What is the recommended tapering schedule for discontinuing 45 mg of mirtazapine (Remeron)?

Tapering Protocol for Mirtazapine 45 mg

For patients on 45 mg of mirtazapine, a gradual taper is strongly recommended with dose reductions of approximately 10% every 2-4 weeks to minimize withdrawal symptoms and ensure patient safety.

Recommended Tapering Schedule

• Begin with a reduction from 45 mg to 30 mg daily and maintain this dose for 2-4 weeks 1, 2
• After 2-4 weeks at 30 mg, reduce to 15 mg daily for another 2-4 weeks 1, 2
• For the final step, consider either:
  • Continuing at 15 mg for 2-4 weeks, then discontinuing completely 2
  • For patients who have been on mirtazapine long-term (≥1 year), consider an even more gradual approach by cutting the 15 mg tablet in half (7.5 mg) for 2-4 weeks before discontinuing 3, 1

Managing Withdrawal Symptoms

• Monitor for common withdrawal symptoms which may include:
  • Anxiety, insomnia, irritability
  • Dizziness, headache
  • Nausea, vomiting, diarrhea
  • Flu-like symptoms 3, 1
• If withdrawal symptoms become severe during the tapering process:
  • Return to the previous well-tolerated dose 1
  • Extend the time between dose reductions (4-6 weeks instead of 2-4 weeks) 3, 1
  • Consider an even slower taper for patients who have been on mirtazapine for years 3, 1

Special Considerations

• Tapers should be individualized based on:
  • Duration of previous mirtazapine therapy (longer duration requires slower taper) 3
  • Patient's tolerance of the taper 3, 1
  • Presence of comorbid conditions 1
• For patients who have been taking mirtazapine for ≥1 year, tapers of 10% per month or slower are likely to be better tolerated than more rapid tapers 3
• Consider timing the final discontinuation when the patient has fewer life stressors or demands 1
• Don't set arbitrary time limits for completing the taper; individualize based on patient response 1

Clinical Pearls and Pitfalls

• Mirtazapine has a half-life of 20-40 hours, which allows for once-daily dosing but may also cause withdrawal symptoms if discontinued abruptly 4, 5
• Patients should be advised that withdrawal symptoms do not indicate addiction but are a normal physiological response to medication discontinuation 3
• Clinically significant withdrawal symptoms can signal the need to further slow the taper rate 3
• At times, tapers might have to be paused and restarted again when the patient is ready 3
• Remain alert for signs of anxiety, depression, or other psychiatric symptoms that might be revealed during the taper process 3