Can I discontinue paroxetine (Paxil) and add trazodone?

Transitioning from Paroxetine to Trazodone

Switching from paroxetine to trazodone is not recommended due to the risk of withdrawal syndrome and potential serotonin syndrome, but if necessary, a careful cross-taper approach should be implemented with close monitoring.

Risks of Discontinuing Paroxetine

Paroxetine has one of the highest risks of discontinuation syndrome among SSRIs due to its short half-life 1. The FDA label specifically warns against abrupt discontinuation:

• Withdrawal symptoms typically begin within 24-48 hours after discontinuation, peak around day 5, and can last 2-3 weeks 1
• Common symptoms include dizziness, sensory disturbances (electric shock sensations), anxiety, irritability, insomnia, headache, and flu-like symptoms 2
• The FDA recommends "a gradual reduction in dose rather than abrupt cessation" for paroxetine 2

Trazodone as an Alternative

Trazodone is primarily FDA-approved for Major Depressive Disorder but is commonly used off-label for:

• Insomnia (primary or secondary)
• Anxiety disorders
• Prevention of SSRI side effects such as anxiety, insomnia, and sexual dysfunction 3

While trazodone may be beneficial for sleep issues, it's important to note that clinical guidelines state that "certain antidepressants (amitriptyline, doxepin, mirtazapine, paroxetine, trazodone) are employed in lower than antidepressant therapeutic dosages for the treatment of insomnia" but "their efficacy for this indication is not well established" 4.

Cross-Tapering Approach

If transitioning is necessary, a cross-taper approach is safest:

1. Week 1-2: Begin trazodone at a low dose (25-50mg at bedtime) while maintaining current paroxetine dose
2. Week 3-6: Gradually reduce paroxetine by no more than 10mg per week while slowly increasing trazodone dose
3. Week 7-8: Complete paroxetine taper and adjust trazodone to therapeutic dose (typically 150-300mg for depression)

Monitoring During Transition

During the cross-taper period, monitor closely for:

1. Serotonin syndrome: Both medications affect serotonin, and combining them may increase risk of serotonin syndrome, characterized by:

   • Mental status changes (confusion, agitation)
   • Neuromuscular hyperactivity (tremors, hyperreflexia)
   • Autonomic hyperactivity (hypertension, tachycardia) 4

2. Withdrawal symptoms: Monitor for paroxetine withdrawal symptoms as described above

3. Therapeutic response: Assess if trazodone is effectively managing symptoms

Special Considerations

• Cardiovascular effects: Trazodone may cause orthostatic hypotension and arrhythmias, requiring careful monitoring especially in elderly patients 5
• Sedation: Trazodone is highly sedating and should be taken at bedtime 5
• Sexual function: While paroxetine commonly causes sexual dysfunction, trazodone may have fewer sexual side effects but can rarely cause priapism 5

Alternatives to Consider

If the goal is to address specific side effects of paroxetine:

• For insomnia: Consider non-pharmacological approaches or dedicated sleep medications before adding another antidepressant
• For sexual dysfunction: Consider switching to an SSRI with fewer sexual side effects rather than adding trazodone

Conclusion

While transitioning from paroxetine to trazodone is possible, it carries risks that must be carefully managed. The decision should be based on clear therapeutic goals and the specific reasons for wanting to make this change.