Paroxetine to Escitalopram Tapering Regimen for a 69-Year-Old Female
For a 69-year-old female switching from 20mg Paxil (paroxetine) to 10mg Lexapro (escitalopram), I recommend a slow taper over 8-12 weeks with close monitoring to minimize withdrawal symptoms.
Why Slow Tapering is Necessary
Paroxetine has a high risk of withdrawal symptoms due to its short half-life and strong serotonin reuptake inhibition. The FDA label specifically notes that abrupt discontinuation can lead to significant withdrawal effects including:
- Dysphoric mood and irritability
- Dizziness and sensory disturbances
- Anxiety and confusion
- Emotional lability and insomnia 1
For older adults, these risks are particularly concerning as they may affect balance and cognition, potentially leading to falls or other adverse outcomes.
Recommended Tapering Schedule
Week 1-2:
- Reduce paroxetine from 20mg to 15mg daily
- Monitor for initial withdrawal symptoms
Week 3-4:
- Reduce paroxetine to 10mg daily
- Continue monitoring for withdrawal symptoms
Week 5-6:
- Reduce paroxetine to 5mg daily
- Begin escitalopram 5mg daily (cross-tapering approach)
Week 7-8:
- Discontinue paroxetine
- Increase escitalopram to 10mg daily
If withdrawal symptoms occur:
- Slow the taper further
- Consider extending each step to 2-3 weeks
- Use the previously tolerated dose until symptoms resolve
Monitoring and Support
- Schedule follow-up appointments at least monthly during the taper 2
- Assess for common withdrawal symptoms: dizziness, nausea, anxiety, insomnia, sensory disturbances
- Be prepared to pause the taper if significant symptoms emerge
Special Considerations for Older Adults
For this 69-year-old patient:
- The taper should be particularly gradual as older adults may be more sensitive to withdrawal effects
- Monitor for hyponatremia, which is more common in elderly patients taking SSRIs 1
- Be vigilant for cognitive changes or balance issues that could increase fall risk
Evidence for This Approach
The FDA label for paroxetine specifically recommends "a gradual reduction in the dose rather than abrupt cessation" and notes that if intolerable symptoms occur, "resuming the previously prescribed dose may be considered" followed by "decreasing the dose but at a more gradual rate" 1.
Research shows that very slow tapering is recommended for all patients discontinuing escitalopram, especially those on higher doses 3. Evidence also indicates that patients who have been on antidepressants for longer periods (this patient has been on 20mg Paxil) benefit from slower tapers of 10% per month or less 2.
Common Pitfalls to Avoid
- Tapering too quickly: Even seemingly modest reductions can trigger withdrawal in sensitive individuals
- Failing to recognize withdrawal symptoms: These can be misinterpreted as relapse or physical illness
- Not providing the lowest available dose: Always include the smallest available dose in the taper 4
- Abrupt discontinuation: This significantly increases risk of withdrawal symptoms 5
By following this gradual approach with careful monitoring, the transition from paroxetine to escitalopram can be accomplished with minimal discomfort and risk to the patient.