What can be used to decrease tremors caused by Lexapro (escitalopram)?

Management of Lexapro-Induced Tremors

Beta-blockers, specifically propranolol, are the first-line pharmacological treatment for tremors caused by Lexapro (escitalopram), with typical starting doses of 10-20mg twice daily and maximum benefit usually achieved between 160-320mg/day. 1, 2, 3

Understanding the Mechanism

• SSRIs like escitalopram commonly cause tremor as a dose-related adverse effect through serotonergic mechanisms that enhance physiological tremor 4, 1
• Tremors from SSRIs typically manifest as postural tremors affecting the hands and arms, though jaw tremors have also been reported with related medications like citalopram 5
• The American Academy of Family Physicians recognizes sweating, tremors, and nervousness as typical side effects across the entire SSRI drug class 4, 1

Treatment Algorithm

Step 1: Assess Severity and Timing

• If tremor occurred early in treatment or after a dose increase, consider dose reduction or slower up-titration as the initial strategy 1
• Evaluate whether the patient is on a dose above 20mg daily (the FDA-approved maximum), as higher doses increase side effect risk 6

Step 2: Pharmacological Management

Propranolol (First-Line)

• Start with 10-20mg twice daily and titrate upward as needed 3
• Maximum tremor suppression typically occurs between 160-320mg/day, with doses above this rarely providing additional benefit 7
• Monitor for contraindications including asthma, severe COPD, heart block, or bradycardia 3

Alternative Beta-Blockers

• Other beta-blockers can be considered if propranolol is not tolerated, though propranolol has the strongest evidence base 8, 3

Second-Line Options (if beta-blockers contraindicated or ineffective)

• Primidone: effective for tremor control 3
• Gabapentin: can reduce tremor amplitude 3
• Benzodiazepines: may provide modest benefit but carry dependency risk 3

Step 3: Dose Optimization of Escitalopram

• If tremor persists despite propranolol and the patient is on 20mg or higher, gradually taper escitalopram by 5mg every 1-2 weeks to minimize discontinuation symptoms 6
• Consider augmentation strategies rather than exceeding 20mg daily, such as adding bupropion or mirtazapine (though note these can also cause tremor) 4, 6
• Alternatively, switch to an SNRI like venlafaxine or duloxetine, though these also carry tremor risk through similar mechanisms 1, 6

Critical Pitfalls to Avoid

• Do not abruptly discontinue escitalopram without tapering over 10-14 days, as this causes withdrawal symptoms 4
• Do not combine multiple serotonergic medications without careful monitoring, as this increases risk of serotonin syndrome (which includes tremor as a symptom but requires immediate hospitalization) 1
• Do not exceed propranolol 320mg/day expecting additional tremor benefit, as higher doses increase side effects without improving efficacy 7
• Do not overlook cardiac monitoring if propranolol doses exceed 160mg/day, particularly in elderly patients 3

Special Considerations

• Elderly patients are more susceptible to medication side effects and may require lower starting doses of both escitalopram and propranolol 4, 6
• Approximately 63% of patients on SSRIs experience at least one adverse effect, so tremor should be anticipated and proactively discussed 1
• If the patient has cardiac risk factors, obtain an ECG before initiating propranolol and monitor QT interval if escitalopram dose is near or at maximum 6