Medication for Depression Anxiety Spectrum Disorders – Swapping and Stopping
Factors to Consider
Please note this table includes the most frequently used medications and a summary of key points to be considered when stopping and swapping.
For full details and recommendations for medications not mentioned here please refer to the Summary of Product Characteristics
Antidepressants should NOT be stopped abruptly UNLESS a serious adverse event occurs
When changing from one antidepressant cross tapering is preferred (see table).
In certain cases cross-tapering may NOT be considered necessary e.g. when switching from one SSRI to another (see table).
Cross tapering:
o Dose of the ineffective / poorly tolerated drug is slowly reduced whilst the new drug is slowly introduced (see table)
o Speed of cross-tapering is best judged by monitoring patient tolerability. No clear guidelines are available.
ALL antidepressants have the potential to cause withdrawal phenomena when taken continuously for 6 wks or longer.
Potential Problems
o Withdrawal effects from the first drug being interpreted as side-effects of the second
o Interaction between the two drugs e.g. altered drug levels from altered drug metabolism particularly inhibitors and / or substrates of CYP1A2
(fluvoamine), 2D6 (paroxetine, fluoxetine, tricyclics), 3A4, 2C9 (agomelatine, tricyclics), 2C19 (fluvoxamine). Refer to relevant SmPCs.
o Drugs with active metabolite with long-half-life e.g. fluoxetine where levels of the metabolite nor-fluoxetine persist for up to 5 weeks.
o Cholinergic rebound e.g. with TCAs: headache, restlessness, diarrhea, nausea and vomiting
o Serotonin syndrome at least 3 of the following mental state changes: agitation/ restlessness, diarrhea, fever, hyperreflexia, lack of co-ordination
myoclonus, sweating, tachycardia,, shivering, tremor. Other symptoms can include convulsions, hypertension, nausea, vomiting, and multiple
organ failure.
Please note that the information for switching to or from pregabalin is currently being sourced and the table will be updated with the information
shortly. If information is required please contact the medicines management team at NHS Surrey or at Surrey and Borders Mental Health Trust.
Note: Advice given in this table is partly derived manufactures information and partly theoretical. Caution is required in every instance
a
For other MAOIs e.g. tranylcypromine refer to Summary of Product Characteristics at www.medicines.org.uk
b
Abrupt switching is possible but not recommended
c
Do not co-administer clomipramine and SSRIs or venlafaxine. Withdraw clomipramine before starting.
d
Beware: interactions with fluoxetine may still occur for 5 weeks after stopping fluoxetine because of its long half life
e
Withdrawal effects seem to be more pronounced. Slow withdrawal over 1 – 3 months may be necessary.
Table last updated on 17th June 2011
Medication for Depression Anxiety Spectrum Disorders – Swapping and Stopping
To
Agomelatine
From
Agomelatine
Citalopram/
Escitalopram
Citalopram/
Escitalopram
Duloxetine
Fluoxetine
MAOIsa
(Phenelzine)
Mirtazapine
Moclobemide
Paroxetine
Abrupt switch
possible
Abrupt
switch
possible.
Abrupt
switch
possible.
Start at
60mg/day.
Abrupt
switch
possible.
Withdraw
then start
fluoxetine
at
10mg/day
Abrupt switch
possible.
Abrupt
switch
possible.
Cross taper
cautiously
Abrupt switch
possible.
Withdraw
then start
fluoxetine
Withdraw
and wait 1
week
Withdraw,
then start
mirtazapine
Withdraw
and wait for
5-6 weeks
Withdraw
and wait
for 2
weeks
Withdraw
then start
fluoxetine
Withdraw
and wait for 2
weeks
Withdraw
and wait
24 hours
Withdraw
and wait 24
hours
Start 25mgs
Agomelatine
and withdraw
other drug
Duloxetine
Start 25mgs
Agomelatine
and withdraw
other drug
Withdraw
then start
citalopram
Fluoxetined
Start 25mgs
Agomelatine
and withdraw
other drug
Stop
fluoxetine.
Wait 4-7
days. Start
citalopram at
10mg/day
and ↑ slowly
Abrupt
switch
possible.
Start at
60mg/day.
MAOIsa /
(Phenelzine)
Start 25mgs
Agomelatine
and withdraw
other drug
Start 25mgs
Agomelatine
and withdraw
other drug
Withdraw and
wait for 2
weeks
Withdraw
and wait for
2 weeks
Withdraw
then start
citalopram
Start 25mgs
Agomelatine
and withdraw
other drug
Withdraw and
wait 24 hours
Withdraw.
