What are alternative medications to switch a patient from Lexapro (escitalopram) to?

Alternatives for Switching from Lexapro (Escitalopram)

When switching a patient from Lexapro (escitalopram), the best alternatives include sertraline, citalopram, bupropion, mirtazapine, or venlafaxine, with the choice depending primarily on the patient's symptom profile and side effect concerns.

First-Line Alternatives to Consider

SSRIs

• Sertraline (Zoloft): 50-200 mg daily

  • Well-tolerated with favorable side effect profile 1
  • Good option if Lexapro was partially effective but caused side effects

• Citalopram (Celexa): 20-40 mg daily

  • Similar mechanism to escitalopram but may have different tolerability profile
  • Note FDA warning limiting maximum dose to 40 mg due to QT prolongation risk 1

Other Classes

• Bupropion (Wellbutrin): 100-400 mg daily

  • Excellent choice for patients with fatigue or lack of motivation
  • Start at 150 mg once daily for 3 days, then increase to 150 mg twice daily 2
  • Activating and may provide rapid improvement in energy levels
  • Avoid in patients with seizure disorders or agitation 2

• Mirtazapine (Remeron): 15-45 mg daily

  • Useful for patients with insomnia or appetite issues
  • Sedating at lower doses (15 mg), less sedating at higher doses 1

• Venlafaxine: 37.5-225 mg daily

  • SNRI that may be more effective for severe depression
  • Consider for patients who had partial response to Lexapro 1

Switching Strategy

When switching from Lexapro to another antidepressant, consider one of these approaches:

1. Direct switch: Discontinue Lexapro and start the new medication the next day

   • Appropriate when switching between SSRIs
   • Monitor for discontinuation symptoms

2. Cross-taper: Gradually reduce Lexapro while starting and increasing the new medication

   • Preferred method when switching to a different class
   • Reduces risk of discontinuation symptoms

3. Conservative approach: Complete washout of Lexapro before starting new medication

   • Required when switching to/from MAOIs
   • May be necessary with certain drug interactions 3

Special Considerations

Duration of Trial

• Allow adequate trial of the new medication (4-12 weeks) before determining efficacy
• In the STAR*D trial, only about 20% of patients remitted after switching from an initial SSRI
• Half of responses and two-thirds of remissions occurred after 6 weeks of treatment 4
• 33% of responses occurred after ≥9 weeks of treatment 4

Monitoring

• Assess for improvement in symptoms after 2 weeks - patients with at least 20% reduction in symptoms by week 2 are 6 times more likely to respond or remit 4
• Monitor for side effects specific to the new medication

Medication-Specific Considerations

When Switching to Bupropion

• Start with 37.5 mg every morning
• Increase by 37.5 mg every 3 days
• Target dose: 150 mg twice daily (second dose before 3 PM to minimize insomnia)
• Maximum daily dose: 300 mg to minimize seizure risk 2
• Contraindicated in patients with seizure disorders or agitation
• Requires 14-day washout if switching from MAOIs 2

When Switching to Another SSRI

• Can often be done with minimal washout due to similar mechanisms
• Consider the half-life of escitalopram (27-33 hours) when planning the switch 5
• Escitalopram is metabolized by CYP2C19, CYP2D6, and CYP3A4 - consider potential drug interactions with the new medication 5

Common Pitfalls to Avoid

• Inadequate trial duration: Many patients require 6-12 weeks for full response
• Improper dosing: Ensure therapeutic doses are reached
• Ignoring drug interactions: Check for potential interactions, especially when combining with other medications
• Overlooking discontinuation symptoms: Taper Lexapro gradually to minimize withdrawal effects
• Not considering the original reason for switching: If switching due to side effects, choose a medication with a different side effect profile

Remember that following an ineffective initial SSRI trial, more than half of patients may not achieve meaningful benefit with a second antidepressant, so setting realistic expectations is important 4.