What is the recommended taper schedule for a patient on paroxetine (selective serotonin reuptake inhibitor, SSRI)?

Paroxetine Tapering Protocol

Paroxetine should be tapered gradually with a reduction of 10% of the daily dose per week until 30% of the original dose is reached, followed by slower 10% weekly reductions of the remaining dose to minimize discontinuation symptoms. 1

Tapering Schedule Guidelines

Standard Tapering Approach

• Initial reduction: 10% of current dose per week
• When reaching 30% of original dose: Slow to 10% of remaining dose per week
• For most patients on standard doses (20mg), this translates to approximately:
  • Weeks 1-2: Reduce by 2-2.5mg per week
  • Weeks 3-4: Reduce by 1-1.5mg per week
  • Final weeks: Reduce by 0.5-1mg per week

Factors Affecting Tapering Speed

• Duration of treatment: Longer treatment periods require slower tapering
• Current dose: Higher doses may need more gradual reduction
• Individual sensitivity: Some patients require even slower tapering
• Previous discontinuation attempts: Failed attempts suggest need for slower approach

Managing Discontinuation Symptoms

Common Discontinuation Symptoms

• Dysphoric mood, irritability, agitation
• Dizziness, sensory disturbances (electric shock sensations)
• Anxiety, confusion, headache
• Emotional lability, insomnia, hypomania 2

Symptom Management

• If intolerable symptoms occur: Resume previously prescribed dose
• After stabilization: Continue tapering at a more gradual rate
• Consider adjunctive medications for specific symptoms:
  • α2-agonists (clonidine, tizanidine) for physical withdrawal symptoms
  • Trazodone for insomnia
  • Gabapentin for anxiety and irritability 1

Special Considerations

High-Risk Populations

• Elderly patients: Start with lower doses and taper more slowly due to higher risk of adverse effects 3
• Patients with comorbid anxiety: May experience more pronounced withdrawal symptoms
• Patients on multiple medications: Check for drug interactions that might complicate tapering

Alternative Approaches

• For patients with severe discontinuation symptoms:
  • Consider cross-tapering to fluoxetine (longer half-life) to ease withdrawal 4
  • In specialized settings, inpatient tapering with daily monitoring may be appropriate for difficult cases 1

Common Pitfalls to Avoid

1. Abrupt discontinuation: This significantly increases risk of withdrawal symptoms 2
2. Tapering too quickly: Even "standard" tapering schedules may be too fast for long-term users
3. Failure to recognize protracted withdrawal: Some symptoms may persist for months after discontinuation
4. Misinterpreting withdrawal as relapse: Withdrawal symptoms can mimic the return of the original condition
5. Inadequate patient education: Patients should be informed about potential withdrawal symptoms before starting the taper

Monitoring During Tapering

• Regular assessment of withdrawal symptoms using standardized scales
• Adjustment of tapering schedule based on individual response
• Continued support and reassurance throughout the process
• Documentation of the tapering schedule and patient response

Remember that paroxetine has one of the highest rates of discontinuation symptoms among SSRIs due to its short half-life and high potency, making careful tapering particularly important for this medication.