Switching Antidepressants
Quick-reference guide to switching depression medication.
| Switching Antidepressants | ||
|---|---|---|
| MAOIs - REVERSIBLE | ||
| FROM | TO | WITHDRAWAL ADVICE |
| Moclobemide (Manerix, generic prep also available) | Clomipramine: evidence to suggest that a 24-hour washout period is adequate1 | Not available. As a general rule, antidepressants should be discontinued over 4 weeks2 |
| Duloxetine, MAOIs, mirtazapine, reboxetine, SSRIs,1,2 trazodone, TCADs, venlafaxine: withdraw and wait 1 day2 | ||
| MAOIs - IRREVERSIBLE | ||
| FROM | TO | WITHDRAWAL ADVICE |
| Phenelzine (Nardil) | Clomipramine: withdraw and wait 3 weeks1 | Avoid abrupt discontinuation1 |
| Duloxetine, MAOIs, mirtazapine, moclobemide,2 reboxetine,2 SSRIs, TCADs (excluding clomipramine), trazodone, venlafaxine: withdraw and wait 14 days1,2 | ||
| Tranylcypromine | As for phenelzine | As for phenelzine |
| NORADRENALINE REUPTAKE INHIBITORS | ||
| FROM | TO | WITHDRAWAL ADVICE |
| Reboxetine (Edronax) | Duloxetine, SSRIs, TCADs, trazodone, venlafaxine: cautious cross-tapering* recommended2 | Withdrawal symptoms occurred infrequently in premarketing clinical studies1 |
| MAOIs/moclobemide: withdraw and wait >7 days2 | ||
| Mirtazapine: withdraw then start mirtazapine2(Note: SmPC states that concomitant use with MAOIs should be avoided, use with other antidepressants has not been evaluated)1 | ||
| SNRIs | ||
| FROM | TO | WITHDRAWAL ADVICE |
| Duloxetine (Cymbalta) | MAOIs: withdraw and wait >5 days (concomitant use with moclobemide not recommended).1Other sources recommend delay of 7 days before starting MAOIs/ moclobemide2 | Reduce dose gradually over at least 1–2 weeks1 |
| Mirtazapine, SSRIs, trazodone, venlafaxine: withdraw, start new agent next day2 | ||
| Reboxetine: cautious cross-tapering* recommended2 | ||
| TCADs: cautious cross-tapering* recommended using very low starting dose for TCAD2 | ||
| Venlafaxine (Efexor, generic prep also available) | Duloxetine: withdraw, start duloxetine at 60mg on alternate days and increase slowly2 | Reduce dose gradually over at least 1–2 weeks1 |
| MAOIs/moclobemide: withdraw and wait >7 days1,2 | ||
| Mirtazapine, reboxetine, trazodone: cautious cross-tapering* recommended2 | ||
| SSRIs: cautious cross-tapering* recommended, using 50% of usual starting dose for SSRI (e.g. fluoxetine 20mg on alternate days, citalopram/escitalopram/paroxetine 10mg daily, sertraline 25mg daily)2 | ||
| TCADs (excluding clomipramine): cautious cross-tapering* recommended using very low starting dose for TCAD.2Avoid concomitant use of clomipramine, withdraw before starting venlafaxine2 | ||
| SSRIs | ||
| FROM | TO | WITHDRAWAL ADVICE |
| All SSRIs except fluoxetine | Duloxetine: withdraw, start duloxetine at 60mg on alternate days and increase slowly2 | See recommendations for individual SSRIs below |
| Mirtazapine, reboxetine, TCADs (excluding clomipramine): cautious crosstapering* recommended using very low starting dose for TCAD. Avoid concomitant use of clomipramine, withdraw before starting SSRIs2 | ||
| SSRIs, trazodone: withdraw before starting second agent | ||
| Venlafaxine: cautious cross-tapering* recommended (start venlafaxine at 37.5mg/day and increase very slowly).2Other sources recommend withdrawing SSRI before starting venlafaxine at 37.5mg.day3 | ||
| MAOIs/moclobemide: see individual requirements for each SSRI below | ||
| Citalopram (Cipramil, generic prep also available) | MAOIs: withdraw and wait >7 days1,2 | Reduce dose gradually over at least 1–2 weeks1 |
| Moclobemide: withdraw and wait >7 days.1Other sources recommend delay of >14 days2 | ||
| Escitalopram (Cipralex) | MAOIs: withdraw and wait >7 days1,2 | Reduce dose gradually over at least 1–2 weeks1 |
| Moclobemide: SmPC states that combination with moclobemide not recommended - if necessary then start at min. recommended dose and monitor.1 Other sources recommend delay of >14 days2 | ||
