How to Switch from Lexapro (Escitalopram) to Paxil (Paroxetine)
Taper escitalopram over 10-14 days, allow a washout period of at least 1 week, then start paroxetine at 10 mg daily. This conservative approach minimizes withdrawal symptoms and reduces the risk of adverse effects during the transition 1, 2.
Tapering Escitalopram
- Gradually reduce escitalopram over 10-14 days to limit withdrawal symptoms 1
- For patients on 10-20 mg daily, reduce by 5 mg every 3-5 days 2
- Monitor for discontinuation symptoms including dizziness, fatigue, headaches, nausea, anxiety, irritability, and sensory disturbances 1
- Escitalopram has relatively lower risk of discontinuation syndrome compared to paroxetine, but tapering is still essential 1
Washout Period
- Allow at least 1 week washout between stopping escitalopram and starting paroxetine 2, 3
- This conservative approach prevents drug interactions and allows clearance of the first medication 2
- During washout, monitor closely for worsening depression or anxiety symptoms 2
- The washout period reduces risk of serotonin syndrome from overlapping serotonergic medications 1
Starting Paroxetine
- Begin paroxetine at 10 mg daily (morning or evening) 1
- Paroxetine is less activating but more anticholinergic than other SSRIs 1
- Maximum dose is 40-60 mg daily, though 20-40 mg is typically the effective range 1
- Increase by 10 mg increments every 1-2 weeks as tolerated 1
Critical Monitoring Points
- Monitor closely during the first 2-4 weeks after starting paroxetine for adverse events, including behavioral activation, agitation, or suicidal ideation 1
- Contact (in-person or telephone) should occur within the first week to assess tolerability and adherence 1
- Watch specifically for anticholinergic effects (dry mouth, constipation, urinary retention) as paroxetine has higher anticholinergic activity than escitalopram 1
- Assess for sexual dysfunction, nausea, sweating, and tremors—common SSRI side effects 1
Important Caveats
Paroxetine has the highest risk of discontinuation syndrome among SSRIs 1, so future discontinuation will require very gradual tapering. This should be discussed with the patient upfront 1.
Paroxetine is not recommended as first-line in older adults due to increased anticholinergic effects and should generally be avoided in this population 1.
Paroxetine has been associated with increased risk of suicidal thinking compared to other SSRIs 1, requiring heightened vigilance especially in younger patients.
Alternative Approach: Direct Cross-Taper
If clinical urgency requires avoiding a treatment gap, a direct cross-taper can be considered but requires clinical expertise and close monitoring 2: