What is the recommended protocol for switching from Lexapro (escitalopram) to Zoloft (sertraline)?

Switching from Lexapro to Zoloft: Recommended Protocol

The recommended protocol for switching from Lexapro (escitalopram) to Zoloft (sertraline) is a cross-taper approach, starting with a gradual reduction of escitalopram while simultaneously introducing a low dose of sertraline, with close monitoring for discontinuation symptoms and serotonin syndrome during the transition. 1, 2

Rationale for Switching

Both medications are SSRIs with similar efficacy profiles but different side effect profiles and pharmacokinetic properties:

• Escitalopram has fewer drug interactions due to minimal effect on CYP450 enzymes 1
• Sertraline may be associated with discontinuation syndrome but is considered a preferred agent due to its favorable side effect profile 1

Step-by-Step Switching Protocol

Phase 1: Preparation (1-2 days before switch)

• Assess current escitalopram dose and response
• Ensure no contraindications for sertraline (especially MAOIs, which must never be combined with any SSRI) 1
• Educate patient about potential discontinuation symptoms: dizziness, fatigue, headaches, nausea, sensory disturbances, anxiety, irritability 1, 3

Phase 2: Cross-Tapering (2-4 weeks)

1. Week 1:

   • Reduce escitalopram by 50% of original dose
   • Start sertraline at 25mg daily (lower than typical starting dose) 1
   • Monitor closely for adverse effects, especially in first 24-48 hours 1

2. Week 2:

   • Further reduce escitalopram to 25% of original dose
   • Increase sertraline to 50mg daily if tolerated 1

3. Week 3:

   • Discontinue escitalopram completely
   • Maintain sertraline at 50mg daily

4. Week 4:

   • Adjust sertraline dose as needed (therapeutic range: 50-200mg daily) 1

Phase 3: Monitoring and Dose Optimization

• Schedule follow-up within 1-2 weeks after completing the switch
• Assess for:
  • Discontinuation symptoms from escitalopram
  • Therapeutic response to sertraline
  • Adverse effects of sertraline
• Optimize sertraline dose as needed (up to 200mg daily) 1

Special Considerations

Risk of Discontinuation Syndrome

• Higher risk factors for escitalopram discontinuation syndrome:
  • Higher doses of escitalopram
  • Higher plasma concentrations
  • Abrupt discontinuation 3
• Common symptoms: dizziness (44%), muscle tension (44%), chills (44%), confusion (40%) 3

Risk of Serotonin Syndrome

• Monitor for mental status changes (confusion, agitation)
• Watch for neuromuscular hyperactivity (tremors, hyperreflexia)
• Check for autonomic hyperactivity (hypertension, tachycardia, diaphoresis) 1
• Highest risk during the cross-taper period when both medications are being taken

Contraindications

• Never combine SSRIs with MAOIs 1
• Use caution in patients with:
  • Seizure disorders
  • Bleeding disorders
  • QT prolongation (especially with citalopram, less concern with sertraline) 1

Common Pitfalls to Avoid

• Switching too rapidly: This increases risk of discontinuation syndrome and adverse effects 2
• Inadequate monitoring: Close follow-up is essential during the first 1-2 weeks of switching
• Ignoring breakthrough symptoms: Depression symptoms may worsen during transition
• Overlooking drug interactions: Both medications interact with other serotonergic drugs 1
• Failure to educate patient: Patients should be informed about potential withdrawal symptoms and when to seek help

By following this structured approach, the transition from Lexapro to Zoloft can be accomplished safely while minimizing discontinuation symptoms and maintaining therapeutic efficacy.