Switching from Cymbalta (Duloxetine) 60 mg BID to Lexapro (Escitalopram) in an Inpatient Setting
The most effective approach for switching from Cymbalta 60 mg twice daily to Lexapro in an inpatient setting is to use a cross-tapering method over 2-4 weeks, gradually reducing Cymbalta while simultaneously initiating and increasing Lexapro.
Cross-Tapering Protocol
Week 1:
- Reduce Cymbalta from 60 mg BID (120 mg/day) to 60 mg in the morning and 30 mg in the evening (90 mg/day)
- Start Lexapro 5 mg daily in the evening
Week 2:
- Reduce Cymbalta to 60 mg once daily in the morning
- Increase Lexapro to 10 mg daily in the evening
Week 3:
- Reduce Cymbalta to 30 mg once daily in the morning
- Maintain Lexapro at 10 mg daily (may increase to 15-20 mg if clinically indicated based on response)
Week 4:
- Discontinue Cymbalta completely
- Continue Lexapro at target dose (10-20 mg daily)
Monitoring Requirements
Daily monitoring during the first week of cross-tapering for:
- Discontinuation symptoms (dizziness, headache, nausea, irritability, sensory disturbances)
- Signs of serotonin syndrome (agitation, tremor, hyperthermia, mental status changes)
- Changes in vital signs, particularly blood pressure and heart rate
- Worsening depression or anxiety symptoms
Blood pressure monitoring is essential as Cymbalta withdrawal can cause blood pressure fluctuations 1
Adjust tapering schedule if discontinuation symptoms become severe - slow the taper if needed
Special Considerations
Advantages of Inpatient Setting
- Allows for closer monitoring of withdrawal symptoms and potential adverse effects
- Enables more rapid titration if clinically necessary
- Provides opportunity to address any emergent suicidal ideation or mood deterioration
Potential Complications
- Serotonin syndrome risk is highest during the cross-tapering period when both medications are being administered concurrently 1
- Discontinuation syndrome from Cymbalta can be significant due to its short half-life and may include dizziness, nausea, headache, paresthesia, and irritability 2
- Sleep disturbances may occur during the transition, as Cymbalta and Lexapro have different effects on sleep architecture 3
Evidence-Based Rationale
The cross-tapering approach is supported by clinical evidence showing that escitalopram has better acceptability as a second-line agent compared to duloxetine, with significantly lower discontinuation rates (4.9% vs 19.2%) 4. Additionally, a gradual cross-tapering strategy minimizes the risk of discontinuation symptoms while maintaining therapeutic coverage 1.
Contraindications to This Approach
- Patients with uncontrolled narrow-angle glaucoma
- Patients with severe hepatic impairment
- Concurrent use of MAOIs (absolute contraindication)
- Patients with QT prolongation risk factors 1
If the patient experiences severe discontinuation symptoms despite the gradual taper, the clinician should slow the taper further, particularly when reducing from 30 mg to 0 mg of Cymbalta, as this final step often produces the most pronounced withdrawal effects 2, 5.