What is the recommended dose of paroxetine (SSRI) for hot flashes?

Recommended Dosage of Paroxetine for Hot Flashes

The recommended dosage of paroxetine for hot flashes is 10 mg daily initially, which can be increased to 20 mg daily after one week if symptoms persist. 1

Dosing Algorithm

Initial Approach:

• Start with paroxetine 10 mg daily
• After 1 week, assess symptom response:
  • If adequate symptom control → continue 10 mg daily
  • If inadequate symptom control → increase to 20 mg daily

Evidence for Efficacy:

• Paroxetine 10 mg reduces hot flash frequency by 40.6% and composite score (frequency × severity) by 45.6% compared to placebo (13.7% reduction) 2
• Paroxetine 20 mg reduces hot flash frequency by 51.7% and composite score by 56.1% compared to placebo (26.6% reduction) 2
• Controlled-release paroxetine formulations (12.5 mg) have shown 62.2% reduction in hot flashes 3

Efficacy Considerations

• Onset of action is rapid (within 1 week) 1
• Duration of action has been demonstrated for up to 6 weeks in most studies 1, 3
• Benefits may persist through 24 weeks in longer-duration studies 4
• No significant differences in efficacy were observed between lower (10 mg) and higher (20 mg) doses 2

Side Effect Profile

Common side effects include:

• Nausea (more common with 20 mg dose) 1
• Dizziness 1
• Insomnia 1
• Dry mouth 1
• Sexual dysfunction 1

Most adverse effects are mild-to-moderate in severity, with improved tolerability associated with lower doses (7.5-12.5 mg/day) 4. Side effects typically occur early in treatment and tend to improve over time 5.

Important Caution for Tamoxifen Users

For patients taking tamoxifen, paroxetine should be avoided due to its potent inhibition of CYP2D6, which can interfere with tamoxifen metabolism to its active metabolite endoxifen 1. In these patients, consider alternative SSRIs/SNRIs with minimal CYP2D6 inhibition such as:

• Venlafaxine (37.5 mg daily, increasing to 75 mg if needed)
• Citalopram

Alternative Options When Paroxetine Is Not Appropriate

If paroxetine is contraindicated or not tolerated:

1. Venlafaxine: Start at 37.5 mg daily, may increase to 75 mg daily after 1 week if needed 1
2. Gabapentin: Consider as an alternative first-line treatment, particularly if sexual dysfunction is a concern 1
3. Clonidine: May be useful for mild to moderate hot flashes (0.1 mg/day) 1

Monitoring and Follow-up

• Assess response after 4 weeks - if no response by this time, treatment is unlikely to be effective 1
• Monitor for side effects, particularly during the first few weeks of treatment
• Discontinue gradually to prevent discontinuation symptoms, particularly with paroxetine which has a shorter half-life 1

Paroxetine at 10-20 mg daily is an effective treatment for menopausal hot flashes, with the lower dose offering similar efficacy with better tolerability.