Can a patient who has been off escitalopram (citalopram) 20mg since April be restarted at 20mg or should they start at 10mg?

Restarting Escitalopram After Discontinuation

For a patient who has been off escitalopram 20mg since April (approximately 6-8 months), it is recommended to restart at 10mg for one week before increasing to the previous 20mg dose to minimize potential side effects. 1

Rationale for Gradual Reintroduction

The FDA drug label for escitalopram provides guidance on dosing that supports a gradual approach:

• The recommended starting dose of escitalopram for adults is 10mg once daily 1
• If increasing to 20mg, this should occur after a minimum of one week 1
• This gradual titration helps minimize potential side effects during reintroduction

Recommended Restart Protocol

1. Week 1: Start with 10mg once daily (morning or evening, with or without food)
2. Week 2 and beyond: If tolerated and clinically indicated, increase to 20mg once daily

Pharmacokinetic Considerations

Escitalopram has specific pharmacokinetic properties that support this approach:

• Reaches steady-state concentrations within 7-10 days of administration 2
• Has an elimination half-life of approximately 27-33 hours 2
• After several months off medication, the patient should be considered treatment-naïve from a pharmacokinetic perspective

Safety Considerations

Starting at a lower dose helps minimize potential adverse effects:

• Reduces risk of initial side effects such as nausea, insomnia, or increased anxiety
• Lowers potential for dose-related treatment-emergent adverse events
• Case reports suggest dose-related risk of treatment-emergent mania/hypomania with escitalopram, supporting a gradual titration approach 3

Special Considerations

• Monitoring: Assess for return of therapeutic effect and any adverse reactions during the first 1-2 weeks
• Timing: Administer once daily, either morning or evening, with or without food 1
• Prior to restarting: Screen for any changes in health status, particularly development of bipolar disorder, as recommended in the FDA label 1

Common Pitfalls to Avoid

• Restarting at full dose: Beginning immediately at 20mg may increase risk of side effects and reduce tolerability
• Inadequate monitoring: Failing to assess response during the titration period
• Prolonged low-dose treatment: Unnecessarily remaining at 10mg if 20mg was previously effective and well-tolerated

This approach balances the need for therapeutic efficacy with minimizing potential adverse effects during medication reintroduction.