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Withdrawal Symptoms and Rebound Syndromes Associated with Switching and Discontinuing Atypical Antipsychotics: Theoretical Background and Practical Recommendations

CNS Drugs volume 27, pages 545–572 (2013)Cite this article

Abstract

With the widespread use of atypical or second-generation antipsychotics, switching treatment has become current practice and more complicated, as the pharmacological profiles of these agents differ substantially despite their similarity in being ‘atypical’. All share the ability to block dopamine D2 receptors, and most of them also block serotonin 5-HT2A receptors. Apart from these common features, some atypical antipsychotics are also able to block or stimulate other dopamine or serotonin receptors, as well as histaminergic, muscarinergic or adrenergic receptors. As a result of the varying receptor affinities, in switching or discontinuing compounds several possible pitfalls have to be considered, including the occurrence of withdrawal and rebound syndromes. This article reviews the pharmacological background of functional blockade or stimulation of receptors of interest in regard to atypical antipsychotics and the implicated potential withdrawal and rebound phenomena. A MEDLINE search was carried out to identify information on withdrawal or rebound syndromes occurring after discontinuation of atypical antipsychotics. Using the resulting literature, we first discuss the theoretical background to the functional consequences of atypical antipsychotic-induced blockade or stimulation of neurotransmitter receptors and, secondly, we highlight the clinical consequences of this. We then review the available clinical literature on switching between atypical antipsychotics, with respect to the occurrence of withdrawal or rebound symptoms. Finally, we offer practical recommendations based on the reviewed findings. The systematic evaluation of withdrawal or rebound phenomena using randomized controlled trials is still understudied. Knowledge of pharmacological receptor-binding profiles may help clinicians in choosing adequate switching or discontinuation strategies for each agent. Results from large switching trials indicate that switching atypical antipsychotics can be performed in a safe manner. Treatment-emergent adverse events during or after switching are not always considered to be, at least in part, associated with the pre-switch antipsychotic. Further studies are needed to substantiate the evidence gained so far on different switching strategies. The use of concomitant medication, e.g., benzodiazepines or anticholinergic drugs, may help to minimize symptoms arising from the discontinuation or switching of antipsychotic treatment.

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Acknowledgements

We thank Thelma Coutts for assistance with language. There were no sources of funding for preparation of the manuscript. The authors declare that over the past 3 years Dr. R. Musil has received research support from AstraZeneca and Janssen-Cilag, Dr. M. Riedel and Dr. K.-U. Kühn have received grants/research support from AstraZeneca and Pfizer and are speakers or on the advisory board of AstraZeneca, Pfizer, Bristol-Meyers-Squibb, Otsuka and Servier. All other authors state that they have no conflicts of interest to declare. All authors critically reviewed the final version. All authors contributed to and have approved the final manuscript; Anja Cerovecki and Richard Musil contributed equally.

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Affiliations

  1. Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Nussbaumstr. 7, 80336, Munich, Germany

    Anja Cerovecki, Richard Musil, Florian Seemüller, Rebecca Schennach & Michael Riedel

  2. Vinzenz von Paul Hospital, Rottweil, Germany

    Michael Riedel

  3. Clinic for Psychiatry and Psychotherapy, Vitos Waldkrankenhaus Köppern, Emil-Sioli-Weg 1-3, 61381, Friedrichsdorf, Germany

    Ansgar Klimke

  4. Clinical Pharmacology, Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany

    Ekkehard Haen

  5. Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany

    Kai-Uwe Kühn

  6. Clinic for Psychiatry and Psychotherapy, Schloss Werneck, Werneck, Germany

    Hans-Peter Volz

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  1. Anja Cerovecki
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  2. Richard Musil
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  3. Ansgar Klimke
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  4. Florian Seemüller
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  5. Ekkehard Haen
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  6. Rebecca Schennach
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  7. Kai-Uwe Kühn
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  8. Hans-Peter Volz
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  9. Michael Riedel
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Corresponding author

Correspondence to Richard Musil.

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Cerovecki, A., Musil, R., Klimke, A. et al. Withdrawal Symptoms and Rebound Syndromes Associated with Switching and Discontinuing Atypical Antipsychotics: Theoretical Background and Practical Recommendations. CNS Drugs 27, 545–572 (2013). https://doi.org/10.1007/s40263-013-0079-5

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  • DOI: https://doi.org/10.1007/s40263-013-0079-5

Keywords

  • Clozapine
  • Risperidone
  • Olanzapine
  • Aripiprazole
  • Atypical Antipsychotic