What is the recommended procedure for discontinuing Auvelity (dextromethorphan/bupropion)?

Discontinuing Auvelity (Dextromethorphan/Bupropion)

When discontinuing Auvelity, patients should taper the dose by reducing to 150 mg once daily for at least one week prior to complete discontinuation to minimize withdrawal symptoms and relapse risk.

Recommended Discontinuation Protocol

Step-by-Step Tapering Approach

1. Initial Dose Reduction:

   • Reduce from the standard 300 mg daily dose to 150 mg once daily in the morning
   • Maintain this reduced dose for at least 7 days 1

2. Monitoring During Taper:

   • Watch for withdrawal symptoms including:
     • Anxiety
     • Irritability
     • Insomnia
     • Dizziness
     • Headaches
     • Sensory disturbances

3. Complete Discontinuation:

   • After at least 7 days at the reduced dose, discontinue completely
   • Schedule follow-up within 1-2 weeks after complete discontinuation 2

Special Considerations

Withdrawal Symptoms Management

• If withdrawal symptoms emerge during tapering:
  • Consider slowing the taper further (extending the 150 mg daily period)
  • Implement adjunctive treatments for specific symptoms (e.g., short-term sleep aids for insomnia)
  • Do not abruptly discontinue as this increases risk of withdrawal symptoms 3

High-Risk Situations

• Patients with history of seizures: Extra caution needed as bupropion carries seizure risk; consider even more gradual taper 1
• Patients with anxiety disorders: May be more sensitive to discontinuation effects; monitor closely for rebound anxiety 2
• Patients on concomitant medications: Check for drug interactions that might be affected by discontinuation

Alternative Approaches for Difficult Cases

For patients experiencing significant difficulty with standard tapering:

1. Extended Taper:

   • Consider reducing by smaller increments (e.g., alternating 300 mg and 150 mg every other day for 1-2 weeks before moving to 150 mg daily)
   • This approach may be particularly helpful for patients with sensitivity to medication changes 4

2. Adjunctive Support:

   • Consider adding psychological support during discontinuation
   • Evidence suggests cognitive therapy or mindfulness-based cognitive therapy during tapering may improve discontinuation success rates 5

Contraindications to Rapid Discontinuation

Abrupt discontinuation should be avoided except in cases of:

• Confirmed serious medical toxicity
• Severe allergic reactions
• Development of seizures

Even in these cases, patients should be monitored closely for withdrawal effects 3, 2

Follow-Up Recommendations

• Schedule follow-up appointment 1-2 weeks after complete discontinuation
• Monitor for:
  • Return of depressive symptoms (distinct from withdrawal)
  • Persistent withdrawal symptoms
  • Need for alternative treatment

Common Pitfalls to Avoid

1. Confusing withdrawal symptoms with relapse: Withdrawal symptoms typically emerge within days of dose reduction and gradually resolve, while true relapse develops more gradually and persists 5

2. Inadequate duration of taper: Tapering too quickly can lead to unnecessary discomfort and discontinuation failure 3

3. Lack of patient preparation: Educate patients about potential withdrawal symptoms before initiating taper to reduce anxiety about the process

4. Abandoning patients during discontinuation: Ensure adequate support and follow-up during the tapering process 3

By following this structured approach to discontinuing Auvelity, clinicians can help minimize withdrawal symptoms and optimize patient outcomes during the discontinuation process.