Start at
60mg
alternate
days. ↑
slowly
Withdraw
and wait 24
hours
Mirtazapine
Moclobemide
Withdraw
and wait for 1
week
Sertraline
Trazodone
Tricyclics
Venlafaxine
Stopping
Abrupt
switch
possible.
Withdraw
then start
paroxetine
at
10mg/day
Abrupt
switch
possible.
Withdraw
and start
sertraline
at
25mg/day
Abrupt
switch
possible.
Withdraw
before
starting
titration of
trazodone
Abrupt
switch
possible.
Cross
taper
Cautiously
Abrupt
stop
Withdraw,
and wait 1
week
Withdraw,
then start
paroxetine
Withdraw,
then start
sertraline
Withdraw,
then start
trazodone
Withdraw,
wait 4-7
days and
start
mirtazepine
cautiously
Withdraw and
wait at least 5
weeks
Stop
fluoxetine.
Wait 4-7
days, then
start
paroxetine
10mg/day
Stop
fluoxetine.
Wait 4-7
days then
start
sertraline
25mg/day
Stop
fluoxetine.
Wait 4-7
days then
start lowdose
trazodone
Withdraw.
Start
venlafaxine
at 37.5
mg/day. ↑
very slowly
At 20mg
/day just
stop, at
40mg/day
reduce
over 2
weeks
Withdraw
and wait for
2 weeks
Withdraw and
wait for 2
weeks b
Withdraw
and wait
for 2 weeks
Withdraw
and wait for
2 weeks
Withdraw
and wait for
2 weeks
Reduce
over 4
weeks
Withdraw and
wait 1 week
Withdraw
then start
paroxetine
Withdraw
and wait
for 2
weeks
Withdraw
then start
sertraline
Withdraw
then start
trazodone
Cross
taper
cautiously
with very
low dose
of tricyclic
Stop
fluoxetine.
Wait 4-7
days. Start
tricyclic at
very low
dose and
↑ very
slowly
Withdraw
and wait
for 2
weeks
Withdraw
then start
tricyclic
Abrupt
switch
possible.
Cross taper
cautiously.
Start
venlafaxine
37.5mg/day
and ↑ very
slowly
Withdraw ,
then start
venlafaxine
Cross taper
cautiously
Reduce
over 4
weeks
Withdraw
and wait 24
hours
Withdraw
and wait
24 hours
Withdraw
and wait 24
hours
Withdraw
and wait
24 hours
Withdraw
and wait 24
hours
Reduce
over 4
weeks
Withdraw
and wait 1
week
Withdraw
and wait 24
hours
Withdraw and
wait at least 1
week
Pregabalin
Note: Advice given in this table is partly derived manufactures information and partly theoretical. Caution is required in every instance
a
For other MAOIs e.g. tranylcypromine refer to Summary of Product Characteristics at www.medicines.org.uk
b
Abrupt switching is possible but not recommended
c
Do not co-administer clomipramine and SSRIs or venlafaxine. Withdraw clomipramine before starting.
d
Beware: interactions with fluoxetine may still occur for 5 weeks after stopping fluoxetine because of its long half life
e
Withdrawal effects seem to be more pronounced. Slow withdrawal over 1 – 3 months may be necessary.
Table last updated on 17th June 2011
c
Reduce
over 4
weeks
Reduce
over 4
weeks
Medication for Depression Anxiety Spectrum Disorders – Swapping and Stopping
To
From
Paroxetine
Agomelatine
Citalopram/
Escitalopram
Duloxetine
Fluoxetine
MAOIsa
(Phenelzine)
Mirtazapine
Moclobemide
Start 25mgs
Agomelatine
and withdraw
other drug
Withdraw and
start
citalopram
Abrupt
switch
possible.
Start at
60mg/day
Withdraw
then start
fluoxetine
Withdrawal
and wait for 2
weeks
Cross taper
cautiously
Withdraw and
wait for 1
week
Paroxetine
Pregabalin
Sertraline
Trazodone
Tricyclics
Venlafaxine
Stopping
Withdraw
and start
sertrline at
25mg/day
Withdraw
before
starting
titration of
trazodone
Cross
taper
cautiously
with very
low dose
of tricyclic
Cross taper
cautiously.
Start
venlafaxine
37.5mg/day
and ↑ very
slowly
Reduce
over 4
weeks or
longer if
necessary
Cross Taper
Cautiously
Cross
Taper
Cautiously
Cross Taper
Cautiously
Withdraw
before
starting
trazadone
Cross
taper
cautiously
with very
low dose
of tricyclic
Cross taper
cautiously.
