Internal Medicine News Digital Network: Antidepressant Discontinuation Syndrome - Start Slow? Stop Fast?

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Antidepressant Discontinuation Syndrome - Start Slow? Stop Fast?

04-19-2011 10:05

By: MICHELE G. SULLIVAN, Internal Medicine News Digital Network

SAN DIEGO – The risk of discontinuation syndrome is small when antidepressant

treatment is suddenly stopped, but the symptoms – though somewhat brief – are

still unpleasant for patients, according to Dr. Kurt Kroenke.

Unfortunately, he said, there are no firm data that predict who might develop

discontinuation syndrome, which drugs are likely to cause it, or whether

medication tapering can avoid it.

" If you just immediately stop an antidepressant, you can expect to have a 5%-15%

incidence of discontinuation syndrome, " Dr. Kroenke said at the annual meeting

of the American College of Physicians. " It usually starts within a few days and

stops within a few weeks, " but it’s no picnic for patients.

FINISH is the acronym that describes this syndrome, said Dr. Kroenke, an

internist at Indiana University, Bloomington. Patients experience flulike

symptoms, insomnia, nausea, imbalance, strange sensory dysesthesias, and

hyperarousal or anxiety.

The syndrome is probably less likely if a patient is switching to another drug

rather than ceasing medication altogether, but no studies have determined the

best way to implement either change. " It’s not clear if a long taper is better

than a short taper, or even if discontinuation syndrome is something that’s dose

related, " he said. " If you’re on 200 mg of sertraline and you stop, as opposed

to 50 mg, we can’t say the higher dose equals an increased risk. "

Some studies seem to suggest that the risk is highest with paroxetine.

" Fluoxetine probably has the lowest risk because of its long half-life.

Venlafaxine is associated with an intermediate risk and all the others fall

somewhere below that, " Dr. Kroenke said.

The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial

provides the largest single body of evidence on antidepressant switching (Am. J.

Psychiatry 2006;163:1905-17). The methodology in the trial, which involved four

levels of treatment and seven antidepressants, was basically simple, Dr. Kroenke

said. " You either discontinued one medication and immediately began another or

you decreased the first medication while initiating the second at a low dose,

doing this taper/titration over 1 week. It doesn’t get much simpler than that. "

Most investigators in the study chose the first option, he said.

" Having said that, I would probably go for some version of option two, and if

the patient is on a higher dose, I might spend a week tapering one while

titrating the other. "

In a few specific situations, Dr. Kroenke said he strongly favors the

taper/titrating method. " I always consider tapering if I’m working with

paroxetine or venlafaxine, especially if it’s at a higher dose and has been

taken for a long duration, " he said. " And definitely if the patient has

experienced discontinuation syndrome in the past. "

Dr. Kroenke said he has consulted for, and received honoraria from, Eli Lilly

and Forest

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