What is the recommended tapering schedule to safely discontinue risperidone (2 mg daily) in an adult patient who has been on the medication for several weeks?

How to Wean Off Risperidone

For an adult on risperidone 2 mg daily for several weeks, reduce the dose by 0.5 mg every 2–4 weeks, targeting a final dose of approximately 1 mg before complete discontinuation over 8–16 weeks total. 1

Recommended Tapering Protocol

Standard Reduction Schedule

• Begin by reducing from 2 mg to 1.5 mg daily and maintain this dose for 2–4 weeks before the next reduction 1
• Continue with 0.5 mg decrements every 2–4 weeks until reaching 1 mg daily 1
• The entire tapering process typically requires 8–16 weeks to complete safely 1
• Each new dose reduction should be calculated as a percentage of the current dose, not the original starting dose, to avoid disproportionately large final decrements 2

Slower Tapering for Specific Situations

• If withdrawal symptoms emerge or original psychiatric symptoms return during any reduction, switch to smaller 0.25 mg decrements and extend the interval between reductions to 4–6 weeks 1
• Patients who have been on risperidone for years rather than weeks require much slower tapers, potentially extending over several months 3
• Gradual tapering is prudent even after short-term use of several weeks, as neurobiological adaptations occur rapidly 1, 4

Critical Safety Principles

Never Discontinue Abruptly

• Abrupt discontinuation of antipsychotics is considered unacceptable medical care and can precipitate severe withdrawal symptoms and rapid symptom destabilization 1, 3
• Sudden cessation can trigger rebound psychosis, agitation, insomnia, anxiety, and other withdrawal phenomena 1, 4

Why Gradual Tapering Matters

• Slower tapering (over months) is associated with significantly lower relapse rates compared to rapid discontinuation (over weeks) 4
• Gradual reduction allows time for homeostatic adaptations made during antipsychotic treatment to resolve, minimizing disruption and reducing relapse risk 4
• Exacerbation of symptoms during tapering may represent withdrawal effects rather than true relapse, indicating the need for slower reduction rather than dose escalation 4

Monitoring During Tapering

Schedule Regular Follow-Up

• Evaluate the patient every 2–4 weeks during active dose reductions to assess for symptom return and withdrawal effects 1
• Document baseline symptoms and functioning before initiating the taper to establish a comparison point 1

Watch for These Warning Signs

• Return of original psychiatric symptoms that prompted risperidone treatment (psychosis, agitation, mood instability) 1, 5
• Withdrawal symptoms including insomnia, anxiety, irritability, restlessness, or worsening of baseline symptoms 1
• In Alzheimer's patients specifically, discontinuation after 4–8 months of treatment was associated with a 60% relapse rate within 16 weeks versus 33% in those continuing medication 5

When to Pause or Slow the Taper

• If clinically significant withdrawal symptoms or psychiatric symptom return occurs, temporarily return to the previous dose and allow stabilization for 2–4 weeks 1, 3
• After stabilization, attempt a smaller dose reduction (0.25 mg instead of 0.5 mg) with longer intervals between changes 1
• Pauses in the taper are acceptable and often necessary—the goal is durability, not speed 2, 3

Adjunctive Strategies to Support Successful Tapering

Non-Pharmacological Support

• Implement psychosocial support during tapering to help manage stress and anxiety accompanying medication changes 1
• Consider cognitive-behavioral therapy (CBT) during the taper, which significantly increases success rates in medication discontinuation 2

Managing Specific Withdrawal Symptoms

• For insomnia that emerges during tapering, consider trazodone 25–50 mg at bedtime for short-term management 1
• Address anxiety with evidence-based psychological therapies rather than substituting another medication 2

Important Considerations and Pitfalls

Patient Collaboration is Essential

• Ensure patient agreement and understanding of the tapering plan, including the rationale, expected timeline, and option to slow down if needed 3
• Use shared decision-making and explain both the risks of continued use and benefits of discontinuation 2

Do Not Abandon the Patient

• If the patient struggles with tapering, consider pausing at a stable reduced dose rather than pushing forward or discontinuing care 3
• Maintenance at a lower dose is a legitimate outcome if complete discontinuation proves too difficult 2, 3

Avoid These Common Mistakes

• Do not use a fixed timeline—the taper must be adjusted based on individual response, not a predetermined schedule 3
• Do not make "cold referrals" to other clinicians during the taper without ensuring they have agreed to accept the patient's care 3
• Never calculate reductions as a percentage of the original dose—always reduce by a percentage of the current dose 2

Ensure Access to Urgent Care

• Have a plan for urgent psychiatric evaluation if acute decompensation occurs during the taper 3
• Be prepared to temporarily increase the dose back to a previously tolerated level if severe symptoms emerge 1

Context: Optimal Dosing of Risperidone

The current recommended target dose of risperidone for most patients is 4 mg/day, with lower doses (1–2 mg/day) often appropriate for elderly patients, young patients, and first-episode patients 6. Doses above 6 mg/day are associated with increased extrapyramidal side effects without additional therapeutic benefit 1. Since your patient is on 2 mg daily—already at the lower end of the therapeutic range—careful monitoring during tapering is particularly important, as this dose may be providing meaningful symptom control.