What is the recommended approach for deprescribing antipsychotics, such as olanzapine (olanzapine) or risperidone (risperidone), in patients on long-term therapy?

Deprescribing Antipsychotics in Long-Term Therapy

When deprescribing antipsychotics in patients on long-term therapy, a gradual withdrawal strategy over a period greater than 1 month is strongly recommended to minimize potential discontinuation effects including dyskinesias, parkinsonian symptoms, dystonias, and neuroleptic malignant syndrome. 1

Assessment Before Deprescribing

• Evaluate clinical stability and duration of stability
• Determine original indication for antipsychotic therapy
• Assess for ongoing symptoms that might worsen with discontinuation
• Consider risk factors for relapse:
  • History of multiple relapses
  • Severity of previous episodes
  • Incomplete remission

Deprescribing Protocol

For Schizophrenia and Related Disorders:

1. Timing of Deprescription:

   • Consider withdrawal only in individuals stable for several years on antipsychotic treatment 1
   • Antipsychotic treatment should be continued for at least 12 months after the beginning of remission 1

2. Tapering Schedule:

   • Gradual withdrawal extending over a period greater than 1 month 1
   • Reduce dose by approximately 25% every 4-8 weeks
   • Monitor for withdrawal symptoms or symptom recurrence at each step

3. Monitoring During Tapering:

   • Regular assessment for emergence of psychotic symptoms
   • Watch for discontinuation effects (dyskinesias, parkinsonian symptoms)
   • Be prepared to re-escalate dosing if withdrawal symptoms cause patient distress 1

For Dementia-Related Behavioral Disturbances:

1. Tapering Approach:

   • Complete withdrawal is achievable in approximately 80% of long-term care patients 2
   • Reduce to minimum effective dose in remaining patients

2. Implementation Strategy:

   • Establish a multidisciplinary team including pharmacist involvement
   • Implement non-pharmacological interventions before and during tapering
   • Monitor for neuropsychiatric symptom changes

Non-Pharmacological Support During Deprescribing

Implement psychosocial interventions to support antipsychotic reduction:

• Caregiver education on redirection and reorientation techniques
• Environmental modifications
• Task simplification
• Structured activities
• Optimization of sensory input
• Social engagement opportunities
• Sleep-wake cycle maintenance 1

Special Considerations

1. Dose Optimization Before Discontinuation:

   • Consider dose reduction by 50% before complete discontinuation, which may improve cognitive function and negative symptoms while maintaining stability 3
   • Dose reduction of risperidone or olanzapine by 50% has shown improvements in processing speed, working memory, and negative symptoms without worsening other symptoms 3

2. Monitoring for Relapse:

   • Most frequent during first 6 months after discontinuation
   • Continue monitoring for at least 2 years after complete discontinuation
   • Document baseline symptoms to enable early detection of recurrence

3. Addressing Common Pitfalls:

   • Avoid abrupt discontinuation which increases risk of rebound symptoms
   • Be aware that antipsychotics are often continued as maintenance treatment without ongoing assessment of need 4
   • Regular medication reviews are often recommended (62% of cases) but not implemented 4
   • Ensure proper informed consent for both continuation and discontinuation

4. Shared Decision Making:

   • Involve patient and family in the deprescribing decision 1
   • Discuss risks of continued treatment versus risks of discontinuation
   • Consider patient preferences regarding oral versus depot preparations 1

The evidence supports that gradual tapering of antipsychotics is safer than immediate discontinuation, particularly for patients who have been on long-term therapy. While some studies show no significant differences between immediate and gradual discontinuation 5, the potential serious risks of abrupt discontinuation make gradual tapering the preferred approach, especially given the minimal downside of a more cautious approach.