How should I safely taper and discontinue Wellbutrin XL 150 mg (bupropion), Invega 3 mg (paliperidone), and Vraylar 1.5 mg (cariprazine)?

Tapering Wellbutrin XL 150 mg, Invega 3 mg, and Vraylar 1.5 mg

Wellbutrin XL 150 mg (Bupropion) Discontinuation

Bupropion can be discontinued abruptly at 150 mg daily without a formal taper, as this dose is low and withdrawal symptoms are minimal. 1

• Stop the medication immediately rather than tapering, since 150 mg XL once daily represents a low therapeutic dose and bupropion does not require gradual discontinuation like benzodiazepines or other CNS depressants 2
• Monitor for return of depressive symptoms over the following 2–4 weeks, as mood changes may not manifest immediately after stopping 3
• Watch for decreased energy levels during the first 1–2 weeks post-discontinuation, since bupropion has activating properties and patients may experience transient fatigue 3
• Do not prolong discontinuation unnecessarily, as extended tapers can become a source of patient anxiety without clinical benefit 3

Critical Safety Points for Bupropion Discontinuation

• Unlike benzodiazepines, baclofen, or barbiturates, abrupt cessation of bupropion does not cause life-threatening withdrawal 2
• If the patient is under 24 years old, assess for suicidal ideation weekly for the first month after stopping, as the black-box warning applies during treatment changes 1
• Bupropion discontinuation does not require the same gradual approach mandated for medications with serious withdrawal syndromes 2

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Invega 3 mg (Paliperidone) Tapering

Taper Invega gradually over at least 4–6 weeks to minimize withdrawal dyskinesias, parkinsonian symptoms, and potential neuroleptic malignant syndrome. 2

Recommended Taper Schedule

• Week 1–2: Reduce to 2 mg daily (33% reduction) 2
• Week 3–4: Reduce to 1.5 mg daily (50% reduction from starting dose) 2
• Week 5–6: Reduce to 1 mg daily 2
• Week 7: Discontinue completely 2

Monitoring During Invega Taper

• Assess weekly for withdrawal dyskinesias (involuntary movements of face, tongue, or extremities), parkinsonian symptoms (tremor, rigidity, bradykinesia), or dystonias (sustained muscle contractions) 2
• Watch for signs of neuroleptic malignant syndrome: fever, muscle rigidity, altered mental status, autonomic instability (tachycardia, labile blood pressure, diaphoresis) 2
• If withdrawal symptoms cause significant distress, re-escalate to the previous dose and slow the taper further 2

Non-Pharmacological Support During Antipsychotic Withdrawal

• Implement environmental interventions: simplify tasks, maintain sleep-wake cycle, ensure social engagement 2
• Use caregiver redirection and reorientation techniques if behavioral symptoms emerge 2
• Optimize sensory environment and participation in structured activities 2

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Vraylar 1.5 mg (Cariprazine) Tapering

Taper Vraylar gradually over 4–8 weeks, as abrupt discontinuation of antipsychotics risks withdrawal dyskinesias, parkinsonian symptoms, and neuroleptic malignant syndrome. 2

Recommended Taper Schedule

• Week 1–2: Reduce to 1 mg daily (33% reduction) 2
• Week 3–4: Reduce to 0.75 mg daily (alternate-day dosing of 1.5 mg may be used if 0.75 mg capsules unavailable) 2
• Week 5–6: Reduce to 0.5 mg daily 2
• Week 7–8: Discontinue completely 2

Cariprazine-Specific Considerations

• Cariprazine has a long half-life (1–3 weeks for active metabolites), so withdrawal symptoms may be delayed or less severe than with shorter-acting antipsychotics 4
• Despite the long half-life, gradual dose reduction is still recommended to minimize discontinuation effects 2
• Monitor for return of manic or depressive symptoms if cariprazine was prescribed for bipolar disorder, as remission rates are 2-fold higher with cariprazine than placebo 4

Monitoring During Vraylar Taper

• Assess weekly for extrapyramidal symptoms: akathisia (restlessness), tremor, rigidity, or abnormal movements 2
• Screen for neuroleptic malignant syndrome (same criteria as Invega taper above) 2
• If withdrawal symptoms persist or worsen, return to the previous dose and extend the taper over 8–12 weeks 2

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Critical Pitfalls to Avoid

• Never abruptly discontinue Invega or Vraylar, as this significantly increases the risk of withdrawal dyskinesias and neuroleptic malignant syndrome 2
• Do not taper all three medications simultaneously—stagger discontinuations by 2–4 weeks to isolate withdrawal symptoms to a single agent 2
• Avoid "cold referrals" to other clinicians without confirming acceptance of care, as this constitutes patient abandonment 2
• Do not mistake early behavioral activation for worsening psychiatric symptoms—transient agitation during tapers often resolves with dose adjustment 1

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Suggested Discontinuation Sequence

Discontinue bupropion first (immediate stop), then taper Invega over 4–6 weeks, followed by Vraylar over 4–8 weeks. 2, 3

1. Day 1: Stop Wellbutrin XL 150 mg (no taper needed) 1, 3
2. Week 2: Begin Invega taper (reduce to 2 mg daily) 2
3. Week 8: Complete Invega discontinuation, then begin Vraylar taper (reduce to 1 mg daily) 2
4. Week 16: Complete Vraylar discontinuation 2

This staggered approach allows you to identify which medication is responsible for any withdrawal symptoms and adjust the taper accordingly 2