Should I restart divalproex (Depakote) 750 MG every night (QHS) and gabapentin (Neurontin) 600 MG three times a day (TID), as well as mirtazapine (Remeron) 15 MG every night (QHS) and quetiapine (Seroquel) 50 MG every night (QHS), in a patient who abruptly discontinued them two weeks ago to avoid withdrawal symptoms?

Management of Abruptly Discontinued Medications

You should immediately restart divalproex, gabapentin, and mirtazapine to prevent potentially dangerous withdrawal symptoms, while quetiapine can be restarted if the patient was taking it for a psychiatric condition that still requires treatment.

Priority Medications to Restart

Divalproex (Depakote) 750 mg QHS

• Highest restart priority due to risk of seizures with abrupt discontinuation
• Abrupt discontinuation can lead to status epilepticus if used for seizure control
• Restart at full dose of 750 mg QHS if patient was on long-term therapy
• Monitor for return of symptoms of the original condition (bipolar disorder, seizures, or migraine)

Gabapentin (Neurontin) 600 mg TID

• High restart priority due to documented withdrawal syndrome
• Withdrawal symptoms include akathisia, agitation, disorientation, and confusion 1, 2, 3
• Can cause withdrawal symptoms after as little as 3-4 weeks of treatment 2
• Restart at full dose of 600 mg TID since it's been only two weeks since discontinuation

Other Medications to Consider

Mirtazapine (Remeron) 15 mg QHS

• Should be restarted to prevent discontinuation syndrome
• Abrupt discontinuation can cause dizziness, abnormal dreams, sensory disturbances, agitation, anxiety, headache, tremor, nausea, vomiting, and sweating 4
• FDA label specifically recommends "a gradual reduction in dosage, rather than abrupt cessation" 4
• Restart at full dose of 15 mg QHS since it's been only two weeks

Quetiapine (Seroquel) 50 mg QHS

• Consider restarting if used for a psychiatric condition that still requires treatment
• Low dose (50 mg) suggests it was likely used for sleep or as adjunctive therapy
• Less urgent than the other medications but should be reintroduced if the original indication persists
• If restarting, can resume at 50 mg QHS since this is a relatively low dose

Monitoring After Restarting

1. Monitor for return of withdrawal symptoms within 24-48 hours of restarting medications
2. Assess for side effects from restarting medications, particularly sedation, dizziness, and cognitive effects
3. Evaluate the need for continued therapy for each medication once the patient is stabilized
4. Develop a proper tapering plan if any medications are to be discontinued in the future

Future Tapering Recommendations

If discontinuation is desired in the future, follow these guidelines:

For Divalproex

• Taper by 10% of original dose every 1-2 weeks
• More gradual tapering (10% per month) for long-term users 5

For Gabapentin

• Taper gradually to avoid withdrawal symptoms 1, 3
• Consider reducing by 300 mg every 3-7 days

For Mirtazapine

• Gradual reduction rather than abrupt cessation 4
• Consider reducing by 7.5 mg every 2-4 weeks

For Quetiapine

• Can be tapered more quickly than other psychotropics
• Consider reducing by 25 mg every 3-7 days

Common Pitfalls to Avoid

1. Assuming withdrawal symptoms have passed - Even after two weeks, restarting is safer than risking protracted or delayed withdrawal symptoms
2. Restarting at lower doses - For most medications, restarting at the original dose is appropriate after only two weeks of discontinuation
3. Ignoring the original indication - The need for these medications should be reassessed once the patient is stabilized
4. Failing to create a proper tapering plan if future discontinuation is desired

Remember that abrupt discontinuation of psychotropic medications can lead to withdrawal symptoms that may be uncomfortable or even dangerous 5, 6, 7. A thoughtful and safe plan for medication discontinuation is as important as a thoughtful and safe plan for starting medications 5.