Restarting Lexapro After Discontinuation
Yes, restarting escitalopram at 10mg is appropriate and follows FDA-approved dosing guidelines for patients resuming treatment after a period of discontinuation. 1
Recommended Dosing Strategy
Start at 10mg once daily, which is the standard initial dose for both major depressive disorder and generalized anxiety disorder. 1 The FDA label explicitly states that 10mg once daily is the recommended starting dose for adults, regardless of previous treatment history. 1
Rationale for 10mg Starting Dose
The 10mg dose has demonstrated effectiveness in controlled trials and represents the therapeutic threshold for most patients. 1 While your patient previously tolerated 20mg, restarting at the lower dose minimizes the risk of early adverse effects such as agitation, nausea, or behavioral activation that can occur when initiating or restarting SSRI therapy. 2
Escitalopram reaches steady-state concentrations within 7-10 days, with an elimination half-life of 27-33 hours. 3 Since the patient has been off medication, there is no residual drug effect, making this functionally equivalent to a new start.
Dose Escalation Timeline
If clinical response is inadequate after a minimum of one week at 10mg, increase to 20mg once daily. 1 However, allowing 4-6 weeks at 10mg before considering dose escalation is more clinically prudent, as full therapeutic response may take 4-8 weeks. 4
Evidence Supporting Gradual Titration
Studies demonstrate that both 10mg and 20mg doses are effective, though the 20mg dose showed statistically significant superiority in some anxiety disorder trials. 5, 4 The Japanese study referenced in guidelines showed that 20mg produced greater reduction in anxiety symptoms compared to placebo, while sensitivity analyses suggested benefit at both doses. 5
Slow up-titration minimizes early adverse effects, particularly in patients who may have heightened sensitivity after a treatment gap. 2 Most adverse events (nausea, fatigue, somnolence) are mild to moderate and emerge within the first few weeks, then typically diminish. 4
Monitoring and Follow-up
Evaluate treatment response every 2-4 weeks during the first 8-12 weeks after restarting. 5 Use standardized anxiety or depression rating scales to objectively track symptom improvement. 5
Key Monitoring Points
Watch for early behavioral activation or increased anxiety in the first 2-4 weeks, which may require temporary dose reduction or supportive management. 2
If inadequate response persists after 8 weeks at 20mg, consider switching to an SNRI (venlafaxine) or another SSRI (sertraline) rather than exceeding the FDA-approved maximum dose. 5
Common Pitfalls to Avoid
Do not restart at 20mg immediately. While the patient previously tolerated this dose, the risk-benefit ratio favors starting at 10mg to minimize discontinuation due to early adverse effects. 1
Do not rush dose escalation. Allow adequate time (at least 4-6 weeks) at 10mg to assess full therapeutic benefit before increasing. 4, 1
Ensure once-daily dosing compliance. Escitalopram's favorable half-life permits once-daily administration, which improves adherence. 3