How should I manage abrupt discontinuation of quetiapine (Seroquel) 100 mg twice daily in a 71‑year‑old male hospice patient?

Management of Abrupt Quetiapine Discontinuation in a Hospice Patient

In a 71-year-old male hospice patient who has had quetiapine 100 mg twice daily abruptly discontinued, you should monitor for withdrawal symptoms (nausea, vomiting, agitation, insomnia, tachycardia) and manage any distressing symptoms with comfort-focused medications rather than restarting the quetiapine, as medications inconsistent with comfort goals should remain discontinued in hospice care. 1, 2

Rationale for Not Restarting Quetiapine

• Medications inconsistent with comfort-focused goals should be discontinued when transitioning to hospice care, while only those providing symptom palliation should be continued. 2
• Quetiapine was likely being used for psychiatric indications (delirium, agitation, or psychosis) that may no longer align with end-of-life comfort goals, particularly if the patient is imminently dying. 1
• The abrupt discontinuation has already occurred; restarting would require following the gradual titration schedule (starting at 25-50 mg/day with slow increases), which is impractical in hospice settings focused on immediate comfort. 3

Monitoring for Withdrawal Symptoms

Watch specifically for these somatic withdrawal symptoms, which typically emerge within 24-72 hours of cessation:

• Gastrointestinal: Nausea, vomiting 4

• Autonomic: Diaphoresis, tachycardia, hypertension 4

• Neuropsychiatric: Agitation, restlessness, irritability, anxiety, dysphoria, insomnia, dizziness 4

• Movement disorders: Rarely, withdrawal dyskinesia with choreiform movements, confusion, or speech disturbance 4

• Focus monitoring exclusively on comfort parameters—not vital signs or blood pressure targets—as routine vital sign monitoring should not be performed in imminently dying patients. 2

Managing Distressing Withdrawal Symptoms

For Agitation or Restlessness

• First-line: Midazolam 0.5-1 mg/hour continuous subcutaneous infusion, titrated up to 1-20 mg/hour as needed for comfort. 1
• Alternative: Lorazepam 0.5-2 mg every 4-6 hours if agitation is refractory to neuroleptics. 1

For Delirium with Confusion

• Haloperidol 0.5-2 mg every 1 hour as needed until controlled, then 0.5-1 mg twice daily for maintenance. 1
• Alternative neuroleptics: Levomepromazine 12.5-25 mg every 8 hours (up to 300 mg/day continuous infusion) or chlorpromazine 12.5 mg every 4-12 hours IV/IM. 1
• Note: If the original indication for quetiapine was delirium management and delirium symptoms recur, these agents are appropriate substitutes. 1

For Nausea and Vomiting

• Haloperidol 0.5-1 mg every 6-8 hours or levomepromazine 6.25-12.5 mg every 8 hours. 1
• Avoid restarting quetiapine solely for nausea, as more targeted antiemetics are preferable in hospice. 1

For Insomnia

• If insomnia is distressing and not part of the natural dying process, consider low-dose lorazepam 0.5-1 mg at bedtime or midazolam 2.5-5 mg subcutaneously at night. 1

Critical Pitfalls to Avoid

• Do not restart quetiapine simply because withdrawal symptoms appear—treat the symptoms directly with comfort-focused medications instead. 2
• Do not perform aggressive monitoring (frequent vital signs, ECGs) that shifts focus away from comfort. 2
• Do not mistake withdrawal agitation for pain, which could lead to inappropriate opioid escalation that worsens delirium. 1
• Avoid combining multiple sedatives (benzodiazepines + neuroleptics) initially; start with one agent and add the second only if refractory. 1, 5

Special Considerations for Hospice Context

• Gradual deterioration of physiological parameters (hypotension, tachycardia) is expected as patients near death and should not trigger intervention unless causing distress. 2
• Family education is essential: Explain that withdrawal symptoms are temporary, manageable, and do not indicate suffering if the patient appears comfortable. 2
• If the patient was on quetiapine for chronic schizophrenia or delusional disorder and has weeks-to-months life expectancy (not imminently dying), reconsider whether restarting at a lower dose (25-50 mg twice daily) might improve quality of life by preventing psychotic symptom recurrence. 6, 7 However, this decision should be made only if psychotic symptoms themselves are causing distress.

Timeline Expectations

• Withdrawal symptoms typically peak within 2-5 days and resolve within 1-2 weeks without intervention. 4
• If symptoms are managed with comfort medications, most patients stabilize within 3-7 days. 4
• Death may occur during this period independent of withdrawal, which should be anticipated and discussed with family beforehand. 2