Initial Dosing and Titration Instructions
The patient should be prescribed an initial dose of 25 mg daily, with instructions to increase by 25-50 mg every 3-4 days as tolerated, targeting a maintenance dose of 100-300 mg daily. 1, 2
Starting Dose
- Begin with 25 mg once daily to minimize the risk of side effects and allow assessment of tolerability 1, 2
- This conservative starting approach is supported by evidence showing that gradual titration significantly enhances patient tolerability without delaying therapeutic response 3
Titration Schedule
Week-by-Week Titration Protocol:
- Days 1-3 to 1-4: 25 mg daily 1, 2
- Days 4-7 to 7-10: Increase to 50 mg daily (if tolerated) 1, 2
- Days 8-11 to 11-14: Increase to 75-100 mg daily 1, 2
- Continue increasing by 25-50 mg every 3-4 days until reaching the target therapeutic range 1, 2
The specific increment (25 mg vs 50 mg) should be determined by the patient's tolerance of side effects at each dose level 1, 2, 3
Target Maintenance Dose
- Aim for 100-300 mg daily as the therapeutic maintenance dose 1
- Most patients will achieve adequate symptom control within this range 1
- The entire titration process typically takes 5-6 weeks to reach the target dose safely 2
Patient Instructions
The patient should be instructed to:
- Take the medication at the same time each day to maintain consistent blood levels 1, 2
- Do not increase the dose faster than prescribed, even if symptoms persist, as rapid titration significantly increases the risk of serious adverse effects 2, 3
- Report any concerning side effects immediately, particularly rash, dizziness, or cognitive changes 2, 4
- Never skip dose levels during titration—each increment must be maintained for the full 3-4 days before advancing 2, 3
Critical Safety Considerations
Common pitfalls to avoid:
- Premature dose escalation: Patients must allow adequate time at each dose level before increasing, as rushing titration is associated with higher discontinuation rates due to side effects 2, 3
- Ignoring tolerability signals: Side effects like sedation, dizziness, or gastrointestinal disturbances should prompt holding at the current dose or reducing by one increment 4, 3
- Slow, cautious up-titration is generally associated with better long-term outcomes and treatment adherence 5, 6
Monitoring During Titration
- Assess tolerability at each dose increment before advancing 1, 2, 3
- If side effects occur, maintain the current dose for an additional 3-4 days or reduce by one increment 3
- Patient education and frequent monitoring are critical during the titration phase 5
Special Populations
For elderly patients or those with multiple comorbidities, consider even slower titration (increasing by 25 mg every 4-7 days rather than every 3-4 days) to minimize adverse effects 4