2. Meaning?
symptoms that are experienced on stopping
prescribing drugs that are not drugs of dependence.
Occurs after stopping many drugs , including anti
depressants
d/f between discontinuation and withdrawal
symptoms – latter implies “ addiction”.
3. Explained in context of “RECEPTOR REBOUND” eg :
an anti depressant in potent anti cholinergic side
effects may be associated with diarrohea on
discontinuation.
depends on the elimination half-life of the drug and
the patient's metabolism.
can mimic serious illness and can be very distressing
and intensely uncomfortable
4. Various
Roughly divided into six categories
Affective : Irritability
Gastrointestinal : Nausea
Neuromotor : Ataxia
Vasomotor : diaphoresis
Neurosensory: Paraesthesia
Other neurological : increased day dreaming.
5. Diagnostic criteria
duration symptoms are experienced by at least a third of
patients.
Onset of symptoms – 5 days of stopping treatment
(depends on half life)
Occasionally during taper or after missed doses.
Symptoms can vary in form and intensity and occur in any
combination.
symptoms cause clinically significant distress or
impairment and are not due to a general medical condition
or recurrence of a mental disorder
Normally mild and self limiting but occasionally be severe
and prolonged.
6. Theories?
electrophysiological changes in the brain (particularly
on the 5-HT receptor)
electrophysiological changes in the body (nerve
growth factor) in the absence of the SSRI,
dopamine dependency
over-excited immune system
7. Quantifies using discontinuation – emergent signs and
symptoms scale (DESS)
Some symptoms are more likely with individual drugs.
11. Clinical relevance
Symptoms may be mistaken for a relapse of illness or
the emergence of new physical illness.
Symptoms may be some enough to interfere with daily
functioning.
Evidence showing emerging suicidal thoughts on
discontinuation with “Paroxetine”.
discontinuation of SSRIs may result in sexual
dysfunction
12. Who is most at risk?
Risk is increased in those short half life drugs e.g.
paroxetine , venlafaxine particularly if not taken
regularly.
Those who have been taking anti depressant for 8 wks
or longer.
Those who develop symptoms of anxiety at the start of
the therapy.
Centrally acting medication.
Child and adolescents.
13. Those who experienced discontinuation symptoms.
Common in neonates born to woman taking
antidepressants and possibly breast feeding.*
*Drug Saf. 2001;24(3):183-97 Antidepressant discontinuation syndromes. Haddad PM
14. How to avoid
Anti depressant therapy should be discontinued over
at least a 4 week period.
Patient over MAOI’s need to be tapered over a long
period.
At risk patients may need slow tapering.
Psycho education about the symptoms.
15. How to treat
Pragmatic
If symptoms are mild – reassurance
Reintroduce the original anti depressant (another with
a long half life from the same class) and taper
gradually while monitoring the dose.
Evidence suggestive use of anti cholinergic agents in
tricyclic withdrawal of fluoxetine for symptoms
associated with stopping clomipramine and
venlafaxine.