How can I discontinue quetiapine without nausea or vomiting due to emetophobia?

Discontinuing Quetiapine to Minimize Nausea and Vomiting Risk

Gradual withdrawal is essential when discontinuing quetiapine, as abrupt cessation can cause acute withdrawal symptoms including insomnia, nausea, and vomiting, which is particularly concerning given your emetophobia. 1

Understanding the Risk

• Acute withdrawal symptoms such as nausea and vomiting have been specifically documented after abrupt cessation of quetiapine 1
• In clinical trials, 12.1% of patients experienced one or more discontinuation symptoms after abrupt cessation, compared to 6.7% with placebo 1
• A case report documented severe quetiapine withdrawal syndrome with nausea and vomiting in a 65-year-old patient, where multiple tapering attempts provoked severe withdrawal symptoms 2
• The incidence of individual adverse reactions (including nausea and vomiting) typically did not exceed 5.3% and usually resolved after 1 week post-discontinuation 1

Recommended Tapering Strategy

Implement a slow, gradual taper rather than abrupt discontinuation to minimize withdrawal symptoms. 1

• Reduce the dose in small increments (no more than 25% of the current dose at a time) 1
• Space dose reductions at least 1-2 weeks apart to allow your body to adjust 1
• Monitor for any emergence of withdrawal symptoms between dose reductions 1
• If withdrawal symptoms appear, hold at the current dose until symptoms resolve before continuing the taper 1

Prophylactic Antiemetic Strategy for Emetophobia

Given your emetophobia, prophylactic antiemetic treatment is highly recommended during the tapering process. 3

First-Line Prophylaxis:

• Start a dopamine receptor antagonist such as metoclopramide 5-10 mg orally 30 minutes before your morning dose of quetiapine 3, 4
• Consider adding a benzodiazepine such as lorazepam 0.5-1 mg orally every 4-6 hours as needed for anxiety-related nausea 3, 4

If Breakthrough Nausea Occurs:

• Add a 5-HT3 receptor antagonist such as ondansetron 4-8 mg orally every 8 hours 3
• Consider adding an antihistamine such as meclizine or an anticholinergic agent such as scopolamine for refractory symptoms 3, 4
• For severe cases, add dexamethasone 4-8 mg orally 3, 4

Special Consideration from Case Report:

• In the documented case of severe quetiapine withdrawal with nausea and vomiting, pretreatment with domperidone (a dopamine antagonist) largely prevented withdrawal symptoms and allowed successful discontinuation 2

Practical Implementation Algorithm

1. Week 1-2: Start prophylactic metoclopramide 5-10 mg orally 30 minutes before your quetiapine dose 3, 4

2. Week 2-3: Reduce quetiapine dose by 25% while continuing metoclopramide 1

3. Week 4-5: If no nausea/vomiting occurs, proceed with next 25% dose reduction 1

4. If symptoms emerge: Hold at current dose, add ondansetron 4-8 mg orally every 8 hours, and wait until symptoms resolve before continuing taper 3

5. Continue pattern: Reduce by 25% every 2 weeks as tolerated until completely discontinued 1

6. Post-discontinuation: Continue antiemetics for 1 week after final dose, as symptoms typically resolve within 1 week 1

Critical Pitfalls to Avoid

• Never abruptly stop quetiapine, as this significantly increases the risk of withdrawal symptoms including nausea and vomiting 1
• Do not attempt to taper faster than every 1-2 weeks, as this increases withdrawal symptom risk 1
• Be cautious with long-term benzodiazepine use due to dependence risk; use short-term only during the taper 4
• Monitor for extrapyramidal symptoms with dopamine receptor antagonists like metoclopramide 4
• If you suddenly stop taking quetiapine and experience side effects, contact your healthcare provider immediately 1

Psychological Support for Emetophobia

• Consider cognitive-behavioral therapy with exposure-response prevention specifically for emetophobia during the tapering process 5, 6, 7
• Behavioral therapy with systematic desensitization may help manage anticipatory anxiety about potential nausea 3
• Having prophylactic antiemetics readily available can provide psychological reassurance 3