What is an appropriate taper schedule for an adult on venlafaxine 150 mg (extended‑release) who wants to discontinue it?

How to Taper Off Venlafaxine 150mg

For an adult on venlafaxine ER 150 mg, reduce the dose by approximately 10% per week (decreasing by 15 mg weekly) or even slower at 10% per month (decreasing by 15 mg monthly), never discontinue abruptly, as venlafaxine carries a well-documented high risk of severe withdrawal syndrome. 1, 2

Why Gradual Tapering is Critical

Venlafaxine has a particularly high risk of discontinuation syndrome compared to other antidepressants due to its short elimination half-life and dual mechanism of action on both serotonin and norepinephrine. 3, 4, 5

• Withdrawal symptoms can occur within hours of a missed dose and may include dizziness, nausea, headache, fatigue, dysphoria, irritability, and in severe cases even hallucinations or stroke-like symptoms. 4, 5
• The FDA explicitly warns that abrupt discontinuation can be associated with serious withdrawal symptoms and mandates that medication should be tapered "as rapidly as is feasible, but with recognition that abrupt discontinuation can be associated with certain symptoms." 2
• Venlafaxine withdrawal is more intense than SSRI withdrawal due to its dual action on both serotonin and norepinephrine systems. 5

Recommended Taper Schedule

Standard Taper Protocol (10% Weekly Reduction)

• Starting from 150 mg/day, reduce by approximately 15 mg (10%) per week. 1
• This translates to: 150 mg → 135 mg → 120 mg → 105 mg → 90 mg → 75 mg → 60 mg → 45 mg → 30 mg → 15 mg → discontinue
• This approach takes approximately 10 weeks to complete. 1

Slower Taper for High-Risk Patients (10% Monthly Reduction)

• For patients with previous withdrawal symptoms or anxiety about tapering, reduce by 10% per month (approximately 15 mg monthly). 1
• This slower approach may require several months but significantly reduces withdrawal distress. 1
• Some patients may need an even more gradual taper extending beyond 1 month per dose reduction. 1

Alternative Taper Using Available Formulations

• Week 1-4: Continue 150 mg daily (establish baseline stability)
• Week 5-8: Reduce to 112.5 mg daily (using 75 mg + 37.5 mg capsules)
• Week 9-12: Reduce to 75 mg daily
• Week 13-16: Reduce to 37.5 mg daily
• Week 17-20: Reduce to 37.5 mg every other day, then discontinue 1, 6

Managing Withdrawal Symptoms

Common Withdrawal Symptoms to Anticipate

• Physical symptoms: Dizziness (most common), nausea, headache, fatigue, sweating, diarrhea 4, 5, 6
• Neurological symptoms: "Brain zaps," tremor, paresthesias 4, 5
• Psychiatric symptoms: Irritability, anxiety, dysphoria, insomnia, agitation 4, 5
• Pain amplification: Increased pain perception is a withdrawal symptom itself, not necessarily worsening of original condition 3

Symptom Management Strategies

• If withdrawal symptoms emerge, hold at current dose for 1-2 weeks before attempting further reduction. 1
• If symptoms are severe, return to the previous dose and attempt a slower taper (5% reductions instead of 10%). 1
• Provide close follow-up, patient education, and reassurance that symptoms are typically transient and self-limiting. 1
• Consider adjuvant medications for specific symptoms (e.g., antihistamines for nausea, NSAIDs for headache), though this is supportive care only. 1

Critical Pitfalls to Avoid

Never Abruptly Discontinue

• Abrupt discontinuation can precipitate severe withdrawal syndrome, including stroke-like symptoms, hallucinations, and extreme distress. 4, 5
• Even missing a single dose can trigger withdrawal symptoms in some patients. 4

Monitor for Protracted Withdrawal

• Months after complete discontinuation, patients may experience dysphoria, irritability, insomnia, anhedonia, or vague malaise (protracted withdrawal syndrome). 3
• These symptoms must be anticipated, discussed with the patient beforehand, and differentiated from relapse of the original condition. 3

Watch for Depression Relapse

• Monitor for worsening depression, suicidal ideation, or emergence of psychiatric symptoms during and after tapering. 2
• Use standardized depression scales (e.g., PHQ-9) at each visit during the taper. 6
• If depression worsens significantly, consider pausing the taper or restarting treatment. 2

Special Considerations

When Taper Must Be Faster

• If rapid discontinuation is medically necessary (e.g., serotonin syndrome risk, drug interaction), consider switching to fluoxetine (long half-life SSRI) as a bridge, then tapering fluoxetine. 1
• Alternatively, provide intensive supportive care and symptomatic treatment during a faster taper. 1

Blood Pressure Monitoring

• Venlafaxine can cause dose-dependent hypertension, so monitor blood pressure during tapering, especially if patient was on doses >150 mg previously. 3, 1
• Blood pressure may normalize as dose decreases. 1

Patient Education is Essential

• Inform patients upfront about the possibility of withdrawal symptoms and the need for gradual tapering. 5
• Provide written instructions about the taper schedule and what symptoms to report. 1
• Emphasize that withdrawal symptoms do not indicate addiction or that they "need" the medication, but rather reflect neuroadaptation. 1