How to taper mirtazapine 7.5 mg?

Tapering Mirtazapine 7.5 mg

For safe discontinuation of mirtazapine 7.5 mg, implement a gradual taper by reducing the dose by 10% of the original dose per month, which means cutting the 7.5 mg tablet into quarters (approximately 1.875 mg reductions) and extending the interval between doses in the final stages. 1

Understanding Mirtazapine Discontinuation

Mirtazapine is a noradrenergic and specific serotonergic antidepressant (NaSSA) with an elimination half-life of 20-40 hours 2, 3. The FDA label specifically warns about discontinuation syndrome and advises patients "not to abruptly discontinue mirtazapine tablets and to discuss any tapering regimen with their healthcare provider" 1.

Tapering Approach

While there are no specific guidelines for mirtazapine tapering, we can apply principles from tapering other psychotropic medications:

1. Initial Reduction: Since you're already at a low dose (7.5 mg), implement a slow taper:

   • Reduce by approximately 1.875 mg (25% of current dose) every 2-4 weeks
   • This can be accomplished by cutting the 7.5 mg tablet into quarters

2. Tapering Schedule:

   • Weeks 1-4: Continue 7.5 mg daily
   • Weeks 5-8: 5.625 mg daily (¾ of a 7.5 mg tablet)
   • Weeks 9-12: 3.75 mg daily (½ of a 7.5 mg tablet)
   • Weeks 13-16: 1.875 mg daily (¼ of a 7.5 mg tablet)
   • Weeks 17-20: 1.875 mg every other day
   • Then discontinue

3. Final Phase: When reaching the smallest practical dose (1.875 mg), extend the interval between doses before complete discontinuation 4

Monitoring for Withdrawal Symptoms

Even at low doses, abrupt discontinuation of mirtazapine can cause withdrawal symptoms. A case report documented severe panic attacks occurring after sudden discontinuation of mirtazapine at 30 mg/day, which persisted until the medication was reintroduced 5.

Common withdrawal symptoms to monitor for include:

• Anxiety and agitation
• Sleep disturbances
• Dizziness
• Nausea
• Headache
• Mood changes

Adjusting the Taper

If withdrawal symptoms emerge during the taper:

• Return to the previous well-tolerated dose
• Stabilize for 2-4 weeks
• Resume tapering at a slower rate (e.g., 5% reductions instead of 10%) 4

Special Considerations

• Timing: Conduct the taper during a period of relative stability in the patient's life
• Support: Consider non-pharmacological interventions like cognitive-behavioral therapy during the tapering process
• Monitoring: Weekly contact during active tapering is recommended to assess for withdrawal symptoms or depression recurrence 4

Distinguishing Withdrawal from Recurrence

It's important to differentiate withdrawal symptoms from recurrence of the underlying condition:

• Withdrawal symptoms typically emerge within days of dose reduction
• Withdrawal symptoms are often somatic (dizziness, nausea, headache)
• Recurrence symptoms typically develop more gradually and mirror the original condition

Remember that even at low doses like 7.5 mg, a hyperbolic tapering approach that reaches very small doses may minimize withdrawal symptoms 6.