How do I switch from Cymbalta (duloxetine) to Lexapro (escitalopram)?

Switching from Cymbalta (Duloxetine) to Lexapro (Escitalopram)

Use a cross-taper approach: start escitalopram 10 mg daily while maintaining your current duloxetine dose for 1 week, then gradually reduce duloxetine by 25% of the original dose every 1-2 weeks while continuing escitalopram. 1

Recommended Switching Protocol

Week 1: Initiate Cross-Taper

• Start escitalopram 10 mg once daily (standard starting dose) while maintaining your full duloxetine dose 1, 2
• This overlap period allows escitalopram to begin working while preventing withdrawal symptoms from duloxetine 1

Weeks 2-6: Gradual Duloxetine Taper

• Reduce duloxetine by 25% of the original dose every 1-2 weeks while continuing escitalopram 10 mg daily 1
• For example, if taking duloxetine 60 mg daily:
  • Week 2-3: Reduce to 45 mg daily
  • Week 4-5: Reduce to 30 mg daily
  • Week 6-7: Reduce to 15 mg daily (or discontinue from 30 mg)
  • Week 8: Complete discontinuation 1

Rationale for Gradual Taper

• Duloxetine has a short elimination half-life requiring slow discontinuation to prevent withdrawal symptoms 3
• Abrupt discontinuation can cause dizziness, headache, nausea, diarrhea, paresthesia, irritability, vomiting, insomnia, anxiety, hyperhidrosis, and fatigue 3
• A gradual dose reduction rather than abrupt cessation is recommended whenever possible 3

Monitoring and Dose Adjustment

Assess Response at 4 Weeks

• Evaluate therapeutic response to escitalopram after 4 weeks at the target dose of 10 mg 1
• If inadequate response after 4 weeks, consider increasing to 20 mg daily (maximum dose) 2
• Dose increases to 20 mg should occur after a minimum of one week at 10 mg 2

Monitor for Withdrawal Symptoms

• Watch specifically for duloxetine withdrawal effects including dizziness, headache, nausea, paresthesias, and irritability during the taper 3
• If intolerable symptoms occur, slow the taper rate or temporarily return to the previous dose 2

Critical Safety Considerations

Serotonin Syndrome Risk

• Both duloxetine and escitalopram are serotonergic agents, creating potential risk during overlap 4, 5
• Monitor closely for serotonin syndrome symptoms, especially in the first 24-48 hours after any dose changes: agitation, confusion, tremor, hyperthermia, muscle rigidity 4
• The cross-taper approach with gradual duloxetine reduction minimizes this risk compared to abrupt switching 5

MAOI Interactions

• Do not combine with MAOIs: at least 5 days must elapse after stopping duloxetine before starting an MAOI, and 14 days after stopping an MAOI before starting escitalopram 2, 3
• Avoid linezolid or IV methylene blue during the switch unless benefits clearly outweigh risks 2, 3

Blood Pressure and Cardiovascular Monitoring

• Duloxetine can cause sustained hypertension and increased pulse 4, 6
• Monitor blood pressure and pulse during the taper, as withdrawal may cause fluctuations 4
• Escitalopram has minimal cardiovascular effects but can prolong QT interval at doses >40 mg daily 4

Special Populations

Hepatic or Renal Impairment

• Avoid duloxetine in patients with chronic liver disease or cirrhosis 3
• Use caution with duloxetine in severe renal impairment (GFR <30 mL/min) 3
• Escitalopram dose of 10 mg daily is recommended for elderly patients and those with hepatic impairment 2

Expected Tolerability Differences

Duloxetine-Specific Effects That Will Resolve

• Duloxetine has noradrenergic effects (sweating, dry mouth) that escitalopram lacks 4, 6
• Anticholinergic and antihistaminic withdrawal symptoms may occur as duloxetine is tapered 1
• Nausea and dry mouth associated with duloxetine typically emerge early and may improve with the switch 6

Escitalopram-Specific Effects to Anticipate

• Escitalopram may cause diarrhea and weight gain, which tend to emerge later in treatment 6
• Escitalopram has superior tolerability with lower discontinuation rates (55% vs 62% over 8 months) 6
• Sexual dysfunction can occur with escitalopram but may be less prominent than with duloxetine 4

Common Pitfalls to Avoid

• Never abruptly stop duloxetine: This significantly increases withdrawal syndrome risk 3, 5
• Do not rush the taper: Taking 6-8 weeks for the complete switch is safer than rapid transitions 1, 5
• Do not increase escitalopram prematurely: Wait at least 4 weeks at 10 mg before considering dose escalation 1, 2
• Do not ignore withdrawal symptoms: If they occur, slow the taper rather than pushing through 2, 3