How can I restart Lexapro (escitalopram), Depakote (valproate), clonidine, guanfacine, Risperidone (risperidone), melatonin, and hydroxyzine after being off them for two months?

Restarting Multiple Psychiatric Medications After a Two-Month Discontinuation

For an 18-year-old patient who has been off Lexapro, Depakote, clonidine, guanfacine, risperidone, melatonin, and hydroxyzine for two months, restart medications in a systematic, stepwise approach with close monitoring for side effects and efficacy, prioritizing mood stabilizers and antipsychotics first.

General Principles for Medication Restart

• When restarting multiple psychiatric medications after discontinuation, implement a clear plan with careful monitoring to ensure safety and efficacy 1
• Perform a thorough medication review before restarting to assess continued indication for each medication and potential drug interactions 1, 2
• Restart medications one at a time with adequate intervals between additions to monitor for side effects and efficacy 1

Prioritization and Sequencing

Step 1: Restart Mood Stabilizers and Antipsychotics First

• Begin with restarting Depakote (valproate) and risperidone as these medications address core mood symptoms and are typically prioritized in bipolar disorder management 1

• For risperidone:

  • Start with a lower dose than previously prescribed, such as 0.5-1 mg daily 3
  • Gradually increase to previous therapeutic dose over 1-2 weeks 3
  • Monitor for extrapyramidal symptoms, sedation, and metabolic effects 3

• For Depakote (valproate):

  • Start at a lower dose (250-500 mg daily) and gradually titrate up to previous therapeutic dose 1
  • Obtain baseline liver function tests and complete blood count before restarting 1
  • Monitor serum levels after reaching steady state (approximately 5-7 days) 1

Step 2: Add Lexapro (After 1-2 Weeks)

• After mood stabilizers are reestablished, add Lexapro (escitalopram) starting at a lower dose (5-10 mg) 1
• When combining with mood stabilizers, monitor for potential serotonin syndrome and activation of manic symptoms 1
• Titrate to previous therapeutic dose over 1-2 weeks if tolerated 1

Step 3: Add Alpha-2 Agonists (After Another 1-2 Weeks)

• Once mood medications are stabilized, add clonidine or guanfacine (but not both simultaneously) 4, 5

• For clonidine:

  • Start with 0.05-0.1 mg once or twice daily 4, 6
  • Monitor for hypotension, sedation, and rebound hypertension 4
  • Titrate gradually to previous effective dose 4

• For guanfacine:

  • Start with 0.5-1 mg daily 5, 7
  • Has less sedation but longer duration of action compared to clonidine 5, 7
  • Monitor for hypotension and dizziness 5

Step 4: Add Hydroxyzine and Melatonin Last

• After all other medications are stabilized, add hydroxyzine and melatonin as needed 2
• These medications have fewer drug interactions and can be started at full previous doses 2
• Melatonin can be taken at bedtime at previous dose (typically 1-10 mg) 2
• Hydroxyzine can be used as needed for anxiety or sleep at previous effective dose 2

Monitoring and Follow-up

• Schedule weekly follow-up appointments during the first month of medication restart 1
• Monitor for return of target symptoms and emergence of side effects with each medication addition 1
• Assess medication adherence at each visit and address any barriers 1
• For adolescents with bipolar disorder, consider that most will require ongoing medication therapy to prevent relapse 1
• Obtain baseline and follow-up laboratory monitoring as indicated for specific medications (particularly for Depakote and risperidone) 1

Special Considerations

• If the patient was initially stabilized on combination therapy, they may require return to combination therapy for optimal symptom control 1
• Adolescents may be more difficult to treat than adults and may need additional interventions alongside pharmacotherapy 1
• If ADHD symptoms are present, address these only after mood symptoms are adequately controlled 1
• Consider potential drug interactions, particularly between mood stabilizers and other medications 1, 2

Common Pitfalls to Avoid

• Restarting all medications simultaneously increases risk of adverse effects and makes it difficult to identify which medication is causing problems 2
• Restarting at full previous doses rather than titrating gradually increases risk of side effects 2
• Inadequate monitoring during restart period may miss early signs of adverse effects 1
• Failing to communicate a clear plan to the patient and family about medication restart schedule 1