What is the recommended approach for hyperbolic tapering of risperidone (antipsychotic medication)?

Hyperbolic Tapering of Risperidone

For risperidone discontinuation, a hyperbolic tapering approach is recommended, reducing by approximately 25% of the most recent dose every 1-2 weeks, with smaller reductions as the total dose decreases, to minimize relapse risk. 1

Understanding Hyperbolic Tapering

Hyperbolic tapering recognizes the non-linear relationship between antipsychotic dose and dopamine D2 receptor blockade:

• Tapering should follow a hyperbolic curve (not linear) to reduce D2 receptor blockade evenly 1
• This approach accounts for neuroadaptations that persist after medication cessation, including dopaminergic hypersensitivity 1
• The goal is to allow underlying adaptations time to resolve, potentially reducing relapse risk 1

Recommended Tapering Protocol for Risperidone

Initial Approach

• Begin with reducing the dose by 25% of the most recent dose (approximately 5 percentage points of D2 blockade) 1
• Allow 1-2 weeks between dose reductions (though 3-6 months between reductions would be ideal for maximum safety) 1, 2
• Each subsequent reduction should be 25% of the current dose, not the original dose 1

Example of Hyperbolic Tapering Schedule

• Starting dose: 4 mg daily (common target dose for most patients) 3
• First reduction: 3 mg daily (25% reduction)
• Second reduction: 2.25 mg daily (25% reduction from 3 mg)
• Third reduction: 1.7 mg daily (25% reduction from 2.25 mg)
• Continue with progressively smaller reductions 1

Final Phase

• Final doses before complete cessation may need to be as small as 1/40th of the therapeutic dose 1
• This prevents a large decrease in D2 blockade when completely stopped 1

Monitoring During Tapering

• Monitor closely for signs of psychotic relapse during and after the tapering process 4
• Be prepared to reinstate antipsychotic treatment immediately if symptoms emerge 5
• Patients with schizoaffective disorder require particular attention as discontinuation significantly increases relapse risk 5

Important Considerations

• Abrupt discontinuation or overly rapid tapering predisposes patients to relapse 4
• Studies show gradual individualized dose reduction still carries relapse risk (NNH = 5) 4
• Long-acting injectable antipsychotics may be beneficial for patients with adherence issues 5

Cautions and Contraindications

• Patients with a history of multiple relapses may require more gradual tapering 2
• Some patients may prefer even more gradual tapering at 10% or less of their most recent dose each month 1
• Discontinuation should be avoided in patients with treatment-resistant schizophrenia 4

Alternative Approach

If a more rapid transition to another antipsychotic is needed:

• Add-on of the new antipsychotic while simultaneously tapering risperidone has been shown to be safe and well-tolerated 6
• This approach can be used when clinical circumstances don't allow for extended tapering periods 6