Management of Anxiety After Abrupt Paroxetine Discontinuation in a Patient with Hashimoto's Disease
The best course of action for Catherine is to gradually reintroduce paroxetine (Paxil) starting at a lower dose (10-20mg daily) and titrating back to her previous effective dose, while monitoring for symptom improvement and potential side effects. 1
Assessment of Current Situation
Catherine's case presents several key clinical considerations:
- 21-year history of well-controlled anxiety on Paxil (paroxetine) 25mg extended-release
- Abrupt discontinuation of paroxetine by PCP on August 13
- Recurrence of significant anxiety symptoms affecting daily functioning
- History of Hashimoto's disease (currently on Synthroid/levothyroxine)
- Recent hysterectomy in June with noted decreased medication effectiveness afterward
Recommended Treatment Plan
1. Paroxetine Reinitiation
- Begin with 10mg daily of paroxetine (standard release) for elderly, debilitated patients, or those with renal/hepatic impairment, but Catherine may start at 20mg daily as this is the standard starting dose 1, 2
- Gradually increase by 10mg increments at weekly intervals if needed 2
- Target returning to her previous effective dose of 25mg (or equivalent in standard release formulation)
- Monitor response after 2-3 weeks with full effect assessment at 4-6 weeks 3
2. Monitoring and Follow-up
- Schedule follow-up within 1-2 weeks of restarting medication to assess initial response 4
- Continue regular monitoring during dose titration
- Once stabilized, assess patient status, therapeutic response, and adverse effects regularly 4
3. Long-term Management
- Continue treatment for at least 4-9 months after satisfactory response 4
- For patients with 2 or more episodes of anxiety (as in Catherine's case with 21-year history), longer duration of therapy may be beneficial 4
- Consider indefinite maintenance therapy given her long history and relapse upon discontinuation 4
Special Considerations
Hashimoto's Disease
- Monitor thyroid function regularly as thyroid dysfunction can exacerbate anxiety symptoms 5, 6
- Ensure adequate levothyroxine dosage as hypothyroidism can worsen anxiety and depression symptoms 6, 7
- Be aware that Hashimoto's thyroiditis is associated with higher prevalence of anxiety disorders even in euthyroid patients 5
Medication Discontinuation
- Never abruptly discontinue paroxetine as was done in this case 1
- If discontinuation is ever considered in the future, implement a gradual taper:
- Reduce dose by no more than 10mg/day at weekly intervals
- When reaching 20mg/day, continue for one week before further reduction
- Monitor for discontinuation symptoms: dysphoric mood, irritability, dizziness, sensory disturbances, anxiety, confusion, headache, emotional lability, insomnia 1
Potential Pitfalls to Avoid
Abrupt discontinuation: The FDA label explicitly warns against this practice due to risk of discontinuation syndrome 1
Inadequate duration of treatment: Given Catherine's long history and clear relapse upon discontinuation, she likely needs long-term maintenance therapy 4
Overlooking thyroid status: Ensure optimal management of Hashimoto's disease as thyroid dysfunction can mimic or exacerbate anxiety symptoms 5, 6
Failure to address post-hysterectomy changes: Consider whether hormonal changes following hysterectomy may be contributing to decreased medication effectiveness
Adjunctive Approaches
While restarting paroxetine is the primary intervention, consider:
- Continuing therapy with Lon Barnes (started August 25)
- Cognitive-behavioral therapy (CBT) as an evidence-based approach for anxiety 3
- Regular physical activity for anxiety reduction 3
By implementing this treatment plan, Catherine should experience improvement in her anxiety symptoms and return to her previous level of functioning. The focus should be on reinstating effective pharmacotherapy with appropriate monitoring while addressing her concurrent Hashimoto's disease.