symptoms occur during tapering:

1. Return to Previous Dose: Go back to the last well-tolerated dose 3
2. Slow the Taper: Reduce the rate of taper (smaller decrements or longer intervals between reductions)
3. Adjunctive Medications: In severe cases, short-term use of medications to manage specific symptoms may be considered 4

Common Pitfalls to Avoid

1. Abrupt Discontinuation: Even at low doses (15mg), abrupt discontinuation can lead to significant withdrawal symptoms 3
2. Mistaking Withdrawal for Relapse: Withdrawal symptoms can mimic depression or anxiety recurrence, potentially leading to unnecessary medication reinstatement 5
3. Insufficient Monitoring: Patients should be monitored during the tapering process for emergence of withdrawal symptoms or relapse of the original condition

Conclusion

Tapering mirtazapine is essential to minimize withdrawal symptoms. The FDA drug label explicitly states that mirtazapine should be gradually reduced rather than stopped abruptly 1. Case reports demonstrate that even after moderate treatment duration (10 weeks), abrupt discontinuation can lead to significant withdrawal symptoms 2, supporting the need for gradual tapering in all cases.