What is the recommended tapering schedule for quetiapine (Seroquel)?

Quetiapine Tapering Schedule

Quetiapine should be tapered gradually over a period of greater than 1 month, with dose reductions of approximately 25% of the most recent dose every 1-2 weeks to minimize withdrawal symptoms and risk of relapse. 1, 2

Recommended Tapering Protocol

General Approach

• Start with a 25% reduction of the most recent dose every 1-2 weeks 1
• For long-term users (>1 year) or higher doses, consider an even more gradual approach:
  • Reduce by 10-25% of the most recent dose every 3-4 weeks 2, 3
  • Continue this pattern until reaching very low doses before complete cessation

Specific Considerations

• Higher starting doses (>300 mg/day): Begin with larger absolute reductions
• Lower doses (<100 mg/day): Make smaller absolute reductions as the dose decreases
• Final stages: Consider extremely small reductions (as little as 1/40th of therapeutic dose) before complete discontinuation 3

Managing Withdrawal Symptoms

Quetiapine withdrawal can manifest as:

• Nausea and vomiting 4
• Insomnia
• Anxiety
• Rebound psychosis
• Dyskinesias and movement disorders 1

Interventions for Withdrawal Symptoms

• If withdrawal symptoms occur, slow the taper further or temporarily return to the previous dose
• Consider antiemetics like domperidone for nausea/vomiting 4
• For severe withdrawal symptoms, re-escalate dosing and attempt a more gradual taper 1

Special Populations

Elderly Patients

• Use a more gradual tapering schedule (5% reduction every 2-3 weeks)
• Monitor more closely for withdrawal symptoms and adverse effects

Patients with Psychiatric Disorders

• Implement non-pharmacological interventions during tapering:
  • Psychosocial support
  • Environmental interventions
  • Sleep hygiene practices
  • Cognitive behavioral therapy 1

Evidence-Based Rationale

Recent research indicates that slower tapering of antipsychotics (over months rather than weeks) is associated with lower relapse rates 2. This is likely because:

1. Rapid discontinuation disrupts homeostatic equilibria in the brain 2
2. Slower tapering allows time for neuroadaptations to resolve 3
3. Hyperbolic tapering (smaller reductions as dose decreases) may provide more even reduction in receptor occupancy 3

Common Pitfalls to Avoid

• Tapering too quickly: This increases risk of withdrawal symptoms and relapse
• Mistaking withdrawal for symptom recurrence: Withdrawal symptoms can mimic psychiatric symptoms, leading to unnecessary long-term medication 5
• Stopping at minimum therapeutic doses: Tapering should continue to doses much lower than minimum therapeutic doses before complete cessation 5, 3
• Abrupt discontinuation: This can lead to severe withdrawal effects including dyskinesias, parkinsonian symptoms, dystonias, and potentially neuroleptic malignant syndrome 1

Monitoring During Tapering

• Schedule follow-up visits every 2 weeks during tapering
• Assess for:
  • Withdrawal symptoms
  • Return of psychiatric symptoms
  • Sleep quality
  • Anxiety levels
  • Movement disorders

By following this gradual tapering approach, the risk of withdrawal symptoms and relapse can be significantly reduced while successfully discontinuing quetiapine when appropriate.