How to Taper Doxepin (Tricyclic Antidepressant)
Taper doxepin by reducing the dose by 10% of the previous dose every 2-4 weeks, extending to 10% per month for patients on long-term therapy, continuing down to very small final doses before complete cessation to minimize withdrawal symptoms.
Recommended Tapering Protocol
Start with a 10% reduction of the most recent dose (not the original dose) every 2-4 weeks. 1 This hyperbolic tapering approach—where each reduction is 10% of the current dose rather than the original dose—results in progressively smaller absolute dose decrements as you approach discontinuation. 2
Specific Tapering Strategy
- For short-term use (months): Reduce by 10% of the previous dose every 2-4 weeks 1
- For long-term use (years): Slow to 10% reductions per month or even slower 1, 3
- Example for 100mg daily:
Critical Final Dosing Considerations
Do not stop at the lowest commercially available dose. The final doses before complete cessation may need to be as small as 1/40th of a therapeutic dose to prevent large receptor changes when stopped. 4 This hyperbolic tapering method reduces the biological effect at receptors by fixed amounts, minimizing withdrawal. 2
Monitoring and Adjustment
Monitor for withdrawal symptoms after each dose reduction before proceeding to the next step. 1 Tricyclic antidepressant withdrawal symptoms include anxiety, insomnia, flu-like symptoms, nausea, headache, and mood changes. 1
If Withdrawal Symptoms Emerge
- Pause the taper and maintain the current dose until symptoms resolve 3
- Return to the previous well-tolerated dose if symptoms are severe 1, 5
- Slow the taper further by extending time between reductions or making smaller decrements 5
- Tapers may need to be paused and restarted when the patient is ready 3
Timeline Expectations
The taper will likely take 6-12 months minimum, possibly longer for patients on doxepin for years. 3 Tapers are considered successful as long as the patient is making progress—durability matters more than speed. 3
Extending the Interval Method
Once you reach the smallest dose you can practically administer, extend the interval between doses rather than continuing to reduce the dose. 3 For example, transition from daily dosing to every other day, then every third day, before complete cessation.
Managing Withdrawal Symptoms
If withdrawal symptoms occur despite gradual tapering:
- For insomnia: Short-term trazodone 3
- For increased sympathetic activity: α2-adrenergic agonists like clonidine 1
- For muscle aches: Acetaminophen or NSAIDs 1
Special Populations
For elderly patients: Use more gradual tapers with smaller dose reductions, as they face particular risks from tricyclic antidepressants including cognitive impairment and fall risk. 3
For pregnant patients: Do not taper during pregnancy without specialist consultation. 3
Critical Pitfalls to Avoid
- Never taper too quickly (faster than 10% every 2-4 weeks for short-term use, or 10% per month for long-term use) 1, 3
- Never set arbitrary time limits for completing the taper; individualize based on patient response 1, 5
- Never abandon the patient during the tapering process; ensure continued support and monitoring 3, 1
- Never abruptly discontinue except in cases of serious medical toxicity 1
Follow-Up Schedule
Follow up at least monthly during the taper, with more frequent contact during difficult phases. 3 Set clear expectations with patients about the tapering process and potential withdrawal symptoms. 1
When to Refer to a Specialist
Refer patients with: