What is the recommended procedure when starting vilazodone and discontinuing Trintellix (vortioxetine)?

Starting Vilazodone While Discontinuing Trintellix (Vortioxetine)

When transitioning from Trintellix (vortioxetine) to vilazodone, taper vortioxetine to 10 mg daily for one week before full discontinuation (if on 15-20 mg doses), then initiate vilazodone at 10 mg daily with food, increasing to 20-40 mg after 7-day intervals. 1, 2

Discontinuing Trintellix (Vortioxetine)

Tapering Protocol

• For patients on 15 mg or 20 mg daily: Reduce to 10 mg daily for one week before complete discontinuation 1
• For patients on 10 mg or lower doses: Trintellix can be discontinued abruptly without tapering 1
• The FDA label explicitly states that vortioxetine can be discontinued abruptly, but recommends the one-week taper at higher doses to minimize potential withdrawal symptoms 1

Monitoring During Vortioxetine Discontinuation

• Watch for withdrawal symptoms including anxiety, insomnia, irritability, dizziness, and nausea during the tapering process 3
• Most antidepressants require 10-14 days of gradual discontinuation to limit withdrawal symptoms, though vortioxetine's label allows for more flexibility 4

Initiating Vilazodone

Starting Protocol

• Week 1: Begin vilazodone at 10 mg once daily with food 2
• Week 2: Increase to 20 mg once daily with food 2
• Week 3 and beyond: May increase to target dose of 40 mg daily after minimum 7-day intervals between increases 2
• Critical requirement: Vilazodone must be taken with food to ensure proper absorption and efficacy 2, 5

Timing of Cross-Taper

Option 1 (Conservative approach): Complete the vortioxetine taper first, then start vilazodone after a brief washout period of 2-3 days. This minimizes any theoretical risk of serotonin syndrome, though both medications work primarily through serotonin mechanisms 5, 6

Option 2 (Direct cross-taper): Start vilazodone 10 mg during the final week of vortioxetine taper (when vortioxetine is at 10 mg). This approach maintains antidepressant coverage and is reasonable given both medications' serotonergic profiles 3, 5

Safety Considerations

Serotonin Syndrome Risk

• The risk of serotonin syndrome during this transition is low, as both medications enhance serotonergic activity but through slightly different mechanisms 3, 5
• Vortioxetine combines serotonin reuptake inhibition with multiple receptor activities (5-HT3, 5-HT1D, 5-HT7 antagonism; 5-HT1A agonism) 6
• Vilazodone combines serotonin reuptake inhibition with 5-HT1A partial agonism 5, 7
• Monitor for confusion, agitation, muscle rigidity, hyperthermia, tremor, and autonomic instability during the transition period 3

Expected Timeline for Therapeutic Effect

• Vilazodone shows improvement in depressive symptoms within 1 week of initiating therapy, with increased remission rates at 6 weeks 5
• Full therapeutic effect typically observed at 4-6 weeks 5
• This is comparable to vortioxetine's timeline of 2 weeks for initial improvement and 4-6 weeks for full effect 6

Common Pitfalls to Avoid

• Do not start vilazodone without food: This significantly impacts absorption and efficacy 2, 5
• Do not abruptly discontinue vortioxetine at doses of 15-20 mg: Follow the one-week taper to 10 mg to minimize withdrawal symptoms 1
• Do not rush vilazodone titration: Maintain minimum 7-day intervals between dose increases to assess tolerability 2
• Do not assume withdrawal symptoms are relapse: Distinguish between antidepressant discontinuation syndrome (typically peaks within 1-2 weeks and resolves) and true depressive relapse 3, 8

Monitoring During Transition

Weekly Assessment Points

• Week 1: Monitor for vortioxetine withdrawal symptoms (anxiety, dizziness, irritability) and vilazodone tolerability (nausea, diarrhea) 3, 5
• Weeks 2-4: Assess for adequate symptom control, emergence of side effects, and any signs of serotonin syndrome 3, 5
• Weeks 4-6: Evaluate therapeutic response and consider dose optimization if needed 5, 7

Side Effect Profile Differences

• Vortioxetine: Most common adverse event is dose-dependent nausea; low rates of sexual dysfunction; well-tolerated discontinuation 6, 9
• Vilazodone: Most common adverse events are diarrhea, nausea, and insomnia; low rates of sexual dysfunction compared to traditional SSRIs; self-limited side effects typically resolve in 4-5 days 5, 7, 9

Special Populations

• Screen for bipolar disorder before initiating vilazodone, as with all antidepressants, to avoid precipitating manic episodes 2
• No dose adjustment needed for vilazodone based on age, gender, or mild-to-moderate renal/hepatic impairment 2
• For CYP2D6 poor metabolizers: Maximum vortioxetine dose is 10 mg daily, which simplifies the taper 1