What is a recommended tapering plan for a patient taking 15mg of mirtazapine (Remeron) for 12 months?

Tapering Plan for 15mg Mirtazapine After 12 Months

For a patient on 15mg mirtazapine for 12 months, reduce the dose by 50% to 7.5mg daily for 1-2 weeks, then discontinue if tolerated; if withdrawal symptoms emerge, maintain 7.5mg for an additional 1-2 weeks before attempting discontinuation. 1

Initial Dose Reduction

• Reduce from 15mg to 7.5mg once daily as the first step in tapering, which represents a 50% dose reduction and is a reasonable initial approach for patients on mirtazapine for 6-12 months 1
• Maintain the 7.5mg dose for 1-2 weeks to assess tolerance before proceeding to discontinuation 1
• The FDA label supports gradual dose reduction rather than abrupt discontinuation to minimize withdrawal reactions 2

Monitoring During the Taper

• Schedule follow-up appointments every 1-2 weeks during the tapering process to assess for withdrawal symptoms and return of depressive symptoms 1
• Monitor specifically for withdrawal symptoms including anxiety, insomnia, irritability, mood changes, and physical symptoms 3, 1
• Patient collaboration is essential—ensure the patient understands they can request slower tapering if withdrawal symptoms emerge 1

Managing Withdrawal Symptoms

• If withdrawal symptoms become severe at any dose reduction, return to the previous well-tolerated dose (in this case, back to 15mg) and attempt a slower taper with smaller reductions 3, 1
• For patients experiencing withdrawal at the 7.5mg reduction, consider extending the time at 7.5mg to 3-4 weeks before attempting discontinuation 1
• Short-term adjunctive medications may be used for specific withdrawal symptoms, such as temporary sleep aids for insomnia 1

Alternative Slower Taper (If Needed)

• If the standard taper proves too rapid, consider an even slower approach: reduce by 25% increments (from 15mg to approximately 11mg, then 7.5mg, then 3.75mg) with 2-4 weeks between each reduction 3
• For patients who have been on mirtazapine for years or who are particularly sensitive, extending the time between dose reductions to 3-4 weeks is appropriate 3, 1
• Don't set arbitrary time limits for completing the taper—individualize based on patient response 3

Timing Considerations

• Consider timing the final discontinuation when the patient has fewer life stressors or demands, as this may improve tolerability 3
• The elimination half-life of mirtazapine is approximately 20-40 hours, making once-daily dosing appropriate throughout the taper 4, 5, 6

Common Pitfalls to Avoid

• Do not abruptly discontinue mirtazapine without gradual dose reduction, as the FDA label specifically warns against this approach 2
• Do not proceed with discontinuation if the patient experiences significant withdrawal symptoms at 7.5mg—instead, maintain that dose longer or return to 15mg and taper more slowly 3, 1
• Be prepared to slow the taper or temporarily return to a higher dose if significant withdrawal symptoms or return of depressive symptoms occur 1