Antidepressants, a Guide to Switching and Withdrawing

Instructions for changing or stopping antidepressants.

Switching and Withdrawing Antidepressants
MAOIs - REVERSIBLE
FROM TO WITHDRAWAL ADVICE
Moclobemide
(Manerix, generic prep also available)
Agomelatine: cautious cross-tapering* recommended1 Reduce dose gradually over 4 weeks1
Duloxetine, MAOIs, mirtazapine, reboxetine, SSRIs, trazodone, TCADs, venlafaxine, vortioxetine: withdraw and wait 1 day1
MAOIs - IRREVERSIBLE
FROMTOWITHDRAWAL ADVICE

All
(phenelzine [Nardil]; tranylcypromine [generic
prep])

Agomelatine: cautious cross-tapering* recommended1 Reduce dose gradually over 4 weeks or longer 1
Clomipramine, imipramine: withdraw and wait 3 weeks1,2
Duloxetine, other MAOIs/moclobemide, mirtazapine, reboxetineSSRIsTCADs (excl clomipramine and imipramine), trazodonevenlafaxinevortioxetine: withdraw and wait 2 weeks1,2
NORADRENALINE REUPTAKE INHIBITORS
FROMTOWITHDRAWAL ADVICE
Reboxetine
(Edronax)
Agomelatineduloxetine, mirtazapine, SSRIs, TCADs, trazodone, venlafaxine, vortioxetine: cautious cross-tapering* recommended1 Reduce dose gradually over 4 weeks1
MAOIs/moclobemide: withdraw and wait 7 days1
SNRIs
FROMTOWITHDRAWAL ADVICE
Duloxetine
(Cymbalta, generic prep also available)
Agomelatine, mirtazapine, reboxetine, trazodone: cautious cross-tapering* recommended1 Reduce dose gradually over 4 weeks or longer1
Clomipramine, fluoxetine, fluvoxamine: withdraw before starting new agent at low dose (eg, fluoxetine 10mg/day)1
MAOIs/moclobemide: withdraw and wait 7 days1
SSRIs (excl fluoxetine and fluvoxamine), TCADs (excl clomipramine), venlafaxine, vortioxetine: cautious cross-tapering* recommended, using low starting dose of new agent1
Venlafaxine
(Depefex XLEfexor XL, Politid XL, VenlaBlue XL, Venlalic XL, Vensir XL, generic prep also available)
Agomelatine, mirtazapine, reboxetine, trazodone: cautious cross-tapering* recommended1 Reduce dose gradually over 4 weeks or longer1
Clomipramine, fluoxetine, fluvoxamine: withdraw before starting new agent at low dose (eg, fluoxetine 10mg/day)1
Duloxetine, SSRIs (excl fluoxetine and fluvoxamine), TCADs (excl clomipramine), vortioxetine: cautious cross-tapering* recommended, using low starting dose of new agent. Abrupt switch to duloxetine is possible starting at 60mg/day1
MAOIs/moclobemide: withdraw and wait 7 days1,2
SSRIs
FROMTOWITHDRAWAL ADVICE
All except fluoxetine and fluvoxamine Agomelatine, mirtazapine, reboxetine: cautious cross-tapering* recommended1 See recommendations for individual SSRIs below
Clomipramine, fluoxetine, fluvoxamine: withdraw before starting new agent at low dose (eg, fluoxetine 10mg/day)1
Duloxetine, other SSRIs (excl fluoxetine and fluvoxamine), TCADs (excl clomipramine), trazodone, venlafaxine, vortioxetine: cautious cross-tapering* recommended, using low starting dose of new agent. Abrupt switch to duloxetine is possible starting at 60mg/day1
MAOIs/moclobemide: see individual requirements for each SSRI below
Citalopram
(Cipramil, generic prep also available)
MAOIs/moclobemide: withdraw and wait 7 days1,2 Reduce dose gradually over 4 weeks or longer1
Escitalopram
(Cipralexgeneric prep also available)
MAOIs/moclobemide: withdraw and wait 7 days1,2 Reduce dose gradually over 4 weeks or longer1
Fluoxetine
(OlenaOxactin, Prozac, Prozep, generic prep also available)
Agomelatine, mirtazapine, reboxetine, trazodone: cautious cross-tapering* recommended, starting trazodone at low dose1 Doses ≤20mg daily,no dose tapering required; doses >20mg daily, reduce gradually over 2 weeks1
Duloxetine, venlafaxine: withdraw before starting new agent at low dose (eg, duloxetine 60mg/day)1
Fluvoxamine: withdraw and wait 2 weeks before starting at low dose1
MAOIs/moclobemide: withdraw and wait 5–6 weeks (longer if prolonged use and/or high dose of fluoxetine)1,2
Other SSRIs (excl fluvoxamine), vortioxetine: withdraw and wait 4–7 days before starting new agent at low dose1
TCADs: withdraw and wait 4–7 days (2 weeks for clomipramine) before starting at low dose1
Fluvoxamine
(Faverin, generic prep also available)
Agomelatine: withdraw and wait 7 days1 Reduce dose gradually over 4 weeks1
Clomipramine, fluoxetine: withdraw before starting new agent at low dose (eg, fluoxetine 10mg/day)1
Duloxetine, other SSRIs (excl fluoxetine), venlafaxine, vortioxetine: withdraw before starting new agent at low dose1
MAOIs/moclobemide: withdraw and wait 7 days1,2
Mirtazapine, trazodone, TCADs (excl clomipramine): cautious cross-tapering* recommended, using low starting dose of new agent (eg, mirtazapine 15mg)1
Reboxetine: cautious cross-tapering* recommended1
Paroxetine
(Seroxat, generic prep also available)
MAOIs/moclobemide: withdraw and wait 7 days1,2 Reduce dose gradually over 4 weeks or longer1
Sertraline
(Lustral, generic prep also available)
MAOIs/moclobemide: withdraw and wait 7 days1,2 Reduce dose gradually over 4 weeks or longer1
TRICYCLIC ANTIDEPRESSANTS
FROMTOWITHDRAWAL ADVICE

