How do I switch a patient from Cymbalta (duloxetine) to Lexapro (escitalopram)?

Switching from Duloxetine (Cymbalta) to Escitalopram (Lexapro)

When switching from Cymbalta 60 mg twice daily to Lexapro, use a cross-tapering approach over 2-4 weeks to minimize withdrawal symptoms and maintain therapeutic efficacy. This approach is necessary because duloxetine has a relatively short half-life and can cause significant discontinuation symptoms if stopped abruptly 1.

Cross-Tapering Protocol

Week 1:

• Reduce Cymbalta from 60 mg twice daily to 60 mg once daily
• Start Lexapro 5 mg once daily

Week 2:

• Reduce Cymbalta to 30 mg once daily
• Increase Lexapro to 10 mg once daily

Week 3:

• Discontinue Cymbalta completely
• Continue Lexapro 10 mg once daily
• Assess for therapeutic response and side effects

Week 4:

• If needed, increase Lexapro to 20 mg once daily (maximum recommended dose)

Rationale for Cross-Tapering

Duloxetine is an SNRI (serotonin-norepinephrine reuptake inhibitor) with a half-life of approximately 12 hours, making it prone to causing withdrawal symptoms when discontinued abruptly 2. These symptoms can include:

• Dizziness and light-headedness
• Nausea and vomiting
• Fatigue and flu-like symptoms
• Sensory disturbances
• Anxiety and irritability

Cross-tapering allows for a gradual transition that minimizes these withdrawal effects while maintaining therapeutic coverage for depression 1.

Monitoring During Transition

Monitor for:

1. Serotonin syndrome: Though rare during careful cross-tapering, watch for symptoms like agitation, tremor, hyperthermia, and neuromuscular rigidity 2
2. Withdrawal symptoms: If severe withdrawal symptoms occur, slow the taper by returning to the previous dose step
3. Therapeutic efficacy: Assess for continued control of depressive symptoms
4. Side effect profile changes: Escitalopram may have different side effects than duloxetine

Expected Differences Between Medications

• Sleep: Escitalopram may provide better improvement in sleep compared to duloxetine 3
• Weight changes: Escitalopram is associated with more weight gain over time than duloxetine 3
• Cardiovascular effects: Duloxetine tends to increase pulse and blood pressure more than escitalopram 3
• Acceptability: Studies suggest escitalopram may have better acceptability as a second-line agent with lower discontinuation rates compared to duloxetine 4

Common Pitfalls to Avoid

• Abrupt discontinuation: Never stop duloxetine suddenly due to risk of withdrawal syndrome 5
• Overly rapid cross-tapering: This increases risk of serotonin syndrome and withdrawal symptoms
• Inadequate monitoring: Regular follow-up during the transition period is essential
• Failure to educate the patient: Inform the patient about potential temporary side effects during the transition

Special Considerations

• For patients with severe depression, ensure close monitoring during the transition as this is a vulnerable period
• For elderly patients, consider using lower doses of both medications during the cross-tapering process 2
• If the patient experiences intolerable withdrawal symptoms despite slow tapering, consider temporarily adding a benzodiazepine for symptom management (short-term only)

This cross-tapering approach provides the safest method for transitioning from Cymbalta to Lexapro while maintaining therapeutic efficacy and minimizing adverse effects.