Medications discontinuing

Maintenance Phase Treatment. OCD is typically a lifelong disorder that rapidly recurs when treatment is discontinued. Consequently, maintenance therapy lasting at least 1-2 years is recommended for all patients with OCD. During medication discontinuation, periodic CBT sessions are commonly used to increase the likelihood of sustained remission. Long-term pharmacotherapy is recommended after only two moderately severe episodes of OCD. 

Caution when medication discontinued abruptly after long-term (>4 wk) use— may precipitate withdrawal syndrome... 

Shore, D., and Hyman, S.E. (1999) NIMH symptom challenge and medication discontinuation. Biol Psychiatry 46 1009—10. 

Even when medications were required for clinical resolution, treating clinicians often encouraged medication discontinuation as soon as stability was achieved, believing that medications interfered with the important clinical gains achieved during psychotherapy. 

Ballantine HT, Bouckoms AJ, Thomas EK, et al Treatment of psychiatric illness by stereotactic cingulotomy. Biol Psychiatry 22 807-819, 1987 Ballenger JC Medication discontinuation in panic disorder. J Chn Psychiatry 53 (suppl) 26-31, 1992... 

In preliminary clinical trials, 2 of 2,796 mirtazapine-treated patients developed agranulocytosis, and 1 developed severe neutropenia. All 3 patients recovered after medication discontinuation, and other possible etiologies were present in at least 1 of these individuals. Thirteen patients with pretreatment neutropenia did develop more severe neutropenia or agranulocytosis. Postmarketing evaluation to date has not established a causal relation between mirtazapine and agranulocytosis. Routine laboratory monitoring is not currently recommended. 

Discontinuation of antidepressant medication should be concordant with the guidelines for treatment duration (see Acute Major Depression subsection in the preceding section). It is advisable to taper the dose while monitoring for signs and symptoms of relapse. Abrupt discontinuation is also more likely to lead to antidepressant discontinuation symptoms, often referred to as withdrawal symptoms. The occurrence of these symptoms after medication discontinuation does not imply that antidepressants are addictive. 

Hepatic effects. Increased transaminase levels occur in approximately 2% of the patients taking olanzapine. In many cases, these levels normalize without medication discontinuation, and all cases to date have been clinically benign. Routine laboratory monitoring is not recommended, but olanzapine should be used with caution in patients with hepatic disease or with additional risk factors for hepatic toxicity. In this group of patients, serum transaminase levels must be monitored. 

A partial list of stimulant side effects is outlined in Table 6-2. Common side effects (such as insomnia, nervousness, nausea, decreased appetite, stomachaches, and headaches) tend to be transient and diminish with time or medication discontinuation. Using the lowest effective dose, taking the medications with meals, and avoiding doses late in the day help minimize these side effects as well. 

Common side effects include nausea, vomiting, abdominal pain, diarrhea, and dizziness. These side effects tend to be associated with treatment initiation or early dose increases and are often transient. Anorexia and weight loss also may occur and may persist throughout treatment. Potentially dangerous side effects include myasthenia, respiratory depression, and bradycardia. Dose reduction or medication discontinuation should be considered if serious side effects occur. 

Our recommendation would be to avoid benzodiazepines, especially for patients who are receiving UND ECT. When significant tolerance, withdrawal problems, or use of long-acting benzodiazepines prevents medication discontinuance before starting ECT treatments, use of BILAT stimulus would be preferable. 

Brennan et al. (132) observed that six of eight manic patients responded to VPA. All then had their medication discontinued for a few days, with one relapsing but again improving upon reinstatement of VPA. 

Olanzapine was given to five patients with idiopathic Parkinson s disease and hallucinosis, and after initial treatment for 9 days, the frequency of hallucinations was significantly reduced during this early phase of treatment, parkinsonian motor disability increased, which resulted in medication discontinuation in two of the patients (113). 

If attempted, medication tapering must be slow and closely scrutinized. About 90% of patients relapse quickly after medication discontinuation. 

If dosage reduction or medication discontinuation is either infeasible or undesirable, go to step 3... 

Due to individual physiologic differences, there can be wide variations in effective dosages of the same medication from patient to patient. Also, when a medication is stopped (by either therapeutic plan or noncompliance), complete elimination of the drug does not occur immediately, or even within known half-life parameters. This partially explains why recurrence of psychosis may not immediately appear in the noncompliant schizophrenic and why depressive symptoms reemerge weeks (or days) after an antidepressant is discontinued. (The therapist can help educate the patient as to the potential consequences of medication discontinuation.)... 

Phillips, S.L. Carr-Lopez, S.M. Impact of a pharmacist on medication discontinuation in a hospital-based geriatric clinic. Am. J. Hosp. Pharm. 1990, 47, 1075-1079. 

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