All except clomipramine
(amitriptyline [generic prep], dosulepin [Prothiaden, generic prep also available], doxepin [generic prep], imipramine [generic prep], lofepramine [Lomont, generic prep also available], nortriptyline [generic prep], trimipramine [generic prep]

 

Agomelatine, fluvoxamine, mirtazapine, reboxetine, other TCADs: cautious cross-tapering* recommended1 Reduce dose gradually over 4 weeks1
Duloxetine, venlafaxine: cautious cross-tapering* recommended, using low starting dose of SNRI1
MAOIs: withdraw and wait 2 weeks. Imipramine, withdraw and wait 3 weeks1
Moclobemide: withdraw and wait 7 days1
SSRIs (excl fluvoxamine), trazodone, vortioxetine: halve TCAD dose, add new agent then withdraw TCAD slowly1

Clomipramine (generic prep)

Agomelatine, mirtazapine, reboxetine, trazodone, other TCADs: cautious cross-tapering* recommended, using low starting dose of trazodone1 Reduce dose gradually over 4 weeks1
Duloxetine, SSRIs (excl fluvoxamine), venlafaxine, vortioxetine: withdraw before starting new agent at low dose (eg, fluoxetine 10mg/day).1 SPCs for clomipramine recommend a 2–3-week washout period before starting fluoxetine2
Fluvoxamine: withdraw before starting at low dose1
MAOIs: withdraw and wait 3 weeks1
Moclobemide: withdraw and wait 7 days1
TRICYCLIC-LIKE ANTIDEPRESSANTS
FROMTOWITHDRAWAL ADVICE
Trazodone
(Molipaxin, generic prep also available)
Agomelatine, duloxetine, mirtazapine, reboxetine, SSRIs, venlafaxine, vortioxetine: cautious cross-tapering* recommended1 Reduce dose gradually over 4 weeks1
MAOIs/moclobemide: withdraw and wait 7 days1,2
TCADs: cautious cross-tapering* recommended, using low starting dose of TCAD1
OTHER ANTIDEPRESSANTS
FROMTOWITHDRAWAL ADVICE
Agomelatine
(Valdoxan)
Duloxetine, MAOIs/moclobemidemirtazapine, reboxetine, SSRIs, trazodoneTCADsvenlafaxinevortioxetine: withdraw before starting new agent1 No dose tapering required1,2
Mirtazapine
(Zispin Soltab, generic prep also available)
Agomelatine, duloxetine, reboxetine, SSRIs, trazodone, TCADs, venlafaxine, vortioxetine: cautious cross-tapering* recommended1 Reduce dose gradually over 4 weeks1
MAOIs: withdraw and wait 2 weeks1
Moclobemide: withdraw and wait 7 days1
Vortioxetine
(Brintellix)
Agomelatine, mirtazapine, reboxetine: cautious cross-tapering* recommended1 Reduce dose gradually over 1 week to 10mg/day1
Clomipramine, fluoxetine, fluvoxamine: withdraw before starting new agent at low dose (eg, fluoxetine 10mg daily)1
Duloxetine, SSRIs (excl fluoxetine and fluvoxamine), TCADs (excl clomipramine), trazodone, venlafaxine: cautious cross-tapering* recommended, using low starting dose of new agent. Abrupt switch to duloxetine is possible starting at 60mg/day1
MAOIs: withdraw and wait 3 weeks1
Moclobemide: withdraw and wait 7 days1

*Speed of cross-tapering should be judged by monitoring tolerability of the individual patient1
Switching to reboxetine monotherapy not recommended1

References

  1. The Maudsley Prescribing Guidelines in Psychiatry. 12th ed. Chichester: Wiley-Blackwell; 2015. p298–301
  2. Information sourced from manufacturers' Summaries of Product Characteristics (SPCs) Accessed via www.medicines.org.uk/emc

 

KEYWORDS: Depression


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