How to taper off Elavil (amitriptyline) in a patient taking 20mg daily?

Tapering Amitriptyline (Elavil) 20mg Daily

For a patient on amitriptyline 20mg daily, reduce the dose by 10% of the current dose every 2-4 weeks, which translates to approximately 2mg decrements initially, monitoring for withdrawal symptoms after each reduction before proceeding to the next step. 1

Recommended Tapering Schedule

• Initial reduction: Decrease from 20mg to 18mg daily for 2-4 weeks 1
• Subsequent reductions: Continue reducing by approximately 10% of the current dose (not the original dose) every 2-4 weeks 1
  • 18mg → 16mg → 14mg → 13mg → 11mg → 10mg, etc.
• At lower doses: The reductions become smaller in absolute terms but maintain the same 10% relative reduction, which is critical to minimize withdrawal symptoms 2, 3
• Final doses: Taper down to very small doses (1-2mg) before complete discontinuation rather than jumping off from a "minimum therapeutic dose" 2

Slower Tapering for Long-Term Use

• If the patient has been on amitriptyline for years, use a much slower taper of 10% per month (or even slower) rather than every 2-4 weeks 1
• Patients on long-term therapy require individualized, extended taper schedules based on their response and tolerance 1

Monitoring and Managing Withdrawal Symptoms

• Watch for common withdrawal symptoms including dizziness, nausea, headache, paresthesia (tingling/numbness), irritability, anxiety, insomnia, and flu-like symptoms 4
• After each dose reduction, monitor the patient for withdrawal symptoms before proceeding to the next step 1
• If severe withdrawal symptoms occur: Return to the previous well-tolerated dose and slow the taper further by extending the time at each dose level to 4-8 weeks instead of 2-4 weeks 1, 4
• For persistent insomnia: Consider short-term use of non-benzodiazepine sleep aids 1

Key Principles

• Hyperbolic (exponential) tapering reduces the biological effect at receptors by fixed amounts, which minimizes withdrawal symptoms more effectively than linear dose reductions 2, 3
• Gradual tapers over months show greater success in reducing withdrawal symptoms compared to the traditional 2-4 week tapers recommended in older guidelines 2
• The first dose reduction is critical: It must be well-tolerated to establish confidence in the tapering process 5

Common Pitfalls to Avoid

• Do not use traditional "short tapers" of 2-4 weeks down to half the therapeutic dose then stopping—these show minimal benefit over abrupt discontinuation 2
• Do not mistake withdrawal symptoms for relapse of the underlying condition, which can lead to unnecessary reinitiation of medication 4
• Do not use a "one-size-fits-all" rapid approach—slower is safer, especially for patients on long-term therapy 1, 6
• Do not make equal absolute dose reductions (e.g., 5mg every 2 weeks)—use percentage-based reductions that become smaller as the total dose decreases 2, 3