What is the recommended tapering schedule for paroxetine (selective serotonin reuptake inhibitor) 20mg?

How to Taper Paroxetine 20mg

Gradually reduce paroxetine by 10 mg/day at weekly intervals until reaching 20 mg/day, then continue at 20 mg/day for 1 additional week before stopping completely. This is the FDA-approved tapering regimen used in clinical trials for generalized anxiety disorder and PTSD 1.

Standard FDA-Approved Taper Schedule

The FDA label provides explicit guidance based on clinical trial protocols 1:

• Decrease by 10 mg/day increments at weekly intervals
• When 20 mg/day is reached, maintain this dose for 1 week before discontinuation
• This regimen was specifically designed to minimize discontinuation symptoms in controlled trials 1

Why This Taper Matters

Paroxetine has the highest risk of discontinuation syndrome among SSRIs due to its short half-life (approximately 24 hours) and lack of active metabolites 2, 3. The FDA explicitly warns that abrupt discontinuation causes withdrawal symptoms including 1:

• Dysphoric mood, irritability, and agitation
• Dizziness and sensory disturbances (electric shock sensations, tinnitus)
• Anxiety, confusion, and headache
• Emotional lability and insomnia

When Standard Taper Is Insufficient

If intolerable symptoms emerge during the standard taper 1:

• Resume the previously prescribed dose immediately
• Then decrease at a slower rate (consider 5 mg decrements instead of 10 mg, or extend intervals to 2 weeks)
• The FDA specifically states that gradual reduction is recommended "whenever possible" and physicians should adjust based on tolerability 1

Alternative Evidence-Based Approach

The American Academy of Family Physicians recommends a more conservative 10-14 day gradual taper for all SSRIs except fluoxetine 4. However, emerging evidence suggests much slower tapers may be superior 5:

• Traditional 2-4 week tapers show minimal benefit over abrupt discontinuation 5
• Tapers over months, reaching doses far below therapeutic minimums, demonstrate greater success in reducing withdrawal symptoms 5
• Hyperbolic (exponential) tapering that reduces serotonin transporter occupancy linearly may minimize symptoms more effectively 5

Practical Implementation

For the patient on 20 mg daily 1:

1. Week 1-2: Continue 20 mg daily (current dose)
2. Week 3: Reduce to 10 mg daily
3. Week 4: Continue 10 mg daily
4. Week 5: Stop completely

If withdrawal symptoms occur at any step:

• Return to previous dose for 1-2 weeks
• Consider splitting tablets to achieve 15 mg or 5 mg doses for more gradual reduction
• Extend each step to 2-week intervals instead of 1 week

Critical Monitoring Points

Watch for discontinuation symptoms within 24-48 hours after each dose reduction 4:

• Dizziness, paresthesias (electric shock sensations)
• Nausea, flu-like symptoms
• Anxiety, irritability, insomnia
• These symptoms are generally self-limiting but can be severe 1, 2

Common Pitfall to Avoid

Do not mistake withdrawal symptoms for depression relapse 2. Discontinuation symptoms typically:

• Emerge within days of dose reduction (not weeks)
• Include prominent physical symptoms (dizziness, paresthesias)
• Resolve rapidly with medication reinstatement

True relapse typically develops more gradually over weeks and lacks the prominent somatic features of withdrawal 2.

Special Considerations

Paroxetine exhibits nonlinear pharmacokinetics due to CYP2D6 saturation 4. Approximately 43% of patients on chronic 20 mg/day become functional poor metabolizers, which may complicate tapering and increase withdrawal risk 4. If the patient has unusual sensitivity or severe withdrawal symptoms, consider CYP2D6 genetic testing 4.