How do I taper off Savella (milnacipran)?

How to Taper Off Savella (Milnacipran)

Reduce Savella gradually over at least 2-4 weeks minimum, decreasing by 25% of the current dose every 1-2 weeks, and never discontinue abruptly as withdrawal symptoms are common and can be severe. 1

Recommended Tapering Protocol

Standard Tapering Schedule

• For patients on 100 mg/day (50 mg twice daily), reduce to 75 mg/day for 1-2 weeks, then to 50 mg/day for 1-2 weeks, before complete discontinuation 2, 1
• For patients on 200 mg/day, reduce to 150 mg/day for 1-2 weeks, then to 100 mg/day for 1-2 weeks, then to 50 mg/day for 1-2 weeks before stopping 2
• Each reduction should be approximately 25% of the current dose, not the original starting dose, to prevent disproportionately large final reductions 3

Extended Tapering for Difficult Cases

• If significant withdrawal symptoms emerge during the standard taper, extend the time at each dose level to 2-4 weeks rather than 1-2 weeks 2
• For patients on Savella for more than 1 year or those with previous withdrawal difficulties, plan for a 6-8 week or longer taper 2
• Once at the lowest available dose (25 mg/day), consider extending the interval between doses (e.g., 25 mg every other day) before complete discontinuation 2

Withdrawal Symptoms to Monitor

Common Discontinuation Symptoms

• Watch for dysphoric mood, irritability, agitation, dizziness, sensory disturbances (particularly electric shock sensations/paresthesias), anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania, tinnitus, and seizures 1
• Additional SNRI-specific symptoms include nausea, sweating, and mood changes 2
• These symptoms are generally self-limiting but can be severe in some patients 1

Monitoring Schedule

• Follow up with the patient at least monthly during the taper, with more frequent contact (weekly or biweekly) as needed during difficult phases 2, 3
• Screen for depression, anxiety, and suicidal ideation that may emerge during tapering 3

Managing Withdrawal Symptoms

If Intolerable Symptoms Occur

• Resume the previously prescribed dose if intolerable symptoms develop after a dose reduction 1
• Once symptoms stabilize, attempt a more gradual reduction with smaller decrements (e.g., 10-15% of current dose instead of 25%) 2
• Pause the taper when withdrawal symptoms emerge—pauses are acceptable and often necessary 3

Adjunctive Medications for Symptom Management

• Consider short-term use of trazodone for anxiety or insomnia during the taper 2
• Gabapentin may help with anxiety and sensory symptoms (paresthesias) 2
• Mirtazapine can be used temporarily for insomnia and anxiety 2
• These supportive medications should be used temporarily to ease the transition, not as long-term substitutes 2

Special Considerations

Dose Adjustments in Renal/Hepatic Disease

• Milnacipran requires dose reduction in patients with renal insufficiency 4
• Exercise caution in patients with hepatic disease—Savella should ordinarily not be prescribed to patients with substantial alcohol use or evidence of chronic liver disease 1
• Monitor liver enzymes if continuing treatment in patients with mild hepatic impairment 1

High-Risk Situations

• Patients with a history of seizure disorder require particularly careful monitoring during tapering 1
• Elderly patients may be at greater risk for hyponatremia and should be monitored for headache, confusion, weakness, and unsteadiness 1
• Patients taking NSAIDs, aspirin, or anticoagulants have increased bleeding risk—monitor closely 1

Critical Pitfalls to Avoid

Never Abruptly Discontinue

• Abrupt discontinuation of SNRIs like Savella is inappropriate medical care and can precipitate severe withdrawal symptoms 4, 1
• Even after short-term use (more than a few days), gradual tapering is necessary to minimize rebound and withdrawal effects 4

Don't Use Fixed Timelines

• The taper must be adjusted based on the individual patient's response and tolerance, not a predetermined rigid schedule 3
• Success is measured by tolerability and completion, not speed of the taper 2, 3

Don't Abandon the Patient

• Maintain the therapeutic relationship even if tapering is unsuccessful 3
• If the patient struggles with the taper, consider pausing at a stable dose rather than pushing forward or discontinuing care 5
• Ensure access to urgent psychiatric care if acute decompensation occurs during the taper 5

Hyperbolic Tapering Considerations

• Recent research suggests that hyperbolic (exponential) tapering—where each reduction is a percentage of the most recent dose rather than the original dose—may minimize withdrawal symptoms more effectively than linear tapering 6, 7, 8
• This approach reduces the biological effect at receptors by fixed amounts, similar to successful benzodiazepine tapering protocols 6
• For patients with severe withdrawal symptoms, reductions as small as 10% of the current dose per month may be necessary 9, 8

Realistic Timeline and Patient Education

• The minimum tapering duration for most patients on standard doses will be 2-4 weeks 2
• For patients on higher doses (200 mg/day) or those with previous withdrawal difficulties, expect 6-8 weeks or longer 2
• Patient agreement and understanding of the tapering plan is essential—ensure the patient knows they can request slower tapering if needed 5
• Educate patients that withdrawal symptoms do not indicate the need to remain on the medication long-term, but rather the need for more gradual reduction 10