How to taper off escitalopram (selective serotonin reuptake inhibitor)

Escitalopram Tapering Protocol

Escitalopram should be tapered gradually over several weeks to months rather than abruptly discontinued to minimize withdrawal symptoms and reduce risks to patient health and well-being. 1

Recommended Tapering Schedule

The optimal approach to tapering escitalopram follows a gradual reduction strategy:

1. Initial Phase: Reduce dose by 5-10% of the original dose every 1-2 weeks 2

   • For standard 10mg dose: Reduce to 5mg for 1-2 weeks
   • For 20mg dose: Reduce to 15mg for 1-2 weeks, then 10mg for 1-2 weeks

2. Later Phase: As the dose gets lower, slow the taper further

   • From 5mg: Reduce to 2.5mg for 2-4 weeks
   • Final phase: Consider liquid formulation or alternate-day dosing to achieve doses below 2.5mg

3. Extended Taper: For patients who have been on escitalopram long-term (>6 months), consider an even more gradual taper extending over 2-3 months 3

Monitoring for Withdrawal Symptoms

Common withdrawal symptoms that require monitoring include:

• Psychological symptoms: Anxiety, irritability, mood swings, confusion
• Physical symptoms: Dizziness, electric shock sensations (brain zaps), headache, tremor
• Sleep disturbances: Insomnia, vivid dreams 1

If withdrawal symptoms emerge:

• Return to the previous dose that was well-tolerated
• Stabilize for 1-2 weeks before attempting a slower taper
• Consider extending the interval between dose reductions

Special Populations Considerations

• Elderly patients: Use a more gradual tapering schedule (5% reduction every 2-4 weeks) 2
• Patients with hepatic impairment: Start with a 50% reduction of the initial dose and taper more gradually due to escitalopram's hepatic metabolism 2, 4
• Patients with anxiety disorders: May require a slower taper due to increased risk of rebound anxiety 2

Non-Pharmacological Support During Tapering

Implementing the following strategies can significantly improve tapering success:

• Cognitive behavioral therapy (CBT): Increases tapering success rates 2
• Regular exercise: Helps manage withdrawal symptoms and improves mood
• Sleep hygiene practices: Addresses insomnia that may occur during tapering
• Stress management techniques: Meditation, deep breathing exercises 2

Management of Specific Withdrawal Symptoms

For troublesome symptoms that persist despite slow tapering:

• Insomnia: Consider short-term use of trazodone or hydroxyzine
• Anxiety/agitation: Hydroxyzine may provide temporary relief
• Pain symptoms: Scheduled acetaminophen (not exceeding 3000mg daily) 2

Important Cautions

• Never discontinue escitalopram abruptly as this significantly increases the risk of withdrawal symptoms 1
• Monitor closely for signs of returning depression during and after the taper, as this is different from withdrawal symptoms
• Withdrawal symptoms are generally self-limiting but can be severe in some cases 1

The pharmacokinetic profile of escitalopram, with its elimination half-life of 27-33 hours 4, supports a gradual tapering approach rather than abrupt discontinuation to minimize the risk of withdrawal symptoms while maintaining patient safety and comfort.