What is the next best step in managing a patient on Lexapro (escitalopram) 20mg with persistent anxiety?

Management of Persistent Anxiety in a Patient on Lexapro 20mg

For a patient on Lexapro (escitalopram) 20mg who continues to experience anxiety, the recommended next step is to switch to sertraline (Zoloft), starting at 25-50mg daily and titrating up to an effective dose of 50-200mg daily, as sertraline has well-established efficacy for anxiety disorders with a favorable side effect profile and lower potential for drug interactions. 1

Assessment of Current Treatment

Before making medication changes, evaluate:

• Duration of current escitalopram treatment (adequate trial is 8-12 weeks)
• Adherence to medication regimen
• Current symptom severity using standardized scales
• Side effect profile with current treatment
• Comorbid conditions that may be contributing to anxiety

Treatment Options

Option 1: Switch to Another SSRI (Recommended)

Sertraline is the preferred alternative because:

• Well-established efficacy for multiple anxiety disorders 1
• Lower potential for drug interactions compared to other SSRIs 1
• Better tolerated in many patients with less likelihood of causing discontinuation syndrome than paroxetine or fluvoxamine 1

Switching protocol:

1. Week 1: Reduce escitalopram to 10mg while starting sertraline at 25mg
2. Week 2: Reduce escitalopram to 5mg while increasing sertraline to 50mg
3. Week 3: Discontinue escitalopram and adjust sertraline as needed (50-100mg)
4. Weeks 4-6: Titrate sertraline to optimal dose (typically 50-200mg) 1

Option 2: Augmentation Strategies

If switching is not preferred, consider adding:

• Cognitive Behavioral Therapy (CBT) - The American Academy of Child and Adolescent Psychiatry suggests combination treatment (CBT and an SSRI) could be more effective than medication alone 2
• Buspirone (BuSpar) - Initial dosage: 5mg twice daily; maximum: 20mg three times daily; useful in patients with mild to moderate anxiety 2

Monitoring and Follow-up

• Monitor closely during the first 24-48 hours after medication changes for signs of serotonin syndrome 1
• Avoid abrupt discontinuation of escitalopram to prevent withdrawal symptoms 1
• Schedule follow-up within 1-2 weeks of medication changes
• Assess for common adverse effects: nausea, diarrhea, dizziness, dry mouth, fatigue, headache, sexual dysfunction, sweating, tremor 1
• Expect initial response within 2-4 weeks, with maximal response by 8-12 weeks 1

Important Cautions

• Absolutely avoid MAOIs during transition between medications and for 2 weeks after stopping either medication 1
• Use caution when combining two or more serotonergic drugs due to risk of serotonin syndrome 2
• Be aware that escitalopram at 20mg is already at maximum recommended dose, making dose increases inadvisable 1
• If patient has QT prolongation concerns, sertraline may be preferred as it has less impact on QT interval compared to escitalopram 1

Clinical Pearls

• Escitalopram 10mg has been shown to be as effective as 20mg for many anxiety disorders, with fewer side effects 3
• Paroxetine has been associated with increased risk of suicidal thinking or behavior compared to other SSRIs and should be used with caution 2
• Citalopram/escitalopram may have the least effect on CYP450 isoenzymes compared with other SSRIs, which may reduce drug interactions 2
• Treatment should be continued for at least 6-12 months after remission to prevent relapse 1