Antidepressant Deprescribing Tool

• Choose the patient’s current medicine from the drop-down list.
• Choose the regimen pace from the drop-down list, based on the patient’s withdrawal risk. There is an assessment tool to help with this in the Planning for antidepressant deprescribing page.
• Choose the patient’s current total daily dose from the drop-down list. The tool will then present the first step of the deprescribing plan. Each step will have several product options. Click the product for each dose that is most suitable for the patient. As you select each step, the next step will appear. Select as many steps as you require until the next review.
• To select the tool's 'recommended' products for your chosen number of steps, click '3', '6', '9' or 'All’ at the top of the list. The tool will then show the number of steps you have chosen to view, with the recommended product options pre-selected (note that if you select 3, 6 or 9, you are not veiwing the complete regimen, just the first 3, 6 or 9 steps)
• Once you have selected the options, click on ‘View selected deprescribing plan’ to view the patient-information and a printable version of the plan.
• The deprescribing plan defaults to 4 weeks for each step, but you can amend the number of weeks for each step using the drop-down arrows in the ‘reduction length’ column.
• Add the patient’s name and date of birth to the deprescribing plan. This can then be printed off or saved as a PDF.
• You can use the plan to write the prescription(s) for the patient.
• The plan should be shared with the pharmacy supplying the medication.
• A copy of the plan should be given to the patient or carer.

Each dose in the tool is the total daily dose. Each step at this dose will take approximately 4 weeks. If patients experience unpleasant withdrawal symptoms pause the taper (stay at the same dose) or go back a step (or more steps if necessary). Once stabilised, it may be appropriate to switch regimen to a slower one or slow the pace of the existing regimen. You may be able to speed up the pace of withdrawal depending on how your patient is managing.

In some circumstances, to achieve certain doses we may recommend ‘off-label’ use of a licensed medicine, that is, the use of a medicine outside its product licence. This may include prescribing doses not included in the licence, diluting liquids, or halving tablets which are not scored or licensed to be halved.

All prescribing decisions (including off-label prescribing decisions) are the responsibility of the prescriber and should take into consideration all patient factors including comorbidities and interactions. Further information can be found on the Using our advice page of the SPS website and the Using unlicensed medicines SPS page.

Also see the section below regarding limitations of the tool.

Where at all possible to do so we recommend a licensed medicine. For some doses we may recommend an off-label use of a licensed medicine to achieve certain doses, usually towards the end of a deprescribing regimen. The recommended option is based on the following factors:

• licensed products are recommended in preference to off-label use

• solid dosage forms are recommended in preference to liquids

• once licensed products are no longer an option, the most suitable liquid for ‘at-home' dilution is recommended.

When multiple suitable options are available for the deprescribing step, the recommended product is the one that requires the least number of subsequent changes in formulation, as the dose reduces. This may include recommending a liquid when a solid dose form is available.

The recommended option may not always be the most appropriate option for your patient. Each option should be discussed with the patient before prescribing.

Our approach balances implementing antidepressant withdrawal using hyperbolic tapering regimens with the limits of available suitable formulations.

A fuller explanation of our approach to tailoring doses and recommending products to meet a given dose is available on request.

This tool is currently available for user-testing and is not a final version. The tool is intended to be used as a guide to aid deprescribing and does not replace the usual clinical decision-making processes and considerations for prescribing antidepressants.

Not all antidepressants are currently available in the tool. More antidepressants will be added as the tool is developed.

Combinations of products cannot currently be selected to achieve a dose. For example, a 10mg tablet plus a 20mg tablet cannot be selected to make a 30mg dose. Instead, the tool would suggest an alternative, such as 3 x 10mg tablets or a liquid product. Prescribers may choose to prescribe an alternative suitable option to what is suggested by the tool for a particular dose.

Amitriptyline

Amitriptyline may be given in divided doses. If this is required, prescribers must choose an appropriate product from the tool that allows for the total daily dose to be given in divided doses. For example, if a patient requires a total daily dose of 50mg in two divided doses, the 25mg tablets or liquid must be selected.

Citalopram

Citalopram is available as both tablets and oral drops. Citalopram oral drops have approximately 25% increased bioavailability compared with citalopram tablets.

4 oral drops (8 mg) is equivalent in therapeutic effect to a 10 mg tablet dose. Refer to the citalopram oral drops summary of product characteristics for more information and a full drops-to-tablet dose equivalence table.

In the tool, citalopram doses for each step of deprescribing are currently expressed as the tablet dose. For patients who are prescribed oral drops or the oral solution (made by diluting the drops), the prescriber must first convert the patient’s current oral drops or solution dose to the equivalent tablet dose, before selecting that dose from the ‘current total dose’ field in the tool.

Acknowledgements

The SPS Antidepressant Deprescribing Tool is designed to make the processes of deprescribing as simple as possible for prescribers and patients. It builds upon the recommendations made in the Maudsley Deprescribing Guidelines.