Tapering Lexapro 20mg When Switching to an SNRI
Yes, Lexapro (escitalopram) 20mg requires tapering when switching to an SNRI to prevent discontinuation syndrome and reduce the risk of serotonin syndrome.
Why Tapering is Necessary
- SSRIs like escitalopram are associated with a discontinuation syndrome characterized by dizziness, fatigue, nausea, sensory disturbances, anxiety, and irritability when stopped abruptly 1
- Both escitalopram and SNRIs affect serotonin levels, and starting an SNRI without properly tapering escitalopram could potentially increase the risk of serotonin syndrome 1
- Withdrawal symptoms from SSRIs can be mistaken for relapse of depression, potentially leading to unnecessary treatment or testing 2
Recommended Tapering Protocol
- Gradually reduce escitalopram over 2-4 weeks rather than stopping abruptly 1, 3
- Begin the SNRI after completing the escitalopram taper or during the final stages of tapering when on a very low dose of escitalopram 1
- Standard initial doses of SNRIs (e.g., duloxetine 30mg daily, venlafaxine 37.5mg daily) should be used when starting after the taper 4
Specific Tapering Approach
- For escitalopram 20mg, reduce by 5mg every 1-2 weeks (20mg → 15mg → 10mg → 5mg → stop) 3, 5
- If withdrawal symptoms occur during tapering, slow the taper rate or temporarily return to the previous dose before attempting a more gradual reduction 2, 6
- Recent evidence suggests that hyperbolic tapering (progressively smaller dose reductions) may be more effective than linear tapering for minimizing withdrawal symptoms 3, 6
Potential Complications to Monitor
- Withdrawal symptoms typically emerge within days of dose reduction and may include somatic symptoms (dizziness, nausea, fatigue, sensory disturbances) and psychological symptoms (anxiety, irritability) 2, 7
- Serotonin syndrome risk increases if therapeutic doses of both medications overlap significantly 1, 4
- Symptoms of serotonin syndrome include mental status changes, neuromuscular hyperactivity, and autonomic hyperactivity 4
Special Considerations
- Escitalopram has a relatively shorter half-life compared to fluoxetine, making it more likely to cause discontinuation symptoms 2, 7
- Patients should be educated about the importance of not missing doses during the transition period 1
- If withdrawal symptoms are severe, reinstating the original dose and slowing the taper rate is recommended 2, 5
Common Pitfalls to Avoid
- Starting the SNRI at too high a dose while still on significant amounts of escitalopram 1
- Tapering too quickly (less than 2 weeks), which increases risk of discontinuation syndrome 3, 5
- Failing to distinguish between withdrawal symptoms and relapse of the underlying condition 2, 5
- Abrupt discontinuation, which significantly increases the risk of withdrawal symptoms 4, 7