Deprescribing, Tapering Down, Reducing or Stopping Use of Serotonin Reuptake Inhibitor Antidepressants

"Currently, available dosage strengths in standard drug formularies are too limited to support gradual SRI tapers (Table 2). For instance, the lowest marketed dose of duloxetine (20 mg) averages at least 70% SERT occupancy with short-term treatment, 9 and 10 mg of citalopram averages at least 60% SERT occupancy. 9 Discontinuation at these dosages is a precipitous and high-risk discontinuation strategy. Several selective SRIs (SSRIs) are available in prepackaged prescription liquid form, but newer SRIs — including the serotonin–norepinephrine reuptake inhibitors (SNRIs), vilazodone, and vortioxetine — are not available as liquids (Table 2). To obtain dosages at lower SERT occupancies, patients often split small unscored tablets, open capsules to count beads or weigh powder, self-manufacture liquid dilutions, or rely on a compounding pharmacy.

"Although a number of leading guidelines clearly recommend hyperbolic tapering of SRIs (which can involve transitioning to liquid formulations to obtain the needed doses), for some, these methods can be prone to error, time consuming, and expensive.6,12 Certain patients may lack the physical or cognitive capacity to consistently carry out extemporaneous tapering methods. Psychiatric providers often receive limited training in deprescribing psychotropics, including hyperbolic tapering as a means of safely and successfully deprescribing SRIs.8

"In light of current deprescribing challenges at the level of the pharmaceutical formulary, patient, and clinician, there is a clear need for novel antidepressant tapering approaches that are safe and effective but also practical and easy to implement for patients."