Switching from Escitalopram 20mg to Duloxetine
Start duloxetine 30mg once daily while simultaneously reducing escitalopram from 20mg to 10mg, then discontinue escitalopram after one week while increasing duloxetine to 60mg daily. 1
Cross-Tapering Protocol
The Mayo Clinic recommends a cross-taper approach rather than abrupt switching to minimize withdrawal symptoms while maintaining therapeutic coverage 1:
Week 1:
- Start duloxetine 30mg once daily (lower dose reduces nausea risk) 1
- Reduce escitalopram from 20mg to 10mg daily 1
- Monitor for side effects and withdrawal symptoms
Week 2 and Beyond:
- Discontinue escitalopram completely 1
- Increase duloxetine to 60mg once daily (standard therapeutic dose for depression) 1
- Continue monitoring for 2-4 weeks to assess response
Alternative Direct Switch Approach
If a more rapid transition is needed, immediate switching without tapering is supported by clinical trial evidence 2, 3:
- Abruptly stop escitalopram and immediately start duloxetine 60mg once daily 2, 3
- This approach showed comparable efficacy and was well-tolerated in clinical trials 2, 3
- Discontinuation rates due to adverse events were actually lower with direct switching (4.5%) compared to initiating duloxetine in antidepressant-naive patients (17.9%) 2
However, the cross-taper method is preferred as it allows assessment of duloxetine tolerability before complete escitalopram discontinuation 1, which is particularly important in real-world practice where individual patient factors may not match clinical trial populations.
Monitoring and Management
Expected Side Effects:
- Nausea is the most common side effect when initiating duloxetine 1
- Other common effects include headache, dry mouth, dizziness, insomnia, diarrhea, and sweating 1
- Starting at 30mg for one week significantly reduces nausea risk 1
Cardiovascular Monitoring:
- Monitor blood pressure and pulse regularly during the transition 1
- Duloxetine can increase both parameters 1
Withdrawal Symptoms from Escitalopram:
- Gradual tapering over 10-14 days limits withdrawal symptoms 4
- Common discontinuation symptoms include dizziness, headache, paresthesia, irritability, and nausea 5
- Most withdrawal symptoms resolve within 7 days if they occur 5
Special Populations
Elderly or Frail Patients:
- Consider starting duloxetine at 20mg with a slower cross-taper schedule 1
- Extend the transition period to 2-3 weeks if needed
Renal Insufficiency:
- Duloxetine dosage may require adjustment in patients with kidney disease 1
- Avoid duloxetine in severe renal impairment
Common Pitfalls to Avoid
- Do not combine escitalopram at full dose with duloxetine 60mg for extended periods, as this increases serotonin syndrome risk 6
- Do not abruptly discontinue escitalopram without starting duloxetine in patients with moderate-to-severe depression, as this risks relapse 6
- Do not skip the 30mg duloxetine starting dose unless there is urgent clinical need, as this significantly increases nausea 1
- Do not forget to taper escitalopram even when using the direct switch method in patients who have been on treatment for months 4, 6