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

Lexapro 20 mg Tapering Instructions

Taper Lexapro 20 mg gradually over several weeks to months by reducing the dose by 10% of the previous dose every 2-4 weeks, eventually reaching doses as low as 1-2 mg before complete cessation to minimize withdrawal symptoms. 1, 2

Understanding Escitalopram (Lexapro) Discontinuation

• Escitalopram, like other SSRIs, is associated with a significant discontinuation syndrome when stopped abruptly or tapered too quickly 1
• Withdrawal symptoms include dizziness, fatigue, nausea, headaches, paresthesias, anxiety, irritability, insomnia, and abnormal dreams 1
• These symptoms typically appear within 1-3 days of dose reduction and can be mistaken for depression relapse, leading to unnecessary long-term medication continuation 1

Recommended Tapering Protocol for Lexapro 20 mg

Step 1: Initial Preparation

• Discuss the tapering plan with your healthcare provider before starting 1
• Avoid initiating the taper during stressful life periods 1
• Consider cognitive-behavioral therapy during tapering to increase success rates 1

Step 2: Gradual Hyperbolic Dose Reduction

The key principle is hyperbolic tapering (reducing by a percentage of the current dose, not fixed amounts), which reduces serotonin transporter occupancy linearly and minimizes withdrawal. 3

• Reduce by 10% of the previous dose every 2-4 weeks (not 10% of the original 20 mg dose) 2
• For patients on long-term therapy (years), use slower tapers of 10% per month or less 2
• Allow at least 1-2 weeks between each dose reduction 1

Sample hyperbolic tapering schedule from 20 mg:

• 18 mg daily for 2-4 weeks 2
• 16 mg daily for 2-4 weeks 2
• 14.5 mg daily for 2-4 weeks 2
• 13 mg daily for 2-4 weeks 2
• 11.5 mg daily for 2-4 weeks 2
• 10 mg daily for 2-4 weeks 1
• Continue reducing by 10% of the previous dose 2
• Final doses before cessation should be as low as 1-2 mg 3

Step 3: Monitoring Between Reductions

• Monitor for withdrawal symptoms after each dose reduction before proceeding to the next step 2
• If severe withdrawal symptoms occur, return to the previous well-tolerated dose and slow the taper further 2
• The taper may need to be paused and restarted when ready, and should be slowed once reaching low doses 1

Step 4: Final Cessation

• The final step from the lowest dose (1-2 mg) to zero may require frequency reduction rather than dose reduction 1
• Consider taking the medication every other day or every third day before complete cessation 1
• This prevents a large decrease in serotonin transporter blockade when stopped completely 3

Critical Pitfalls to Avoid

• Do not use standard "therapeutic minimum dose" tapers (e.g., 20→10→5→0 mg over 2-4 weeks) - these show minimal benefit over abrupt discontinuation and are often not tolerated 4, 3
• Do not mistake withdrawal symptoms for depression relapse - withdrawal can mimic depression and lead to unnecessary medication resumption 1
• Do not taper too quickly - successful tapering may require several months to years, especially for long-term users 1, 4
• Do not stop at 5 mg or 10 mg as the final dose - doses must go much lower (1-2 mg) to prevent severe withdrawal when completely stopped 3

Special Considerations for Long-Term Users

• Patients on Lexapro for years require much slower tapers than those on short-term therapy 2
• Some patients may prefer to taper at 10% or less of their most recent dose each month for better tolerance 5
• The first dose reduction is critical - it must go well to predict success with the rest of the taper 6

Managing Withdrawal Symptoms

• Common withdrawal symptoms include dizziness, nausea, headache, paresthesia, irritability, anxiety, and insomnia 2
• For insomnia during tapering, short-term use of non-benzodiazepine sleep aids may be beneficial 2
• If withdrawal symptoms are severe, return to the previous dose and slow the taper further 2

Duration Expectations

• Successful tapering typically requires several weeks to months, with some patients needing 6-12 months or longer 1, 4
• Tapering strips (compounded formulations allowing precise small-dose reductions) show 72% success rates when used over a median of 56 days, though many patients require multiple strips 7
• The prescribing clinician is obligated to either offer a comfortable tapering regimen or obtain agreement from another physician to provide care - "cold referrals" are inappropriate 1