A Method for Tapering Antipsychotic Treatment That May Minimize the Risk of Relapse Mark Abie Horowitz, Schizophrenia Bulletin, Volume 47, Issue 4, July 2021, Pages 1116–1129, https://doi.o

[StillSinging]

A Method for Tapering Antipsychotic Treatment That May Minimize the Risk of Relapse 

Mark Abie Horowitz,  Sameer Jauhar,  Sridhar Natesan,  Robin M Murray,  David Taylor

Schizophrenia Bulletin, Volume 47, Issue 4, July 2021, Pages 1116–1129, https://doi.org/10.1093/schbul/sbab017

Published:

 

23 March 2021

 

Hi I found this article while searching google scholar! It highlights some important stuff that many on here learned the hard way (including me). There are some info graphs that are interesting about dose occupancy and what types of symptoms of withdrawal correspond to the parts of the brain which I thought was helpful. There's some good nuggets in here so just ignore the bits of psychiatrist jargon that's in there.

 

Here's the abstract:

 

The process of stopping antipsychotics may be causally related to relapse, potentially linked to neuroadaptations that persist after cessation, including dopaminergic hypersensitivity. Therefore, the risk of relapse on cessation of antipsychotics may be minimized by more gradual tapering. There is converging evidence that suggests that adaptations to antipsychotic exposure can persist for months or years after stopping the medication—from animal studies, observation of tardive dyskinesia in patients, and the clustering of relapses in this time period after the cessation of antipsychotics. Furthermore, PET imaging demonstrates a hyperbolic relationship between doses of antipsychotic and D₂ receptor blockade. We, therefore, suggest that when antipsychotics are reduced, it should be done gradually (over months or years) and in a hyperbolic manner (to reduce D₂ blockade “evenly”): ie, reducing by one quarter (or one half) of the most recent dose of antipsychotic, equivalent approximately to a reduction of 5 (or 10) percentage points of its D₂ blockade, sequentially (so that reductions become smaller and smaller in size as total dose decreases), at intervals of 3–6 months, titrated to individual tolerance. Some patients may prefer to taper at 10% or less of their most recent dose each month. This process might allow underlying adaptations time to resolve, possibly reducing the risk of relapse on discontinuation. Final doses before complete cessation may need to be as small as 1/40th a therapeutic dose to prevent a large decrease in D₂ blockade when stopped. This proposal should be tested in randomized controlled trials.

 

 

Link to full article: https://academic.oup.com/schizophreniabulletin/article/47/4/1116/6178746

 

Excerpts (bold type mine):

 

"Standard guidelines do not mention antipsychotic deprescribing,⁷⁰ or tapering,⁷¹although some current guidelines encourage reduction to minimum effective doses without specifying how to do so.^72,73 The principal means to mitigate withdrawal symptoms is to reduce the rate at which the equilibrium is disturbed, so allowing time for the reversal of underlying neuroadaptations to return to baseline.^16,70,74Gradual tapering of antipsychotics, when cessation is the goal, is sometimes advised on this principle.^56,70,74 Tapering may reduce the likelihood and intensity of withdrawal symptoms, including, potentially, the risk of withdrawal psychosis.^70,74

The persistence of TD, the most visible manifestation of dopaminergic hypersensitivity,⁷⁵ for a considerable time following cessation of antipsychotics, provides evidence that neuro-adaptations to antipsychotics persist for many years and supports the need for long tapering. An early review of studies found that it took 2–5 years for 60%–90% of symptoms of TD to resolve following antipsychotic cessation (supplementary table S1).⁷⁶ Another study found that 92.8% of patients achieved a 50% reduction in TD symptoms 46 weeks after discontinuing on average 10 years of antipsychotic treatment.⁷⁷ "

 

"Indeed, even reductions from 0.5 mg of haloperidol (the smallest available tablet) to 0 mg will produce a reduction in D₂ antagonism of 40.0 percentage points, and reduction from 0.25 mg (half the smallest tablet) to 0 mg will produce a 25.5 percentage point reduction (larger than the change from 20 to 2 mg [19.6 percentage points]); this may account for the relative ease of reductions at higher doses of antipsychotic and the difficulties in tapering at lower doses.^45,51,74 

 

"Given that reduced antagonism of D₂ dopaminergic receptors has been implicated in many of the withdrawal phenomena attributed to antipsychotics, including psychotic symptoms,^17,20,23 we suggest that tapering regimes should aim to reduce D₂receptor antagonism in a linear fashion with adequate time provided in between dose reductions to allow adaptation to lower doses of the drug, as this may produce more “evenly spread” perturbations to the system, which may minimize withdrawal-associated effects (figure 3).^16,99 "

 

 

 

[manymoretodays]

Previous publication, and topic here:

This one is dated March 23, 2021

(I need to study them a bit more to see if there are differences between the 2, ??)