Switch medication from fluoxetine to nortriptyline.
- Before day 1: reduce dosage of fluoxetine with about 20 mg per week.
- Day 1: when a dosage of 20 mg/day is reached, stop fluoxetine.
Caution is necessary for at least four weeks.
- Day 2: start administration of nortriptyline in a low dosage of 25 mg/day.
- Day 15: increase dosage of nortriptyline to 50 mg/day.
- Day 29: gradually increase dosage of nortriptyline to 75 mg/day and more.
- Fluoxetine and norfluoxetine slow the metabolism of nortriptyline via CYP2D6.
- Fluoxetine and its metababolite desmethyl-fluoxetine have a very long elimination time of about 1 week; phasing out fluoxetine is therefore not necessary.
- Start low, go slow for nortriptyline.
- Occurrence of the serotonin syndrome is not likely, but theoretically possible, so caution is necessary.
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