Switching Antidepressants
Quick-reference guide to switching depression medication.
| Switching Antidepressants | ||
|---|---|---|
| MAOIs - REVERSIBLE | ||
| FROM | TO | WITHDRAWAL ADVICE |
| Moclobemide (Manerix, generic prep also available) |
Duloxetine, MAOIs, mirtazapine, reboxetine, SSRIs, trazodone, TCADs, venlafaxine: withdraw and wait 1 day1,2 | |
| Not available. As a general rule, antidepressants should be discontinued over 4 weeks2 | ||
| MAOIs - IRREVERSIBLE | ||
| FROM | TO | WITHDRAWAL ADVICE |
| Phenelzine (Nardil) |
Clomipramine: withdraw and wait 3 weeks1 | Reduce dose gradually over 4 weeks2 |
| Duloxetine, MAOIs, mirtazapine, moclobemide, reboxetine, SSRIs, TCADs (excluding clomipramine), trazodone, venlafaxine: withdraw and wait 14 days2 | ||
| Tranylcypromine | As for phenelzine | As for phenelzine |
| NORADRENALINE REUPTAKE INHIBITORS | ||
| FROM | TO | WITHDRAWAL ADVICE |
| Reboxetine (Edronax) |
Duloxetine, mirtazapine, SSRIs, TCADs, trazodone, venlafaxine: cautious cross-tapering* recommended2 | Reduce dose gradually over 4 weeks2 |
| MAOIs/moclobemide: withdraw and wait >7 days2 | ||
| (Note: SPC 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 days2 Moclobemide: withdraw and wait 7 days2 |
Reduce dose gradually over at least 1–2 weeks1 |
| Mirtazapine, SSRIs, trazodone, venlafaxine: withdraw before starting new agent2 | ||
| Reboxetine: cautious cross-tapering* recommended2 | ||
| TCADs: cautious cross-tapering* recommended using very low starting dose for TCAD2 | ||
| Venlafaxine (Efexor XL, Depefex XL, Politid XL, Venlalic XL, generic prep also available) |
Duloxetine: withdraw, start duloxetine at 60mg on alternate days and increase slowly2 | Reduce dose gradually over at least 4 weeks2 |
| MAOIs/moclobemide: withdraw and wait >7 days1,2 | ||
| Mirtazapine, reboxetine, trazodone: cautious cross-tapering* recommended2 | ||
| SSRIs: cautious cross-tapering* recommended, using lower 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 daily2 | 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 agent2 | ||
| Venlafaxine: cautious cross-tapering* recommended (start venlafaxine at 37.5mg/day and increase very slowly).2 | ||
| 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 4 weeks2 |
| Moclobemide: withdraw and wait >7 days.2 | ||
| Escitalopram (Cipralex) |
MAOIs: withdraw and wait >7 days1,2 | Reduce dose gradually over at least 1–2 weeks1 |
| Moclobemide: SPC states that combination with moclobemide not recommended - if necessary then start at min recommended dose and monitor.1 Other sources recommend delay of >7 days2 |
||
| Fluoxetine (Prozac, Oxactin, Prozep, generic prep also available) |
Duloxetine: withdraw and start duloxetine at 60mg daily2 | Reduce over 2 weeks if dose >40mg/day1 |
| MAOIs: withdraw and wait >5 weeks1,2(longer if prolonged use and/or high dose of fluoxetine)1 | ||
| Mirtazapine: withdraw; wait 4–7 days, start mirtazapine cautiously2 | ||
| Moclobemide: withdraw and wait >5 weeks2 | ||
| Reboxetine: withdraw, start reboxetine at 2mg twice daily and increase cautiously2 | ||
| SSRIs, trazodone: stop and wait 4–7 days before starting second agent at low dose (starting dose for SSRI eg citalopram/escitalopram/paroxetine 10mg daily, sertraline 25mg daily)2 | ||
| TCADs (excluding clomipramine): stop and wait 4–7 days before starting TCAD at very low dose.2 In case of clomipramine allow a 2–3-week washout period1 | ||
| Venlafaxine: withdraw before starting venlafaxine at 37.5mg/day, increase very slowly.2 | ||
| 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 4 weeks or longer2 |
| Moclobemide: withdraw and wait >7 days1,2 | ||
| Sertraline (Lustral, generic prep also available) |
MAOIs/moclobemide: withdraw and wait >14 days1,2 | Reduce dose gradually over 4 weeks2 |
| TRICYCLIC ANTIDEPRESSANTS | ||
| FROM | TO | WITHDRAWAL ADVICE |
| All TCADs | Duloxetine: cautious cross-tapering* recommended, start duloxetine at 60mg on alternate days and increase slowly2 | Reduce dose gradually over 4 weeks2 |
| MAOIs/moclobemide: withdraw and wait >7 days.2 In 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.2 SPC 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 | Reduce dose gradually over 4 weeks2 |
| MAOIs/moclobemide: withdraw and wait >7 days1,2 | ||
| Mirtazapine: cautious cross-tapering* recommended2 | ||
| Reboxetine: withdraw, start reboxetine at 2mg twice daily and increase cautiously2 | ||
| SSRIs: withdraw before starting second agent2 | ||
| TCADs: cautious cross-tapering* recommended using very low dose of TCAD2 | ||
| Venlafaxine: cautious cross-tapering* recommended, start venlafaxine at 37.5mg daily2 | ||
| OTHER ANTIDEPRESSANTS | ||
| FROM | TO | WITHDRAWAL ADVICE |
| Mirtazapine (Zispin Soltab, generic prep also available) |
Duloxetine: withdraw, start duloxetine at 60mg on alternate days and increase slowly2 | Withdraw dose gradually over 4 weeks2 |
| MAOIs/moclobemide: withdraw and wait 7 days2 | ||
| Reboxetine, SSRIs, trazodone, TCADs: withdraw before starting new agent2 | ||
| Venlafaxine: 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 (SPCs) Accessed via www.medicines.org.uk/emc
- The Maudsley Prescribing Guidelines. 10th ed. London: Informa Healthcare; 2009. p214-19
KEYWORDS: Depression
