Gradual Tapering of Mirtazapine is Required
Yes, mirtazapine should be gradually tapered rather than stopped abruptly to minimize discontinuation symptoms. 1
Why Tapering is Necessary
The FDA label explicitly states that "adverse reactions may occur upon discontinuation or dose reduction of mirtazapine" and recommends to "gradually reduce the dosage of mirtazapine tablets rather than stopping abruptly whenever possible." 1
Abrupt discontinuation can precipitate withdrawal symptoms including panic attacks, palpitations, dyspnea, dizziness, nausea, and anxiety, as documented in a case report where a patient experienced severe, recurrent panic attacks lasting 20 minutes each, occurring every 1-2 hours for 5 days after sudden cessation. 2
General antidepressant guidelines recommend discontinuing antidepressants over 10 to 14 days to limit withdrawal symptoms. 3
Recommended Tapering Schedule
Reduce the dose by 10-20% every 1-2 weeks, slowing the taper as you approach lower doses:
Begin with a 10-20% reduction of the current dose, maintaining each reduced dose for 1-2 weeks before making further reductions. 4
As the dose decreases to approximately 25% of the original dose, slow the taper to 5-10% reductions to minimize withdrawal effects. 4
The FDA recommends that dose changes should not be made in intervals of less than 1 to 2 weeks to allow sufficient time for evaluation of response. 1
Special Considerations
Elderly patients require even more gradual tapering due to increased sensitivity to medication effects and withdrawal symptoms. 4
Duration of treatment matters: Even after medium-term therapy (10 weeks), progressive tapering is advisable rather than abrupt cessation. 2
Supportive Measures During Tapering
Implement non-pharmacological interventions including cognitive-behavioral therapy, sleep hygiene education, and anxiety management techniques to support the tapering process. 4
Provide clear patient education about the expected timeline and possible withdrawal symptoms to improve adherence to the tapering schedule. 4
Schedule regular follow-up appointments to assess progress and adjust the tapering schedule as needed based on individual tolerance. 4
Common Pitfall to Avoid
Never stop mirtazapine abruptly, even for surgical procedures. The case report demonstrates that stopping mirtazapine suddenly—even for what seemed like a valid medical reason (imminent surgery)—resulted in severe, debilitating panic attacks that only resolved after reintroduction of the medication. 2