What are the guidelines for discontinuing Aricept (Donepezil) 5mg at night and what are the expected side effects of stopping?

Discontinuing Aricept (Donepezil) 5mg

Aricept can be stopped abruptly without a tapering schedule, as there is no established withdrawal protocol in the guidelines or FDA labeling. 1, 2

How to Discontinue

• Simply stop the medication - no gradual dose reduction is required 1, 2
• The FDA label and clinical guidelines do not specify any tapering protocol for discontinuation 2
• The long elimination half-life of donepezil (approximately 70 hours) means the drug will clear gradually from the system over several days even with abrupt cessation 3

Expected Effects After Stopping

Cognitive and Functional Decline

• Expect gradual worsening of cognitive function over the weeks following discontinuation, as the modest benefits provided by the medication will be lost 1, 4
• The American Academy of Family Physicians notes that donepezil provides approximately a 7-point improvement on neuropsychological tests, equivalent to delaying decline by about one year 1
• Cognitive deterioration will resume at the natural disease progression rate, with decline becoming apparent within 3-6 weeks after stopping 4, 5
• Activities of daily living will deteriorate more rapidly after discontinuation, particularly complex tasks 4, 6

Withdrawal-Related Symptoms

• No specific withdrawal syndrome is documented in the FDA labeling or clinical guidelines 2
• Unlike starting the medication, stopping donepezil does not produce the cholinergic side effects (nausea, vomiting, diarrhea) that occur with initiation 2
• Some patients may experience a rebound worsening of behavioral symptoms as acetylcholine levels decline 1

Timeline of Changes

• Week 1-2: Minimal noticeable changes as drug levels decline due to long half-life 3
• Week 3-6: Progressive cognitive decline becomes apparent to caregivers and on formal testing 5
• Beyond 6 weeks: Continued deterioration at the natural disease progression rate 4, 6

Important Clinical Considerations

When Discontinuation May Be Appropriate

• Severe/advanced Alzheimer's disease where the patient has progressed beyond the stage where cholinesterase inhibitors provide meaningful benefit 1
• Intolerable side effects that significantly impact quality of life 2
• End-of-life care where symptomatic treatment is no longer aligned with goals of care 1

Monitoring After Discontinuation

• Assess cognitive function using standardized measures (MMSE or similar) at 4-6 weeks post-discontinuation to document the rate of decline 1, 5
• Monitor behavioral symptoms as these may worsen after stopping the medication 4
• Evaluate caregiver burden, which typically increases after discontinuation as the disease progresses more rapidly 6

Common Pitfall to Avoid

• Do not confuse lack of obvious improvement with lack of benefit - donepezil's primary effect is slowing decline rather than producing dramatic improvements, so stopping it will accelerate deterioration even if benefits weren't readily apparent 1, 4