How to cross-taper Lexapro (escitalopram) 20mg to vortioxetine in a patient also taking bupropion (Wellbutrin) 150 XL?

Cross-Tapering Lexapro 20mg to Vortioxetine in a Patient Taking Bupropion 150 XL

The recommended approach for cross-tapering from escitalopram 20mg to vortioxetine in a patient also taking bupropion 150 XL is to gradually reduce escitalopram while simultaneously titrating up vortioxetine over a 4-week period, with careful monitoring for withdrawal symptoms and drug interactions.

Cross-Tapering Schedule

• Week 1: Decrease escitalopram to 15mg daily while starting vortioxetine at 5mg daily 1
• Week 2: Decrease escitalopram to 10mg daily while increasing vortioxetine to 10mg daily 1, 2
• Week 3: Decrease escitalopram to 5mg daily while maintaining vortioxetine at 10mg daily 1, 2
• Week 4: Discontinue escitalopram completely while increasing vortioxetine to target dose of 10-20mg daily based on response and tolerability 1

Rationale and Considerations

• Antidepressant switching should involve gradual cross-titration informed by the half-life and receptor profile of each medication to minimize withdrawal symptoms and maintain therapeutic efficacy 3
• Vortioxetine is a novel antidepressant with multimodal action (serotonin transporter inhibition plus activity at multiple serotonin receptors) that typically requires 2-4 weeks to achieve full therapeutic effect 1
• Bupropion can be safely maintained at the current dose of 150 XL during the cross-taper as it primarily affects norepinephrine and dopamine with minimal serotonergic activity 1, 4

Monitoring During Cross-Taper

• Monitor for serotonin withdrawal symptoms during escitalopram taper: dizziness, headache, nausea, irritability, and sensory disturbances 2
• Watch for potential drug interactions between vortioxetine and bupropion, though significant pharmacokinetic interactions are not expected 1
• The most common side effect of vortioxetine is nausea (may need management), followed by constipation and vomiting 1
• Track treatment response weekly during the transition period, with particular attention to mood changes, anxiety, and sleep disturbances 3

Special Considerations

• If withdrawal symptoms emerge during the taper, slow the escitalopram reduction by extending each step to 2 weeks instead of 1 week 2
• The combination of vortioxetine and bupropion may provide complementary neurotransmitter effects, as bupropion primarily affects norepinephrine and dopamine while vortioxetine affects serotonin through multiple mechanisms 1, 4
• Studies have shown that the combination of an SSRI with bupropion can be effective and well-tolerated, suggesting that vortioxetine with bupropion may also be a reasonable combination 4

Potential Pitfalls and Caveats

• Avoid abrupt discontinuation of escitalopram as this increases risk of withdrawal symptoms 3
• If intolerable side effects develop during the cross-taper, consider temporarily slowing the titration schedule 3
• If symptoms worsen significantly during the transition, consider returning to the previous effective dose of escitalopram before attempting a slower taper 2
• Be aware that full therapeutic effect of vortioxetine may take 4-6 weeks to develop, so temporary worsening of depression symptoms during the transition period may occur 1