How to switch a patient from Lexapro (escitalopram) 20 mg daily to Zoloft (sertraline)?

Switching from Lexapro 20 mg to Zoloft

For a patient on escitalopram (Lexapro) 20 mg daily switching to sertraline (Zoloft), perform a direct switch by stopping escitalopram and starting sertraline 50 mg the next day, as both are SSRIs with similar mechanisms and no washout period is required. 1

Switching Strategy

Direct Switch Approach

• Stop escitalopram 20 mg and start sertraline 50 mg the following day 1, 2
• Direct switching between SSRIs is well-tolerated and avoids the risk of untreated depression during a washout period 1
• No tapering of escitalopram is necessary when switching to another SSRI, as both medications work through similar serotonergic mechanisms 2

Rationale for Direct Switch

• Escitalopram has negligible effects on cytochrome P450 enzymes and low drug interaction potential, making direct switching safe 3
• The conservative approach (gradual taper with washout) takes longer and includes periods without treatment, risking life-threatening exacerbations of depression 1
• Direct switching is easier and avoids compliance issues associated with complex tapering schedules 4

Sertraline Dosing

Initial Dose

• Start sertraline at 50 mg daily 2
• This is the standard starting dose for adults switching from another antidepressant 2

Dose Titration

• If inadequate response after 4 weeks, increase sertraline to 100 mg daily 3, 4
• Maximum dose of sertraline is 200 mg daily if needed for treatment response 2
• Increase in 50 mg increments every 1-2 weeks based on tolerability and response 2

Monitoring Protocol

Early Follow-up

• Contact patient within 1 week to assess tolerability and adherence 3
• Monitor for new or worsening side effects during the transition 1
• Watch for signs of serotonin syndrome, though risk is low with SSRI-to-SSRI switches 3

Response Assessment

• Assess treatment response at 4 weeks 3, 4
• If response is inadequate at 4 weeks, consider dose escalation 3
• Full therapeutic effect may take 6-8 weeks 4

Important Caveats

What NOT to Do

• Do not combine escitalopram and sertraline - there is no indication for co-administration and this increases serotonin syndrome risk 1
• Do not use a washout period between these two SSRIs - this is only necessary when switching to/from MAOIs 2
• Do not taper escitalopram unless the patient has been on it for many years at high doses and you're concerned about discontinuation symptoms 1

Discontinuation Symptoms

• While direct switching minimizes risk, some patients may experience mild discontinuation symptoms from escitalopram (dizziness, headache, irritability) 1
• These typically resolve within days as sertraline reaches therapeutic levels 1
• If discontinuation symptoms are severe, consider briefly overlapping medications for 3-5 days, though this is rarely necessary 2

When to Use Alternative Strategies

• If the patient is on other serotonergic medications (triptans, tramadol, other antidepressants), exercise additional caution and monitor closely for serotonin syndrome 3
• For patients with history of severe discontinuation symptoms from prior antidepressant switches, consider a brief 3-5 day cross-taper 2