How do I taper and stop taking Risperidone (risperidone)?

How to Taper and Stop Risperidone

Taper risperidone gradually over 1-2 weeks minimum with careful monitoring for psychotic relapse and withdrawal symptoms, using a hyperbolic reduction approach where each new dose is approximately 90% of the previous dose, with smaller reductions as you approach complete discontinuation. 1, 2

Tapering Protocol

Standard Tapering Approach

• Reduce risperidone gradually over a minimum of 1-2 weeks, though longer tapers (months) may be necessary for patients on long-term therapy 1
• Use a hyperbolic tapering method where you reduce by approximately 10% of the current dose (not the original dose) at each step to maintain proportional reductions in dopamine D2 receptor blockade 1, 2, 3
• For patients on risperidone for extended periods (months to years), consider applying 10% reductions per month or slower 1
• Make dose reductions at intervals of 2-4 weeks, allowing time for neuroadaptations to resolve 2, 4

Specific Dosing Considerations

• Once you reach the lowest commercially available dose, consider extending the interval between doses before complete cessation rather than abruptly stopping 1
• Final doses before complete cessation may need to be as small as 1/40th of a therapeutic dose to prevent large decreases in D2 blockade 2
• The FDA label notes that once sufficient clinical response has been achieved and maintained, consider gradually lowering the dose to achieve optimal balance of efficacy and safety 5

Managing Withdrawal Symptoms

Common Withdrawal Symptoms to Monitor

• Monitor for psychotic relapse (hallucinations, delusions, disorganized thinking) as the primary concern 1, 4
• Watch for cholinergic rebound symptoms including nausea, vomiting, insomnia, and restlessness 1
• Assess for anxiety, irritability, dysphoria, and mood changes 1
• Monitor for movement disorders that may emerge or worsen during tapering 2

Response to Withdrawal Symptoms

• If withdrawal symptoms become severe, pause the taper and restart when the patient is ready, potentially at a slower rate 1
• Consider supportive medications for specific symptoms: short-term trazodone for anxiety or irritability 1
• Do not mistake withdrawal symptoms for evidence that a higher dose is needed long-term—they may simply indicate the need for more gradual reduction 4

Critical Safety Considerations

When NOT to Taper Abruptly

• Never abruptly discontinue risperidone except in cases of serious medical toxicity (e.g., severe neutropenia), as this significantly increases the risk of psychotic relapse and severe withdrawal symptoms 1
• Abrupt discontinuation is unacceptable medical care in physically-dependent patients 1

Monitoring Requirements

• Follow up at least monthly during the taper, with more frequent contact during difficult phases 1
• Monitor closely for depression, anxiety, and potential emergence of substance use 1
• Periodically re-evaluate the long-term risks and benefits of continued risperidone use 5

Switching to Another Antipsychotic

• If switching to another antipsychotic is planned, begin the new medication while gradually reducing risperidone to minimize risk of psychotic relapse 1
• Use gradual cross-titration informed by the half-life and receptor profile of each medication 1

Common Pitfalls to Avoid

• Do not taper too quickly—faster tapers (over weeks) are associated with higher relapse rates than slower tapers (over months) 4, 3
• Do not abandon patients during the tapering process—frequent follow-up is essential even if tapering is unsuccessful 1
• Do not reduce by a fixed amount at each step—use percentage-based reductions to avoid disproportionately large final reductions 1, 3
• Do not assume psychotic symptoms during tapering mean lifelong medication is required—they may represent withdrawal effects requiring slower tapering 4

Neurobiological Rationale

• Hyperbolic (exponential) tapering reduces dopamine D2 receptor blockade in a linear manner, potentially allowing underlying neuroadaptations time to resolve 2, 3
• Adaptations to antipsychotic exposure can persist for months or years after stopping, including dopaminergic hypersensitivity 2
• Slower tapering may minimize disruption of homeostatic equilibria, reducing the risk of withdrawal-precipitated psychotic symptoms 4