What can be added to Lexapro (escitalopram) 20 mg po daily for increased anxiety?

Management of Breakthrough Anxiety on Lexapro 20 mg Daily

Before adding another medication, first optimize the current escitalopram regimen by ensuring adequate duration (4-8 weeks minimum at current dose) and confirming medication adherence, as escitalopram 20 mg is within the therapeutic range and has demonstrated efficacy for anxiety disorders. 1

Initial Assessment

• Verify treatment duration: Escitalopram requires 4-8 weeks for full therapeutic effect in anxiety disorders, with some parameters improving within 1-2 weeks 2
• Confirm the 20 mg dose is appropriate: Studies demonstrate escitalopram 10-20 mg/day is effective for generalized anxiety disorder, with 20 mg not significantly superior to 10 mg in controlled trials 3
• Rule out medication non-adherence before considering augmentation strategies 1

First-Line Augmentation Strategy

If anxiety persists after adequate trial duration, bupropion is the optimal augmentation choice due to its demonstrated efficacy and favorable interaction profile with escitalopram 1:

Bupropion Augmentation Protocol

• Starting dose: 37.5 mg every morning 4, 1
• Titration: Increase by 37.5 mg every 3 days as tolerated 4
• Target dose: 150 mg twice daily 4, 1
• Timing: Give second dose before 3 PM to minimize insomnia risk 4, 1
• Assessment timeframe: Evaluate response after 4-6 weeks of combined therapy 1

Advantages of Bupropion

• Minimal drug interactions: Escitalopram has the least effect on CYP450 isoenzymes compared to other SSRIs, resulting in low interaction risk with bupropion 4, 1
• Activating properties: Can help with energy levels and potentially address anxiety when combined with an SSRI 1
• No sexual dysfunction: Unlike adding another serotonergic agent 1

Critical Contraindications

• Absolute contraindication: Seizure disorders 4, 1
• Caution: Agitated patients may not tolerate the activating effects 4

Alternative Augmentation Option

Mirtazapine may be considered as a second-line alternative, particularly if the patient has comorbid insomnia or poor appetite 1:

• Starting dose: 7.5 mg at bedtime 4, 1
• Maximum dose: 30 mg at bedtime 4, 1
• Advantages: Lower rates of sexual dysfunction, promotes sleep and appetite, well tolerated 4, 1

Critical Safety Considerations

Avoid Combining Multiple Serotonergic Agents

• Serotonin syndrome risk: Combining escitalopram with another SSRI, SNRI, or serotonergic medication significantly increases risk of serotonin syndrome 4
• Symptoms to monitor: Mental status changes, neuromuscular hyperactivity (tremors, clonus, hyperreflexia), autonomic hyperactivity (hypertension, tachycardia, diaphoresis) 4
• Onset: Symptoms can arise within 24-48 hours after combining medications 4

Benzodiazepines Are Not Recommended for Long-Term Management

• While buspirone (starting 5 mg twice daily, maximum 20 mg three times daily) may be useful for mild-to-moderate agitation, it requires 2-4 weeks to become effective 4
• Benzodiazepines should be avoided for chronic anxiety management due to dependence risk 4

Monitoring Parameters

• Close monitoring: Especially in the first months of treatment and following dosage adjustments 4
• Behavioral activation: Monitor for motor/mental restlessness, insomnia, impulsiveness, particularly early in treatment or with dose increases 4
• Standardized assessment tools: Use validated scales to monitor anxiety symptoms and treatment response 1