What is the recommended tapering schedule for a patient taking 5mg of escitalopram (Lexapro)?

Tapering 5mg Escitalopram

For a patient on 5mg escitalopram, reduce the dose by 25% (to approximately 3.75mg) every 1-2 weeks initially, then slow to 10% reductions as you approach lower doses, with a total taper duration of at least 4 weeks or longer. 1

Specific Tapering Schedule for 5mg

• Week 1-2: Reduce from 5mg to 3.75mg (25% reduction) 1
• Week 3-4: Reduce from 3.75mg to approximately 2.8mg (25% reduction of current dose) 1
• Week 5-6: Reduce from 2.8mg to approximately 2.5mg (10% reduction as approaching lower levels) 1
• Week 7-8: Reduce from 2.5mg to approximately 2.25mg (10% reduction) 1
• Week 9-10: Reduce from 2.25mg to approximately 2mg (10% reduction) 1
• Continue with 10% reductions every 1-2 weeks until complete discontinuation 1

Critical Principles

Use hyperbolic (percentage-based) tapering rather than linear tapering - this means reducing by a percentage of the current dose, not the original dose, which prevents disproportionately large final reductions that trigger severe withdrawal. 1, 2

• The hyperbolic approach is superior because it reduces the biological effect at serotonin transporters in a linear manner, minimizing withdrawal symptoms 2
• Research demonstrates that standard short tapers (2-4 weeks) show minimal benefits over abrupt discontinuation and are often not tolerated 2

Avoiding Common Pitfalls

Never use alternate-day dosing when tapering escitalopram, as this creates pronounced fluctuations in receptor occupancy that significantly increase withdrawal risk, even at low doses. 3

• Escitalopram has a half-life of 27-33 hours, and skipping days causes receptor occupancy variation that triggers withdrawal symptoms 3, 4
• Maintain daily dosing throughout the entire taper 3

Managing the Taper

The taper rate must be determined by the patient's tolerance, not a rigid schedule - pause the taper if withdrawal symptoms emerge. 1

• Monitor patients at least monthly during the taper, with more frequent contact during difficult phases 1
• Common withdrawal symptoms include dizziness, muscle tension, chills, confusion, amnesia, and emotional lability 5
• Higher doses and lower clearance of escitalopram increase ADS risk, making very slow tapering essential for all patients 5

Practical Considerations

Since 5mg is already half the starting dose recommended in adolescent guidelines (10mg starting dose) 6, you are working with a relatively low dose that still requires careful tapering:

• Escitalopram reaches steady-state in 7-10 days, so allow at least this interval between dose reductions 4
• Consider using liquid formulations or compounded preparations to achieve precise smaller doses below 2.5mg 1
• The final doses before complete cessation may need to be very small (potentially <1mg) to prevent a large decrease in serotonin transporter occupancy 2

Monitoring Requirements

• Assess for withdrawal symptoms after each dose reduction before proceeding 1
• If severe withdrawal symptoms occur, return to the previous well-tolerated dose and slow the taper further 1
• Never abandon the patient during tapering - maintain frequent follow-up throughout the process 1