What is the recommended approach for transitioning from Lexapro (escitalopram) to sertraline?

From the Guidelines

The recommended approach for transitioning from Lexapro (escitalopram) to sertraline involves a cautious cross-tapering method, starting the second medication at a low dose and gradually increasing it while monitoring for symptoms, especially in the first 24 to 48 hours after dosage changes, as suggested by the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders 1. When transitioning from Lexapro to sertraline, it's crucial to consider the potential for discontinuation syndrome associated with sertraline, as well as the risk of serotonin syndrome when combining serotonergic drugs 1. Key considerations for the transition include:

• Gradually reducing the Lexapro dose while starting sertraline at a low dose
• Monitoring for symptoms, especially in the first 24 to 48 hours after dosage changes
• Increasing the sertraline dose slowly, as tolerated, to minimize the risk of adverse effects
• Being aware of the potential for drug-drug interactions, particularly with medications that prolong the QT interval or are metabolized by CYP2D6 1 The cross-tapering method allows for a gradual adjustment to the new medication, minimizing the risk of withdrawal symptoms from Lexapro and allowing sertraline to reach therapeutic levels. Throughout the transition process, it's essential to monitor for side effects and adjust the dosage as needed, under the guidance of a healthcare provider. The entire transition typically takes 2-3 weeks, though individual timeframes may vary based on the specific situation and response. It's also important to note that medical education, training, and experience are necessary to safely and effectively prescribe antidepressant medications, and a conservative medication trial may entail increasing the dose as tolerated within the therapeutic dosage range in the smallest available increments at approximately 1- to 2-week intervals 1.

From the FDA Drug Label

There is limited controlled experience regarding the optimal timing of switching from other drugs effective in the treatment of major depressive disorder, obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, premenstrual dysphoric disorder and social anxiety disorder to sertraline Care and prudent medical judgment should be exercised when switching, particularly from long-acting agents. The duration of an appropriate washout period which should intervene before switching from one selective serotonin reuptake inhibitor (SSRI) to another has not been established.

The recommended approach for transitioning from Lexapro (escitalopram) to sertraline is not explicitly stated in the FDA drug label. However, it is recommended that care and prudent medical judgment should be exercised when switching, particularly from long-acting agents.

• A gradual reduction in the dose of escitalopram rather than abrupt cessation is recommended whenever possible.
• If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered.
• The duration of an appropriate washout period which should intervene before switching from one selective serotonin reuptake inhibitor (SSRI) to another has not been established 2.

From the Research

Transitioning from Lexapro to Sertraline

When transitioning from Lexapro (escitalopram) to sertraline, it is essential to consider the following:

• The transition should be done under the guidance of a healthcare professional to minimize potential withdrawal symptoms or adverse effects.
• According to 3, guidelines recommend short tapers, of between 2 weeks and 4 weeks, down to therapeutic minimum doses, or half-minimum doses, before complete cessation of the initial medication.
• However, studies have shown that these tapers show minimal benefits over abrupt discontinuation, and are often not tolerated by patients. Tapers over a period of months and down to doses much lower than minimum therapeutic doses have shown greater success in reducing withdrawal symptoms.

Considerations for Transition

Some key points to consider when transitioning from Lexapro to sertraline include:

• The dosage of sertraline, which is typically started at 50-200 mg/day, as seen in 4.
• The potential for differences in efficacy and tolerability between escitalopram and sertraline, as noted in 4 and 5.
• The importance of monitoring for withdrawal symptoms, adverse effects, and changes in depressive symptoms, anxiety symptoms, cognitive function, and daily living abilities, as assessed in 4.

Efficacy and Tolerability of Sertraline

Research has shown that:

• Sertraline is an effective treatment for major depressive disorder, with comparable efficacy to escitalopram in some studies, as seen in 4 and 6.
• The incidence of adverse effects with sertraline is generally mild, but may vary compared to escitalopram, as noted in 4.
• Sertraline has been shown to be effective in reducing psychological distress among adults with major depressive disorder, as demonstrated in 6.