What is the proper procedure for discontinuing Seroquel (quetiapine)?

Discontinuing Seroquel (Quetiapine)

When discontinuing quetiapine after more than one week of treatment, follow the initial dosing schedule in reverse, tapering gradually rather than stopping abruptly 1.

Tapering Protocol Based on Treatment Duration

For Patients Off Quetiapine Less Than One Week

• Gradual dose escalation may not be required when restarting
• The maintenance dose may be reinitiated directly 1

For Patients Off Quetiapine More Than One Week

• Must follow the initial dosing schedule when restarting therapy 1
• This indicates that discontinuation should mirror the titration schedule used when starting

Recommended Tapering Approach

Standard Discontinuation Schedule

• Reduce dose by 25-50 mg every 3-7 days based on the patient's current dose and duration of treatment 1
• For patients on higher doses (400-800 mg/day), consider reducing by 100 mg increments every 5-7 days initially, then smaller decrements as you approach lower doses 1
• Monitor closely for withdrawal symptoms and recurrence of psychiatric symptoms during the taper 1

Special Populations Requiring Slower Tapers

Elderly patients and those with hepatic impairment:

• Use even more conservative tapering (25 mg decrements every 5-7 days minimum) 1
• These patients were started at lower doses (25-50 mg/day) and require proportionally gradual discontinuation 1

Monitoring During Discontinuation

Psychiatric Symptom Monitoring

• Reassess need for continued treatment periodically before deciding to discontinue 1
• Watch for re-emergence of psychotic symptoms, mood instability, or behavioral changes 1
• Tardive dyskinesia may emerge or worsen after discontinuation, even if not present during treatment 1

Withdrawal Symptom Surveillance

• Monitor for insomnia, nausea, and vomiting (common anticholinergic withdrawal effects) 1
• Assess for anxiety, agitation, or irritability 1
• Watch for dizziness and orthostatic symptoms as alpha-adrenergic blockade resolves 1

Critical Safety Considerations

Cardiovascular Monitoring

• Blood pressure should be checked regularly during taper, especially in patients who experienced orthostatic hypotension on quetiapine 1
• Risk of falls may paradoxically increase during discontinuation due to withdrawal symptoms combined with residual sedation 1

When Abrupt Discontinuation May Be Necessary

• If tardive dyskinesia signs appear, drug discontinuation should be considered immediately 1
• However, some patients may require continued treatment despite tardive dyskinesia presence 1
• In cases of severe adverse events (QTc prolongation, neuroleptic malignant syndrome), immediate cessation may be warranted with close monitoring 1

Common Pitfalls to Avoid

Do not stop quetiapine abruptly unless medically necessary for safety reasons—the FDA label specifically recommends following the initial dosing schedule in reverse for reinitiation, implying gradual discontinuation is standard practice 1.

Do not assume quetiapine has no withdrawal syndrome—while the evidence provided focuses on SSRI discontinuation syndromes 2, quetiapine affects multiple neurotransmitter systems (serotonin, dopamine, histamine, adrenergic) and abrupt cessation can cause rebound symptoms 1, 3.

Do not discontinue without a plan for ongoing psychiatric management—quetiapine is prescribed for chronic conditions (schizophrenia, bipolar disorder) that require continued treatment 1, 4, 5.