142 - Practical application of these principles

Practical application of these principles

Depression and anxiety disorders CHAPTER 3 with smaller reductions than they have been undertaking (some need to taper at less than 5% of the most recent dose per month). ■ ■At very small doses, liquid formulations or specially compounded formulations may be required to allow small reductions.11 Off-­label options such as crushing and suspending tablets are sometimes used.11 ■ ■Final doses before completely stopping the drug for some people will need to be very small to avoid a larger reduction in effect on the brain (e.g. as low as 0.1mg of diazepam).11 Further details of this process are provided in the Maudsley Deprescribing Guidelines.11 Reduction schedules A guide to diazepam dose reductions: ■ ■Reduce by 5–10mg/day every 2–4 weeks, down to a daily dose of 50mg. ■ ■Reduce by 2–5mg/day every 2–4 weeks, down to a daily dose of 20mg. ■ ■Reduce by 1–2mg/day every 2–4 weeks, down to a daily dose of 10mg. ■ ■Reduce by 0.5–1mg/day every 2–4 weeks, down to a daily dose of 5mg. ■ ■Reduce by 0.25–0.5mg/day every 2–4 weeks, down to a daily dose of 2.5mg. ■ ■Reduce by 0.1–0.25mg/day every 2–4 weeks until stopped. Tapering other drug classes The same principles apply to tapering z-­drugs or gabapentinoids. Gabapentinoids can cause severe withdrawal effects, although there is wide inter-­individual variation. Tolerance and withdrawal are reported, even after brief or intermittent use for z-­drugs as well.39,40 Tapering according to a similar exponential scheme may be required for cessation. Again, specific reduction schedules for all licensed benzodiazepines, gabapentinoids and z-­drugs are provided in the Maudsley Deprescribing Guidelines.11 References

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