What is the recommended protocol for switching from Lexapro (escitalopram) 20mg to Cymbalta (duloxetine) 60mg?

Switching from Lexapro 20mg to Cymbalta 60mg

The recommended protocol for switching from Lexapro (escitalopram) 20mg to Cymbalta (duloxetine) 60mg is a cross-tapering approach where you should start duloxetine 30mg once daily while reducing escitalopram from 20mg to 10mg daily for one week, then continue duloxetine 30mg while further reducing escitalopram to 5mg for another week, before discontinuing escitalopram completely and increasing duloxetine to the target dose of 60mg daily. 1

Cross-Tapering Schedule

Week 1:

• Reduce Lexapro from 20mg to 10mg daily 1
• Start Cymbalta at 30mg once daily 1
• This initial lower dose of duloxetine helps minimize the risk of nausea, which is the most common side effect when initiating treatment 1

Week 2:

• Further reduce Lexapro to 5mg daily 1
• Continue Cymbalta at 30mg once daily 1
• This gradual reduction helps minimize withdrawal symptoms from escitalopram 2

Week 3:

• Discontinue Lexapro completely 1
• Increase Cymbalta to the target dose of 60mg once daily 1
• 60mg daily is the standard therapeutic dose for depression 1

Important Considerations

Potential Side Effects

• Common side effects when initiating duloxetine include diaphoresis, dry mouth, abdominal discomfort, nausea, vomiting, diarrhea, dizziness, headache, tremor, insomnia, and somnolence 3
• Duloxetine may cause increases in blood pressure and pulse, which should be monitored 3, 4
• Escitalopram discontinuation may cause withdrawal symptoms including dizziness, nausea, headache, paresthesia, irritability, and nightmares 5

Special Populations

• For elderly or frail patients, consider a slower cross-taper schedule with a lower initial duloxetine dose (e.g., 20mg) 1
• For patients with renal insufficiency, the duloxetine dosage may need adjustment 1

Monitoring Recommendations

• Monitor blood pressure and pulse regularly during the transition, as duloxetine has been associated with increases in these parameters 3, 4
• Schedule follow-up within 1-2 weeks after completing the transition to monitor for adverse effects and treatment response 1
• Be alert for signs of serotonin syndrome during the cross-tapering period, although this risk is low with the recommended gradual approach 2

Clinical Evidence Supporting This Approach

• Research shows that immediate switching from SSRIs to duloxetine 60mg daily without tapering can be effective but is associated with higher rates of discontinuation due to adverse events (17.9%) compared to a more gradual approach 6
• A study comparing duloxetine and escitalopram found similar efficacy in treating depression over an 8-month period, but with different side effect profiles - duloxetine side effects tend to emerge early in treatment (e.g., nausea, dry mouth), while escitalopram side effects tend to emerge later (e.g., diarrhea, weight increase) 4
• Abrupt discontinuation of duloxetine is associated with discontinuation-emergent adverse events in 44.3% of patients, highlighting the importance of gradual dose changes 5

Practical Tips

• Taking duloxetine with food may help reduce gastrointestinal side effects 1
• If activation symptoms such as anxiety or insomnia occur, consider taking duloxetine in the morning rather than evening 1
• Full therapeutic response to duloxetine may take 4-8 weeks to develop 1
• If severe withdrawal symptoms occur during the cross-taper, consider slowing the taper of escitalopram 2