What happens if a patient stops taking their escitalopram (selective serotonin reuptake inhibitor) and wants to start a different medication, such as sertraline (selective serotonin reuptake inhibitor)?

From the Guidelines

When switching from escitalopram to sertraline, a cross-tapering approach is recommended to minimize discontinuation symptoms and reduce the risk of serotonin syndrome. This involves gradually reducing the escitalopram dose while slowly introducing sertraline over a period of 1-2 weeks 1. For example, a patient might reduce escitalopram from 20mg to 10mg daily for 3-4 days, then to 5mg for another 3-4 days while starting sertraline at 25mg daily, then increasing to 50mg as the escitalopram is discontinued completely.

Key Considerations

• The exact tapering schedule should be determined by a healthcare provider based on the patient's current dose, medical history, and individual response 1.
• Patients should report any unusual or severe symptoms during the transition period, as the schedule may need adjustment.
• It is essential to start the second non-MAOI serotonergic drug, such as sertraline, at a low dose, increase the dose slowly, and monitor for symptoms, especially in the first 24 to 48 hours after dosage changes 1.

Potential Risks and Benefits

• Discontinuation syndrome, characterized by dizziness, fatigue, lethargy, and other symptoms, has been reported following missed doses or acute discontinuation of shorter-acting SSRIs, including sertraline 1.
• Concomitant administration of any of the SSRIs with any of the monoamine oxidase inhibitors (MAOIs) is contraindicated due to the increased risk of serotonin syndrome 1.
• A conservative medication trial for mild to moderate anxiety presentations may entail increasing the dose as tolerated within the therapeutic dosage range in the smallest available increments at approximately 1- to 2-week intervals when prescribing shorter half-life SSRIs, such as sertraline 1.

From the FDA Drug Label

If concomitant use of Escitalopram with other serotonergic drugs including, triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, buspirone, tryptophan, amphetamine, and St. John’s Wort is clinically warranted, patients should be made aware of a potential increased risk for serotonin syndrome, particularly during treatment initiation and dose increases Treatment with Escitalopram and any concomitant serotonergic agents, should be discontinued immediately if the above events occur and supportive symptomatic treatment should be initiated. A gradual reduction in the dose 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.

When a patient stops taking their escitalopram and wants to start a different medication, such as sertraline, caution is advised.

• The patient should be monitored for serotonin syndrome, particularly during treatment initiation and dose increases.
• A gradual reduction in the dose of escitalopram rather than abrupt cessation is recommended whenever possible.
• If the patient experiences intolerable symptoms after stopping escitalopram, resuming the previously prescribed dose may be considered.
• It is essential to wait an appropriate amount of time after stopping escitalopram before starting sertraline to minimize the risk of serotonin syndrome.
• The patient should be made aware of the potential increased risk for serotonin syndrome when taking sertraline, especially if they have a history of taking other serotonergic drugs. 2 3

From the Research

Stopping Escitalopram and Switching to Sertraline

• If a patient stops taking their escitalopram and wants to start a different medication, such as sertraline, it is essential to consider the potential interactions and effects of switching between selective serotonin reuptake inhibitors (SSRIs) 4.
• Escitalopram and sertraline are both SSRIs, but they have different pharmacological profiles, and their efficacy and tolerability may vary between patients 5, 4.
• A study comparing the efficacy and tolerability of escitalopram and sertraline in the treatment of major depressive disorder found that both medications were generally well tolerated, and there were no significant differences in efficacy between the two treatments 4.

Considerations for Switching Medications

• When switching from escitalopram to sertraline, it is crucial to monitor the patient's response to the new medication and adjust the dosage as needed 4.
• The patient should be informed about the potential risks and benefits of switching medications, including the risk of serotonin syndrome, which can occur when combining SSRIs with other medications that increase serotonin levels 6.
• A gradual tapering of escitalopram may be necessary to minimize the risk of discontinuation symptoms, which can occur when stopping or reducing the dosage of an SSRI 7.

Efficacy and Tolerability of Escitalopram and Sertraline

• Both escitalopram and sertraline have been shown to be effective in the treatment of major depressive disorder and anxiety disorders, with response rates ranging from 70% to 75% 5, 4.
• The tolerability profiles of escitalopram and sertraline are similar, with common adverse events including nausea, insomnia, and increased sweating 5, 7.
• Escitalopram has been found to have a faster onset of action and a more favorable side-effect profile compared to other SSRIs, including sertraline 5.