What is the recommended tapering schedule to safely discontinue vilazodone in an adult?

Vilazodone Tapering Protocol

For patients discontinuing vilazodone 40 mg daily, taper to 20 mg daily for 4 days, then 10 mg daily for 3 days before complete discontinuation; patients on 20 mg daily should taper to 10 mg daily for 7 days. 1

FDA-Approved Tapering Schedule

The FDA label provides explicit tapering instructions that should be followed:

• From 40 mg daily: Reduce to 20 mg once daily for 4 days, followed by 10 mg once daily for 3 days, then discontinue 1
• From 20 mg daily: Reduce to 10 mg once daily for 7 days, then discontinue 1
• Critical requirement: All doses must be taken with food to ensure adequate plasma concentrations 1, 2

This represents a relatively rapid taper (7-10 days total) compared to other antidepressants, reflecting vilazodone's pharmacokinetic profile.

Rationale for Gradual Tapering

• Abrupt cessation of vilazodone can produce discontinuation symptoms, making gradual dose reduction necessary 1
• Antidepressants with shorter half-lives require more careful tapering to minimize withdrawal symptoms 3
• Discontinuation symptoms from SSRIs are generally mild and self-limiting but can be distressing enough to cause missed work and decreased productivity 3

Expected Discontinuation Symptoms

Monitor for the following withdrawal manifestations:

• Somatic symptoms: Dizziness, light-headedness, nausea, vomiting, fatigue, lethargy, myalgia, chills, flu-like symptoms, sensory disturbances, and sleep disruption 3
• Psychological symptoms: Anxiety, agitation, crying spells, and irritability 3
• Most symptoms are transient and resolve without intervention 3

Managing Problematic Withdrawal

If severe discontinuation symptoms emerge during the taper:

• Reinstitute the previous dose and slow the tapering rate further 3
• Consider extending each dose reduction phase by several additional days beyond the FDA schedule 3
• Reassure patients that mild symptoms are typically transient and self-limiting 3
• Avoid misdiagnosing withdrawal symptoms as physical illness or depression relapse, which can lead to unnecessary testing and treatment 3

Special Considerations

• Patients with seizure history: Exercise heightened caution, as vilazodone has been associated with breakthrough seizures in patients with pre-existing seizure disorders 4
• Concurrent CYP3A4 inhibitors: If the patient is taking strong CYP3A4 inhibitors (e.g., itraconazole, clarithromycin), they should already be on a reduced dose of 20 mg daily; taper from this lower dose accordingly 1
• Concurrent CYP3A4 inducers: If the patient has been taking doses up to 80 mg daily due to CYP3A4 inducers, reduce the vilazodone dose gradually over 1-2 weeks back to standard dosing before initiating the discontinuation taper 1

Critical Pitfalls to Avoid

• Never allow abrupt discontinuation without tapering, as this increases withdrawal symptom severity 1, 3
• Never skip the food requirement during tapering, as vilazodone requires food for adequate absorption 1, 2
• Do not confuse withdrawal symptoms with depression relapse or medical illness, which may lead to inappropriate interventions 3
• Do not abandon patients who experience difficult withdrawal; instead, slow the taper and provide supportive care 3

Monitoring During Discontinuation

• Schedule follow-up within 1-2 weeks after complete discontinuation to assess for delayed withdrawal symptoms or depression recurrence 3
• Educate patients to report any concerning symptoms immediately rather than waiting for scheduled appointments 3
• Document baseline mood and anxiety symptoms before initiating the taper to distinguish withdrawal from relapse 3