| Fluvoxamine (Faverin, generic prep also available) | MAOIs/moclobemide: withdraw and wait >7 days1 | Reduce dose gradually over at least 1–2 weeks1 |
| Paroxetine (Seroxat, generic prep also available) | MAOIs: withdraw and wait >7 days.1Other sources recommend delay of 14 days before starting phenelzine2 | Reduce dose gradually over several weeks or months1 |
| Moclobemide: withdraw and wait >7 days1,2 | ||
| Sertraline (Lustral, generic prep also available) | MAOIs/moclobemide: withdraw and wait >14 days1,2 | Avoid abrupt discontinuation1 |
| Fluoxetine (Prozac, generic prep also available) | Duloxetine: withdraw and wait 4–7 days before starting duloxetine (start at 60mg on alternate days and increase gradually)2 | Reduce dose gradually over at least 1-2 weeks1 |
| MAOIs: withdraw and wait >5 weeks1,2(longer if prolonged use and/or high dose of fluoxetine)1 | ||
| Mirtazapine: cautious cross-tapering* recommended2 | ||
| Moclobemide: withdraw and wait >5 weeks2 | ||
| Reboxetine: withdraw, start reboxetine at 2mg bd and increase cautiously2 | ||
| SSRIs, trazodone: stop and wait 4–7 days before starting second agent at low dose (approx. 50% of usual starting dose for SSRIs e.g. fluoxetine 20mg on alternate days, citalopram/ escitalopram/paroxetine10mg daily, sertraline 25mg daily)2 | ||
| TCADs (excluding clomipramine): stop and wait 4–7 days before starting TCAD at very low dose.2In case of clomipramine allow a 2–3-week washout period1 | ||
| Venlafaxine: withdraw before starting venlafaxine at 37.5mg/day, increase very slowly.2 Some sources recommend delay of 4–7 days3 | ||
| TRICYCLIC ANTIDEPRESSANTS | ||
| FROM | TO | WITHDRAWAL ADVICE |
| All TCADs | Duloxetine: cautious cross-tapering* recommended, start duloxetine at 60mg on alternate days and increase slowly2 | Avoid abrupt withdrawal1 |
| MAOIs/moclobemide: withdraw and wait >7 days.2In case of clomipramine, withdraw and wait 3 weeks1 | ||
| Mirtazapine, reboxetine, TCADs: cautious cross-tapering* recommended2 | ||
| SSRIs: halve TCAD dose, add SSRI then withdraw slowly. In case of clomipramine, withdraw before starting SSRI.2SmPC for anafranil (clomipramine) recommends a 2-3-week washout period before starting fluoxetine.1 | ||
| Trazodone: halve TCAD dose, add trazodone then withdraw gradually2 | ||
| Venlafaxine: cautious cross-tapering* recommended, start venlafaxine at 37.5mg daily2 | ||
| TRICYCLIC-LIKE ANTIDEPRESSANTS | ||
| FROM | TO | WITHDRAWAL ADVICE |
| Trazodone (Molipaxin, generic prep also available) | Duloxetine: withdraw, start duloxetine at 60mg on alternate days and increase slowly2 | Not available. as a general rule, antidepressants should be discontinued over 4 weeks2 |
| MAOIs/moclobemide: withdraw and wait >7 days1,2 | ||
| Mirtazapine, SSRIs: withdraw before starting second agent2 | ||
| Reboxetine: withdraw, start reboxetine at 2mg bd and increase cautiously2 | ||
| TCADs: cautious cross-tapering* recommended using very low dose of TCAD2 | ||
| OTHER ANTIDPRESSANTS | ||
| FROM | TO | WITHDRAWAL ADVICE |
| Mirtazapine (Zispin Soltab, generic prep also available) | Duloxetine: withdraw, start duloxetine at 60mg on alternate days and increase slowly2 | Withdraw gradually over several weeks1 |
| MAOIs/moclobemide: withdraw and wait 7 days2 | ||
| Reboxetine, trazodone, TCADs: withdraw before starting new agent2 | ||
| Venlafaxine, SSRIs: cautious cross-tapering* recommended2 | ||
*Speed of cross-tapering should be judged by monitoring tolerability of the individual patient2
References
- Information sourced from manufacturers' Summaries of Product characteristics (SmPCs)
- The Maudsley Prescribing Guidelines. 9th ed. London: Informa Healthcare; 2007. p235-43
- CKS (2007) Depression (Topic review). Clinical Knowledge Summaries Service
KEYWORDS: Depression
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