Advice on switching and withdrawing antidepressants in MIMS has been updated to reflect the latest recommendations from the 2015 edition of the Maudsley Prescribing Guidelines in Psychiatry.
The MIMS table now includes specific advice on switching to and from clomipramine, fluvoxamine and vortioxetine.
The updated quick-reference table is available online and will be included in the March print issue of MIMS.
New Agent Vortioxetine
The table includes guidance on the new multimodal antidepressant vortioxetine.
Experience with switching to and from vortioxetine is limited; therefore extra caution is required, particularly when switching to or from CYP2D6 inhibitors such as fluoxetine and paroxetine.
Before initiating treatment with clomipramine, fluoxetine or fluvoxamine, vortioxetine should be reduced over seven days to 10mg daily, then stopped before the new agent is started at a low dose. Cautious cross-tapering is advised when switching from vortioxetine to agomelatine, mirtazapine or reboxetine.
A low starting dose following cautious cross-tapering is recommended for duloxetine, SSRIs (excluding fluoxetine and fluvoxamine), TCADs (excluding clomipramine), trazodone and venlafaxine. An abrupt switch to duloxetine is possible starting with a dose of 60mg daily.
In the case of monoamine oxidase inhibitors (MAOIs), a washout period is required before starting the new drug. The interval should be 7 days for moclobemide and 3 weeks for other (irreversible) MAOIs.
Switching to Duloxetine
When switching from trazodone, mirtazapine or venlafaxine, the recommendation to start duloxetine at 30mg daily and increase the dose slowly has been replaced with advice to cautiously cross-taper the two agents.
Agomelatine, fluoxetine, fluvoxamine and clomipramine should be withdrawn before starting duloxetine (at a low dose in the latter three cases).
Treatment with duloxetine should be initiated at a low dose after cautious cross-tapering from TCADs (except clomipramine) or vortioxetine. Abrupt switching from SSRIs (excluding fluoxetine and fluvoxamine) to duloxetine is possible starting at 60mg daily.
Withdrawing Antidepressants
Most antidepressants should be withdrawn by reducing the dose gradually over a minimum of four weeks, using the duration and dose of treatment as a guide to the speed of withdrawal.
Agomelatine, fluoxetine and vortioxetine are the exceptions. Because of their long half-lives, agomelatine (at any dose) and fluoxetine doses of 20mg or less can be stopped abruptly; at higher doses of fluoxetine, incremental withdrawal is required over two weeks.
Vortioxetine should be reduced to 10mg daily over a period of seven days before stopping.
