Tapering Amitriptyline 150mg and Duloxetine 150mg
Both medications require slow, gradual tapering over 6-8 weeks minimum to prevent withdrawal symptoms, with duloxetine reduced first to 30mg daily then 20mg daily before alternating days, and amitriptyline decreased by 25mg every 1-2 weeks down to very low doses (potentially 10mg or less) before complete discontinuation. 1, 2
Duloxetine Tapering Protocol
Start with duloxetine taper first since it has a well-established withdrawal syndrome that requires careful management:
- Week 1-2: Reduce from 150mg to 120mg daily 1
- Week 3-4: Reduce to 60mg daily 3, 1
- Week 5-6: Reduce to 30mg daily 1
- Week 7-8: Reduce to 20mg daily 1
- Week 9-10: Alternate days at 20mg or reduce further 1
- Week 11-12: Complete discontinuation 1
The American Academy of Child and Adolescent Psychiatry emphasizes that this 6-8 week minimum is critical, though some patients require 3-4 months for safe tapering. 1
If severe withdrawal symptoms develop (anxiety, dizziness, nausea, irritability), return to the previous dose and extend each reduction phase by 1-2 weeks. 1
Amitriptyline Tapering Protocol
Begin amitriptyline taper after duloxetine is at 60mg or lower to avoid managing two withdrawal syndromes simultaneously:
- Week 1-2: Reduce from 150mg to 125mg at bedtime 3
- Week 3-4: Reduce to 100mg at bedtime 3
- Week 5-6: Reduce to 75mg at bedtime 3
- Week 7-8: Reduce to 50mg at bedtime 3
- Week 9-10: Reduce to 25mg at bedtime 3
- Week 11-12: Reduce to 10mg at bedtime 2
- Week 13-14: Complete discontinuation 2
Research on SSRI/SNRI withdrawal demonstrates that hyperbolic tapering down to doses much lower than therapeutic minimums (in this case, going to 10mg amitriptyline before stopping) significantly reduces withdrawal symptoms compared to stopping at 25mg. 2
Critical Monitoring Requirements
Weekly assessments must include:
- Mood symptoms and anxiety levels 1
- Pain levels (both medications are analgesics for neuropathic pain) 3, 4
- Sleep patterns and quality 1
- Cardiovascular symptoms (palpitations, blood pressure changes) 3
- Anticholinergic withdrawal (sweating, nausea, headache) 3
Common Pitfalls to Avoid
Never abruptly discontinue either medication. Duloxetine withdrawal can cause severe anxiety and panic attacks, while amitriptyline cessation can trigger rebound tachycardia and hypertension. 3, 1, 5
Do not taper both medications simultaneously at full speed. This compounds withdrawal symptoms and makes it impossible to identify which medication is causing problems. 1, 5
Do not stop at the "minimum therapeutic dose" (25mg amitriptyline, 30mg duloxetine). Evidence shows that tapering to much lower doses before complete cessation prevents withdrawal. 2
Avoid rushing the taper if the patient has been on these doses for years. Longer duration of use typically requires slower tapering, potentially extending to 3-4 months total. 1
Managing Withdrawal Symptoms
If withdrawal symptoms emerge:
- Return to the previous dose immediately and stabilize for 1-2 weeks 1
- Slow the taper by 50% (reduce by smaller increments or extend time between reductions) 1, 2
- Consider cognitive-behavioral therapy during the taper to address anxiety from medication discontinuation 1
The risk of serotonin syndrome during this taper is minimal since both medications are being reduced, but monitor for confusion, agitation, muscle rigidity, and hyperthermia if any other serotonergic medications are added. 5