What is the recommended tapering schedule for deprescribing antipsychotics like olanzapine (olanzapine) or risperidone (risperidone) according to Maudsley guidelines?

Antipsychotic Tapering Schedule According to Maudsley Guidelines

According to clinical evidence, antipsychotics like olanzapine and risperidone should be tapered gradually over 2-4 weeks, with dose reductions of approximately 25% of the most recent dose at intervals that allow for monitoring of withdrawal symptoms and potential relapse.

General Principles for Antipsychotic Tapering

Tapering Rate

• For most patients, a reduction of 25% of the most recent dose (not the original dose) is recommended
• Allow 1-2 weeks between dose reductions to monitor for withdrawal symptoms or symptom recurrence
• More gradual tapering (over months rather than weeks) may be necessary for:
  • Patients on long-term treatment (>1 year)
  • Elderly patients
  • Those with history of relapse with previous discontinuation attempts

Specific Tapering Approaches

Olanzapine Tapering

• Start with reducing dose by 25% of the most recent dose
• Example for 10mg daily dose:
  • Week 1-2: Reduce to 7.5mg daily
  • Week 3-4: Reduce to 5mg daily
  • Week 5-6: Reduce to 2.5mg daily
  • Week 7-8: Discontinue

Risperidone Tapering

• Start with reducing dose by 25% of the most recent dose
• Example for 4mg daily dose:
  • Week 1-2: Reduce to 3mg daily
  • Week 3-4: Reduce to 2mg daily
  • Week 5-6: Reduce to 1mg daily
  • Week 7-8: Reduce to 0.5mg daily (if available)
  • Week 9-10: Discontinue

Evidence-Based Considerations

Research indicates that slower tapering of antipsychotics is associated with lower relapse rates than rapid discontinuation 1. A hyperbolic tapering approach (where reductions become smaller as the total dose decreases) may be particularly effective for minimizing withdrawal symptoms 2.

One randomized study specifically examining olanzapine discontinuation found that the slowest tapering strategy (100% dose for 1 week, then 50% for second week, then discontinued) had the lowest treatment discontinuation rate (12%) compared to more abrupt strategies (25-28% discontinuation) 3.

Monitoring During Tapering

• Assess for withdrawal symptoms at each follow-up:

  • Insomnia
  • Anxiety
  • Agitation
  • Return of psychotic symptoms
  • Autonomic symptoms (sweating, tachycardia)

• If significant withdrawal symptoms or symptom recurrence occurs:

  • Return to previous dose
  • Consider an even more gradual taper (10% reductions)
  • Extend the interval between dose reductions to 3-4 weeks

Special Considerations

Switching Between Antipsychotics

When switching from one antipsychotic to another, evidence suggests either immediate or gradual discontinuation can be viable options 4. However, for patients with a history of relapse or sensitivity to medication changes, a cross-titration approach is preferred:

1. Start the new antipsychotic at a low dose
2. Gradually increase the new medication over 1-2 weeks
3. Once the new medication reaches therapeutic dose, begin tapering the original antipsychotic

Cognitive Function and Symptom Impact

Research indicates that dose reduction of risperidone or olanzapine by 50% may actually improve cognitive function and negative symptoms in stable patients 5. This suggests that many patients may benefit from lower maintenance doses even if complete discontinuation is not the goal.

Potential Pitfalls to Avoid

• Tapering too quickly: This increases risk of withdrawal symptoms and relapse
• Failing to monitor: Regular assessment during tapering is essential
• Rigid adherence to schedule: Tapering should be individualized based on patient response
• Discontinuing without support: Ensure appropriate psychosocial support is in place

Remember that successful deprescribing requires a multidisciplinary approach, including nursing team members who can monitor and report patient responses to medication reductions 6.