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SNRIs to other antidepressants: switching in adults

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Topics: DuloxetineMental health and illnessSwitchingVenlafaxine

How to switch safely between serotonin and noradrenaline reuptake inhibitors (SNRIs) or to other antidepressants. Seek specialist advice for complex switches.

Contents
  1. Advice for all antidepressants
  2. SNRIs to agomelatine
    1. Cross-taper
  3. SNRIs to mirtazapine
    1. Cross-taper
  4. SNRIs to moclobemide
    1. Taper, washout and switch
  5. SNRIs to monoamine oxidase inhibitors (MAOIs)
    1. Taper, washout and switch with specialist advice
  6. SNRIs to selective serotonin reuptake inhibitors (SNRIs)
    1. Direct switch
  7. SNRIs to another SNRI
    1. Direct switch
  8. SNRIs to trazodone
    1. Cross-taper
  9. SNRIs to tricyclic antidepressants (TCAs)
    1. To all except clomipramine
    2. To clomipramine
  10. SNRIs to vortioxetine
    1. Direct switch
    2. Taper, washout and switch
    3. Deciding on the switching strategy
  11. More advice on individual switches
  12. Bibliography

Advice for all antidepressants

You should read our advice for all antidepressant switching before applying that to individual SNRI switches below.

SNRIs to agomelatine

Cross-taper

Cross-tapering can usually be undertaken cautiously over 2 to 4 weeks, the speed is determined by individual tolerability.

There is limited experience with this switch so extra caution is required. Although interactions are not expected, agomelatine is not expected to mitigate discontinuation reactions from stopping the SNRI.

SNRIs to mirtazapine

Cross-taper

Cross-tapering can usually be undertaken cautiously over 2 to 4 weeks, the speed is determined by individual tolerability.

SNRIs to moclobemide

Taper, washout and switch

Gradually reduce the dose of the SNRI and stop; wait 7 days before starting moclobemide.

Cross-tapering is not recommended due to the high risk of serotonin syndrome.

SNRIs to monoamine oxidase inhibitors (MAOIs)

Switching to an MAOI is always a complex switch and you should follow specialist advice.

Taper, washout and switch with specialist advice

For any SNRI, you should gradually reduce the dose and then stop. You will need to wait a period, dependent on the antidepressant being switched from (see below), before starting MAOI. The specialist will advise the duration of the washout period on a case-by-case basis taking into consideration the MAOI being started.

Cross-tapering is not recommended due to the high risk of serotonin syndrome.

From duloxetine

After stopping duloxetine, wait 5 to 14 days before starting the MAOI.

From venlafaxine

After stopping venlafaxine, wait 7 to 14 days before starting the MAOI.

SNRIs to selective serotonin reuptake inhibitors (SNRIs)

Direct switch

A direct switch, i.e. stopping one antidepressant and then starting the new antidepressant the following day, is normally possible.

SNRIs to another SNRI

Direct switch

A direct switch, i.e. stopping one antidepressant and then starting the new antidepressant the following day, is normally possible.

SNRIs to trazodone

Cross-taper

Cross-tapering can usually be undertaken cautiously over 2 to 4 weeks, the speed is determined by individual tolerability.

SNRIs to tricyclic antidepressants (TCAs)

Switching to dosulepin requires specialist advice and should not be done in primary care due to the increased cardiac risk and toxicity in overdose.

To all except clomipramine

Cross-taper

Cross-tapering, starting with a low dose tricyclic antidepressant can usually be undertaken cautiously over 2 to 4 weeks, the speed is determined by individual tolerability.

To clomipramine

Taper, stop and switch

Gradually reduce the dose of the SNRI and stop. Start low dose clomipramine the following day.

Cross-tapering is not recommended and should only be undertaken if specialist advice is in place, this is because clomipramine is a potent serotonin reuptake inhibitor so there is a high risk of serotonin syndrome.

SNRIs to vortioxetine

There is limited experience with this switch so extra caution is required to avoid serotonin syndrome.

Direct switch

A direct switch, i.e. stopping one medicine and then starting the new medicine the following day, is normally possible.

Taper, washout and switch

Alternatively, gradually reduce the dose of the SNRI and stop; wait for a period before starting vortioxetine. Clinicians should decide the duration of the washout period on a case-by-case basis.

Deciding on the switching strategy

Our guidance on Planning and agreeing an antidepressant switching strategy will help you decide which switching strategy to choose.

More advice on individual switches

We have further advice on how to switch between individual antidepressants of different types. Browse our collection below.