What are the implications of jaw locking up in relation to discontinuing Lexapro (escitalopram)?

Jaw Locking During Lexapro (Escitalopram) Discontinuation

Jaw locking during Lexapro discontinuation is likely a withdrawal symptom that requires gradual tapering of the medication over several weeks to months rather than abrupt cessation to minimize this and other discontinuation effects.

Understanding Antidepressant Discontinuation Syndrome

Antidepressant discontinuation syndrome (ADS) is a well-documented phenomenon that occurs when antidepressants, particularly SSRIs like escitalopram (Lexapro), are stopped abruptly or tapered too quickly. Jaw locking or jaw tension represents a manifestation of the musculoskeletal symptoms that can occur during withdrawal.

Common Discontinuation Symptoms

• Musculoskeletal symptoms: Muscle tension (44%), including jaw locking 1
• Neurological symptoms: Dizziness (44%), confusion/trouble concentrating (40%) 1
• Sensory disturbances: Vertigo, paresthesias 2
• Psychological symptoms: Anxiety, irritability, crying spells (28%) 3
• Somatic symptoms: Nausea, fatigue, flu-like symptoms, chills (44%) 1

Risk Factors for Severe Discontinuation Symptoms

1. Higher dosage: Patients on higher doses of escitalopram are significantly more likely to experience discontinuation symptoms 1
2. Higher plasma concentrations: Lower clearance of escitalopram leads to higher risk of discontinuation syndrome 1
3. Short half-life: While escitalopram has an intermediate half-life, it still poses a risk compared to longer-acting agents like fluoxetine 2
4. Abrupt discontinuation: Stopping the medication suddenly rather than tapering 3

Management of Jaw Locking During Discontinuation

Recommended Approach

1. Gradual tapering:

   • Very slow tapering is recommended for all patients discontinuing escitalopram 1
   • Aim for withdrawal over several weeks to months (not exceeding 6 months) 4
   • For escitalopram specifically, tapering should be more gradual than with fluoxetine 2

2. If jaw locking or other severe symptoms occur:

   • Reinstate the previous effective dose 5
   • Resume tapering at a slower rate once symptoms resolve 3
   • Consider smaller decrements (e.g., 10-25% reductions) with longer intervals between dose reductions

3. Symptomatic management:

   • Reassurance that symptoms are temporary and not dangerous 3
   • Consider muscle relaxants if jaw locking is severe and interfering with function
   • Avoid prescribing benzodiazepines as they carry their own dependence risks 4

Alternative Strategies for Difficult Cases

• Switch to fluoxetine: Consider switching to fluoxetine before discontinuation due to its extended half-life, which creates a natural taper effect 5
• Adjunctive medications: Limited evidence for use of other medications to manage withdrawal symptoms 4

Important Considerations and Pitfalls

• Distinguish from relapse: Withdrawal symptoms typically emerge within days of dose reduction/discontinuation and resolve within 1-2 weeks, whereas relapse symptoms develop more gradually 3

• Avoid misdiagnosis: Symptoms like jaw locking may be misinterpreted as TMJ disorder or other conditions, leading to unnecessary tests or treatments 3

• Patient education: Inform patients about potential withdrawal symptoms before initiating discontinuation 2

• Monitor closely: Assess for withdrawal symptoms including jaw tension at each visit, especially after dose changes 2

Prevention of Future Episodes

• For patients who have experienced severe discontinuation symptoms including jaw locking:
  • Document the reaction for future reference
  • Consider longer-acting antidepressants if treatment needs to be restarted
  • Plan for even more gradual tapering if discontinuation is attempted again

Jaw locking during Lexapro discontinuation represents a manifestation of withdrawal syndrome that should be addressed through proper tapering protocols rather than being dismissed as an unrelated symptom.