Start
venlafaxine
at
37.5mg/day.
Reduce
over 4
weeks
Cross
taper
cautiously
with very
low dose
of tricyclic
Cross
taper
cautiously
Cross taper
cautiously.
Start
venlafaxine
at
37.5mg/day.
Cross taper
cautiously,
staring with
venlafaxine
37.5mg/day
Reduce
over 4
weeks
c
e
Pregabalin
Reboxatine
Start 25mgs
Agomelatine
and withdraw
other drug
Start 25mgs
Agomelatine
and withdraw
other drug
Cross Taper
Cautiously
Cross
Taper
Cautiously
Cross
Taper
Cautiously
Withdraw
then start
citalopram
Abrupt
switch
possible.
Start at
60mg/day
Withdraw
then start
fluoxetine
Trazodone
Start 25mgs
Agomelatine
and withdraw
other drug
Withdraw
then start
citalopram
Tricyclics
Start 25mgs
Agomelatine
and withdraw
other drug
Halve dose
and add
citalopram or
escitalopram
then slow
withdrawal c
Withdraw,
start at
60mg
alternative
days. ↑
slowly
Cross taper
cautiously,
start at
60mg
alternate
days. ↑
slowly
Withdraw
start at
60mg
alternate
days. ↑
slowly
Sertraline
Cross Taper
Cautiously
Withdraw and
wait at least
one week
Cross
Taper
Cautiously
Cross
Taper
Cautiously
Withdraw
and wait for 2
weeks b
Cross taper
cautiously
Withdraw and
wait at least 2
weeks
Withdraw
then start
paroxetine
Withdraw
then start
fluoxetine
Withdraw
and wait at
least 1 week
Cross taper
cautiously
Withdraw and
wait at least 1
week
Withdraw
then start
paroxetine
Withdraw
then start
sertraline
Halve dose
and add
fluoxetine
then slow
withdrawal
Withdraw
and wait for 1
week
Cross
taper
cautiously
Withdraw and
wait at least 1
week
Halve dose
and add
paroxetine
then slow
withdrawal
Halve
dose and
add
sertraline
then slow
withdrawal
Halve dose
and add
trazodone
then slowly
withdraw
Cross
taper
cautiously.
Start 20mg
every other
day
Withdraw
and wait at
least 1 week
Cross
taper
cautiously
& start
sertraline
25mg/day
Cross taper
cautiously
c
Venlafaxine
Start 25mgs
Agomelatine
and withdraw
other drug
Cross taper
cautiously.
Start with
10mg/day
c
c
c
Cross taper
cautiously
Withdraw and
wait at least 1
week
Cross
taper
cautiously.
Start with
10mg/day
Note: Advice given in this table is partly derived manufactures information and partly theoretical. Caution is required in every instance
a
For other MAOIs e.g. tranylcypromine refer to Summary of Product Characteristics at www.medicines.org.uk
b
Abrupt switching is possible but not recommended
c
Do not co-administer clomipramine and SSRIs or venlafaxine. Withdraw clomipramine before starting.
d
Beware: interactions with fluoxetine may still occur for 5 weeks after stopping fluoxetine because of its long half life
e
Withdrawal effects seem to be more pronounced. Slow withdrawal over 1 – 3 months may be necessary.
Table last updated on 17th June 2011
Reduce
over 4
weeks
Cross
taper
cautiously
with very
low dose
tricyclic c
Reduce
over 4
weeks or
longer if
necessary
e
Medication for Depression Anxiety Spectrum Disorders – Swapping and Stopping
This page is available to make notes or write out a schedule for patients
Day of Week
Date of Week
Name of medication to be
STOPPED:
Name of medication to be
STARTED:
Follow dosage schedule
below for medication to be
STOPPED:
Follow dosage schedule below
for medication to be STARTED:
Patients we request you show this dosing
schedule sheet to your community pharmacist
when you present your prescription.
Section for additional notes
Week 1
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Week 2
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Week 3
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Note: Advice given in this table is partly derived manufactures information and partly theoretical. Caution is required in every instance
a
For other MAOIs e.g. tranylcypromine refer to Summary of Product Characteristics at www.medicines.org.uk
b
Abrupt switching is possible but not recommended
c
Do not co-administer clomipramine and SSRIs or venlafaxine. Withdraw clomipramine before starting.
d
Beware: interactions with fluoxetine may still occur for 5 weeks after stopping fluoxetine because of its long half life
e
Withdrawal effects seem to be more pronounced. Slow withdrawal over 1 – 3 months may be necessary.
Table last updated on 17th June 2011