How to taper a patient on 10mg olanzapine (Olanzapine), 4mg twice daily (BID) risperidone (Risperidone) and 500mg Depakote (Valproate) to Abilify (Aripiprazole)?

Tapering Protocol for Switching from Olanzapine, Risperidone, and Depakote to Aripiprazole

A gradual, cross-titration approach over several weeks to months is recommended when switching from multiple antipsychotics and mood stabilizers to aripiprazole to minimize withdrawal symptoms and maintain clinical stability. 1

Initial Assessment and Planning

• Collaborate with the patient on the tapering plan, including decisions about tapering speed and when pauses might be warranted 1
• Set realistic expectations regarding individualized goals, potential withdrawal symptoms, and contingency plans 1
• Clearly communicate that you are not abandoning the patient but helping them safely transition to aripiprazole 1

Recommended Cross-Titration Approach

Phase 1: Start Aripiprazole (Week 1)

• Begin aripiprazole at 5-10mg daily while maintaining current doses of olanzapine, risperidone, and depakote 2
• Allow 1 week for aripiprazole to reach steady state before beginning taper of other medications 1

Phase 2: Taper Olanzapine (Weeks 2-5)

• Reduce olanzapine by 2.5mg every 1-2 weeks (10mg → 7.5mg → 5mg → 2.5mg → 0mg) 1, 2
• Monitor for withdrawal symptoms including rebound psychosis, anxiety, insomnia, or agitation 2

Phase 3: Taper Risperidone (Weeks 6-9)

• After olanzapine is discontinued, begin tapering risperidone by 1mg every 1-2 weeks (4mg BID → 3mg BID → 2mg BID → 1mg BID → 0mg) 1, 2
• Slower taper may be needed at lower doses (below 2mg daily) as receptor occupancy changes become more significant 2

Phase 4: Taper Depakote (Weeks 10-13)

• After antipsychotics are tapered, reduce depakote by 125mg every 1-2 weeks (500mg → 375mg → 250mg → 125mg → 0mg) 1, 3
• Monitor serum levels if available during taper 3

Phase 5: Optimize Aripiprazole Dose (Week 14)

• Adjust aripiprazole to optimal therapeutic dose (typically 10-30mg daily) based on clinical response 2, 3

Managing Withdrawal Symptoms

• Withdrawal symptoms may include anxiety, insomnia, agitation, rebound psychosis, tremor, diaphoresis, and affective symptoms 1, 2
• If significant withdrawal symptoms occur, slow the taper rate or temporarily pause at current dose 1
• Consider using adjunctive medications for specific withdrawal symptoms (e.g., benzodiazepines for acute anxiety/insomnia, but with caution due to dependence potential) 1

Monitoring and Follow-up

• Follow up frequently (at least monthly) during the tapering process 1
• Team members (nurses, pharmacists, behavioral health professionals) can provide additional support through telephone contact, telehealth visits, or face-to-face visits 1
• Monitor for signs of relapse, which should be distinguished from withdrawal symptoms 2

Special Considerations

• If the patient has been on these medications long-term (≥1 year), consider an even slower taper of 10% per month 1, 2
• Cognitive behavioral therapy may increase tapering success rates and help manage psychological aspects of medication changes 1
• At times, tapers might need to be paused and restarted when the patient is ready 1
• For patients struggling to tolerate the taper, maximize non-pharmacological treatments and address behavioral distress 1

Common Pitfalls to Avoid

• Avoid abrupt discontinuation of any of these medications, which can lead to withdrawal syndromes, rebound symptoms, or relapse 1, 2
• Do not taper multiple medications simultaneously; instead, follow a sequential approach 2
• Be aware that withdrawal symptoms may be mistaken for relapse, potentially leading to unnecessary medication increases 4, 2
• Recognize that smaller dose reductions are needed at lower doses due to non-linear receptor occupancy changes 4, 2