How to safely discontinue mirtazapine (an antidepressant) 7.5 mg in an adult patient with a history of depression?

How to Discontinue Mirtazapine 7.5 mg

Gradually taper mirtazapine rather than stopping abruptly, even at the low dose of 7.5 mg, to minimize withdrawal symptoms including potential panic attacks, anxiety, and sleep disturbances. 1

Tapering Strategy

The FDA drug label explicitly states that mirtazapine should be gradually reduced rather than stopped abruptly whenever possible to prevent adverse reactions upon discontinuation. 1 While specific tapering schedules are not provided in the official labeling, the evidence strongly supports a cautious approach:

• Reduce the dose by approximately 25-50% every 1-2 weeks, monitoring closely for withdrawal symptoms 1
• For a patient on 7.5 mg (already half the standard starting dose of 15 mg), consider reducing to 3.75 mg (half tablet) for 1-2 weeks before complete discontinuation 1
• The tapering period should extend over at least 2-4 weeks to minimize discontinuation effects, even though this is a low dose 2

Critical Warning About Abrupt Discontinuation

A documented case report demonstrates that even after 10 weeks of mirtazapine treatment at 30 mg, abrupt discontinuation caused severe, recurrent panic attacks lasting 20 minutes each and recurring every 1-2 hours for 5 days. 3 The patient only achieved complete symptom resolution after mirtazapine was reintroduced. This case illustrates that:

• Withdrawal symptoms can be severe and debilitating even after medium-duration therapy 3
• Symptoms may include panic attacks, palpitations, dyspnea, chest pain, dizziness, nausea, blurred vision, and fear of dying 3
• Progressive tapering is advisable even after relatively short treatment courses 3

Monitoring During Discontinuation

Begin assessing for withdrawal symptoms within the first few days of dose reduction, as the case report showed symptoms emerging on day 2 after abrupt cessation 3. Watch specifically for:

• Anxiety or panic symptoms 3
• Sleep disturbances or insomnia (mirtazapine is commonly used for its sleep-promoting effects) 2, 4
• Return of depressive symptoms 4
• Physical symptoms including dizziness, nausea, or sensory disturbances 3

Special Considerations for 7.5 mg Dose

The 7.5 mg dose is below the standard starting dose of 15 mg recommended by the FDA 1. This sub-therapeutic dose is sometimes used off-label primarily for sleep or appetite stimulation rather than antidepressant effects 2, 4. However:

• Even at this low dose, gradual tapering is still recommended based on the withdrawal case report and FDA guidance 1, 3
• The lower dose may allow for a shorter taper (1-2 weeks total) compared to higher therapeutic doses 1
• If the patient experiences withdrawal symptoms during tapering, slow the taper or temporarily return to the previous dose before attempting reduction again 3

Alternative Approach if Withdrawal Symptoms Occur

If significant withdrawal symptoms develop during tapering, re-escalate to the previous tolerated dose and attempt a slower taper (reducing by smaller increments over longer intervals) 3. The case report demonstrated complete symptom resolution when mirtazapine was reintroduced at the original dose 3.

Context for Discontinuation Decision

Consider why discontinuation is being pursued, as mirtazapine has specific advantages that may be relevant:

• Mirtazapine is considered safe in cardiovascular disease and may be preferable to other antidepressants in patients with cardiac conditions 2
• It provides benefits for sleep, appetite, and anxiety that may be therapeutic even at low doses 2, 4
• Treatment should typically continue for 4-9 months after satisfactory response in first-episode depression, or longer with recurrent episodes 4