What is the recommended tapering schedule for discontinuing Lexapro (escitalopram) 20mg?

How to Taper Lexapro 20mg

Taper Lexapro 20mg gradually over several months using a hyperbolic reduction schedule, decreasing by approximately 10% of the most recent dose every 2-4 weeks, reaching very small final doses (as low as 1-2mg) before complete discontinuation to minimize withdrawal symptoms.

Recommended Tapering Approach

Initial Tapering Phase

• Reduce by 10% of the current dose every 2-4 weeks, not 10% of the original starting dose 1, 2, 3
• From 20mg, the first reduction would be to 18mg (a 2mg decrease), then to approximately 16mg (another 2mg decrease from 18mg) 2, 3
• The FDA label emphasizes gradual dose reduction rather than abrupt cessation whenever possible 1

Why Hyperbolic (Not Linear) Tapering

• Linear tapering (reducing by the same mg amount each time) causes disproportionately large drops in serotonin transporter occupancy at lower doses, dramatically increasing withdrawal risk 2, 4
• Hyperbolic tapering reduces the biological effect on serotonin transporters by equal amounts at each step, minimizing withdrawal symptoms 2, 3
• Research demonstrates that reductions become progressively smaller in absolute mg amounts as the total dose decreases 2, 4

Slower Tapering at Lower Doses

• Once reaching approximately 10mg or below, slow the taper further to 5% reductions of the most recent dose every 2-4 weeks 2, 3
• Final doses before complete cessation may need to be as small as 1-2mg to prevent large decreases in receptor occupancy 2, 4
• Studies show tapers over months (rather than the commonly recommended 2-4 weeks) demonstrate greater success in reducing withdrawal symptoms 2, 3

Critical Pitfalls to Avoid

Never Use Alternate-Day Dosing

• Dosing every other day at any point during the taper causes severe fluctuations in receptor occupancy and significantly increases withdrawal risk 5
• This applies even at minimum therapeutic doses or half-minimum doses 5
• Escitalopram's pharmacokinetic profile makes it particularly unsuitable for alternate-day dosing strategies 5

Avoid Rapid Tapers

• The commonly recommended 2-4 week tapers down to therapeutic minimum doses show minimal benefit over abrupt discontinuation 2
• These short tapers are often not tolerated by patients and may be mistaken for relapse of the underlying condition 2

Monitoring and Management

Assess for Withdrawal Symptoms

• Monitor for anxiety, insomnia, irritability, dizziness, nausea, and flu-like symptoms after each dose reduction 1, 2
• If intolerable symptoms occur, return to the previous well-tolerated dose and slow the taper further 1, 2
• Wait until symptoms resolve before attempting the next reduction 2, 3

Duration Considerations

• Patients on escitalopram for longer durations (≥1 year) should taper even more slowly, potentially over 6-12 months or longer 2, 3
• The risk of withdrawal symptoms increases with longer duration of previous therapy 2

Practical Implementation

Obtaining Flexible Doses

• Liquid formulations allow for precise dose adjustments needed for hyperbolic tapering 3
• Tapering strips (pre-packaged daily doses with gradual reductions) have shown 70-80% real-world effectiveness for antidepressant discontinuation 6
• Compounding pharmacies can prepare custom doses for the final small reductions 3

Sample Hyperbolic Taper Schedule from 20mg

• Week 0: 20mg daily
• Week 2-4: 18mg daily (10% reduction)
• Week 6-8: 16mg daily (11% reduction of 18mg)
• Week 10-12: 14.5mg daily (9% reduction)
• Week 14-16: 13mg daily (10% reduction)
• Continue this pattern, with reductions becoming smaller in absolute mg amounts
• Final weeks may involve reductions from 3mg to 2.5mg to 2mg to 1.5mg to 1mg before stopping 2, 4