Tapering 20 mg Paroxetine
Reduce paroxetine by 10 mg per week down to 10 mg daily, then continue 10 mg for one additional week before complete discontinuation. This FDA-approved taper-phase regimen minimizes withdrawal symptoms while being practical and evidence-based 1.
Recommended Tapering Schedule
The FDA label for paroxetine specifies a structured tapering protocol based on clinical trial data 1:
- Week 1: Decrease from 20 mg to 10 mg daily
- Week 2: Continue 10 mg daily (stabilization week)
- Week 3: Discontinue completely
This regimen was specifically employed in clinical trials for GAD and PTSD and demonstrated acceptable tolerability 1.
Why This Taper Works
Paroxetine has a short half-life and requires gradual tapering, unlike fluoxetine which has an extended half-life 2. The 10 mg weekly reduction followed by a stabilization week at the lowest dose allows the body to adjust to decreasing serotonin transporter inhibition 1, 2.
The FDA explicitly states: "A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible" 1. This approach reduces the incidence and severity of discontinuation symptoms to manageable levels 1.
Expected Withdrawal Symptoms
Even with proper tapering, some patients may experience mild discontinuation symptoms 1, 2:
- Neurological: Dizziness, paresthesias (electric shock sensations), headache 1
- Psychiatric: Abnormal dreams, irritability, anxiety, emotional lability 1
- Physical: Nausea, fatigue, insomnia 2
These symptoms typically occur at an incidence of 2% or greater but are usually mild to moderate, self-limiting, and do not require medical intervention when the recommended taper is followed 1.
Management of Intolerable Symptoms
If significant withdrawal symptoms emerge during tapering 1:
- Resume the previous dose that was tolerated
- Extend the time at each dose reduction (e.g., 2 weeks instead of 1 week per step)
- Slow the rate of taper further if needed
The FDA specifically recommends this approach if intolerable symptoms occur following dose reduction 1.
Alternative Hyperbolic Tapering (For Difficult Cases)
If the standard taper fails, consider a hyperbolic (exponential) tapering approach over several months down to doses much lower than 10 mg 3, 4. This method reduces serotonin transporter occupancy in a linear manner, minimizing withdrawal symptoms more effectively than linear tapers 3. However, this requires liquid formulations or compounded doses and is more complex 4.
A 3-4 week graded withdrawal with possible concomitant fluoxetine coverage has also been suggested for patients with severe discontinuation symptoms 5.
Critical Pitfalls to Avoid
- Never discontinue abruptly from 20 mg—this frequently causes severe withdrawal symptoms that may be mistaken for relapse 1, 2
- Do not taper faster than weekly intervals—the FDA protocol is already relatively rapid 1
- Do not skip the stabilization week at 10 mg—this final week at the lowest dose is crucial 1
- Monitor closely for symptom recurrence versus withdrawal symptoms—these can be confused, leading to unnecessary reinitiation of treatment 2
Special Considerations
Elderly patients and those on diuretics may be at higher risk for hyponatremia during tapering and require closer monitoring 1. Patients should be counseled that withdrawal symptoms, while uncomfortable, are generally self-limiting and do not indicate a medical emergency 2.