Tapering schedules

Alcohol withdrawal seizures do not require anticonvulsant drug treatment unless they progress to status epilepticus. Patients with seizures should be treated supportively. An increase in the dosage and slowing of the tapering schedule of the BZ used for detoxification or a single injection of a BZ may be necessary to prevent further seizure activity. 

It is not yet clear how useful, or how detrimental, chronic BZD therapy may be for patients with GAD. Whenever possible, BZD discontinuation (using a gradual tapering schedule) should be attempted to clarify persistence of anxiety or the existence of masked drug-induced adverse effects. Alternative strategies include the following ... 

Until recently few guidelines were available to help physicians determine whether continued BZD use is appropriate and, if not, how to prevent BZD discontinuation syndromes (e.g., PBDS and the immediate withdrawal syndrome). Rickels (261) and his colleagues suggest tapering schedules, emphasizing the need to treat the patient s underlying psychopathology. 

FIG. 13-1. Suggested alprazolam tapering schedule. To discontinue therapy with alprazolam, patients who have been taking more than 2.0 mg per day should reduce their daily dose by not more than 0.5 mg, and they should maintain that daily dose for 1 week before further reduction. When the total daily dose is reduced to 2.0 mg or when a patient is taking less than 2.0 mg per day, the daily dose should be reduced by not more than 0.25 mg per day each week until complete discontinuation is achieved. 

With respect to a specific and common clinical problem, advice to withdraw hypnotic medication should follow a careful evaluation of self-reported sleep patterns, psychological factors and psychosocial status. Ambulant monitoring can be helpful in patients who have encountered severe problems in effecting withdrawal. A careful psychiatric assessment should be made to ascertain whether the patient has clinically significant anxiety and/or depression. Both should be treated with a selective serotonin receptor inhibitor (SSRI) before withdrawal from the hypnotic is attempted. An optimal tapering schedule should be discussed with the patient some will attempt a rapid withdrawal over less than 8 weeks and others will require much longer. This is particularly so if previous attempts to withdraw have been unsuccessful. Carers, family and friends should be mobilized to help in withdrawal, should the patient wish this. Substitution of zolpidem may facilitate withdrawal but should be kept as a reserve strategy. 

The available steroids vary in their ability to suppress the inflammatory response.Table 12-2 shows the approximate equivalent doses of systemic steroids in current use. Methylprednisolone is commercially available in a package for programmed delivery of oral steroid tapered over 6 days of therapy.This formulation (Medrol DosePak) is highly convenient for short-term treatment and helps to ensure patient compliance in the tapering schedule. 

The conventional drug therapy for opioid withdrawal has been methadone, a synthetic opiate. Recently, buprenorphine has been approved for opioid withdrawal and will be discussed in detail below. In detoxification treatment, methadone is administered in decreasing doses over a period not exceeding 30 days (short-term detoxification) or 180 days (long-term detoxification). There are many tapering schedules recommended in the literature. Most patients in withdrawal... 

Symptomatic treatment focuses on minimizing the withdrawal symptoms to help patients be as comfortable as possible (Tables 33-6 through 33-8). This is combined with the use of methadone or buprenorphine (Suboxone or Subutex ) to suppress the withdrawal symptoms by providing a p opioid full or partial agonist in a tapering dose schedule within a controlled environment. 

Conventional drug therapy for opiate withdrawal has been methadone, a synthetic opiate. Usual starting doses have been 20 to 40 mg/day. The dosage can be tapered in decrements of 5 to 10 mg/day until discontinued. Some clinicians use discontinuation schedules over 30 days or over 180 days. 

If treatment is continued for longer than 2 weeks, a tapering oral schedule should be employed to avoid hypothalamic-pituitary-adrenal axis suppression. 

When SBC-5-IMNs is endangered 3 times by non-compliance to the execution of its 4 fixed schedule phases then the disease becomes refractory. Depending on the level of the ESR when patients drop out relapses occur after several months to several years. The majority of patients acquire remission in 2 months again with IVT - - PA and 100 mg infliximab at week 0-2-6 added to this. After tapering off IVT + PA guided by the ESR levels after induction of remission, oral IMNs will maintain remission and thus avoid the need for long-term use of biological DMARDs. 

Taper dosage gradually do not change dosage schedule or stop taking the drug abruptly... 

Do not discontinue the drug abruptly or change the dosage schedule the dosage must be tapered gradually under medical supervision... 

An important related issue is the ideal frequency of maintenance ECT treatments (e.g., weekly, biweekly, monthly). One common clinical strategy is to taper the frequency of acute treatments to once every week for 4 weeks, then every 2 weeks, and then every 3 weeks, as clinically indicated. From a practical perspective, a monthly or bimonthly schedule would be desirable in terms of cost, convenience, risk, and side effects. Unfortunately, few data presently exist to guide clinicians as to the best interval between maintenance treatments, and this determination remains an empirical process with each patient. 

Steroids are typically administered using a regimen of one drop four times daily for the first 1 to 2 weeks and then tapered on a variety of schedules (e.g., three drops... 

Do not change dose schedule or stop taking drug. MUST taper off gradually under medical supervision. 

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