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

How to Taper Off Escitalopram 20 mg

Escitalopram 20 mg should be tapered gradually rather than stopped abruptly, with dose reductions occurring over weeks to months using a hyperbolic (percentage-based) reduction schedule, where each reduction is a percentage of the current dose rather than a fixed amount. 1, 2

Rationale for Gradual Tapering

• All SSRIs, including escitalopram, must be slowly tapered when discontinued due to the risk of withdrawal effects 3
• The FDA drug label explicitly states that "a gradual reduction in the dose rather than abrupt cessation is recommended whenever possible" 1
• Abrupt discontinuation can cause withdrawal symptoms including anxiety, insomnia, irritability, nausea, headache, and dizziness 1
• Short tapers of 2-4 weeks show minimal benefits over abrupt discontinuation and are often not tolerated by patients 2

Recommended Tapering Schedule

For a patient on escitalopram 20 mg, reduce by 10-25% of the current dose every 2-4 weeks, with smaller reductions as you approach lower doses:

• Week 0-2: Reduce from 20 mg to 15 mg (25% reduction) 2
• Week 2-4: Reduce from 15 mg to 12.5 mg (approximately 17% reduction) 2
• Week 4-6: Reduce from 12.5 mg to 10 mg (20% reduction) 2
• Week 6-8: Reduce from 10 mg to 7.5 mg (25% reduction) 2
• Week 8-10: Reduce from 7.5 mg to 5 mg (33% reduction) 2
• Week 10-12: Reduce from 5 mg to 2.5 mg (50% reduction) 2
• Week 12-14: Reduce from 2.5 mg to 1.25 mg (50% reduction) 2
• Week 14-16: Stop completely 2

This hyperbolic tapering approach reduces the biological effect on serotonin transporter inhibition in a linear manner, minimizing withdrawal symptoms 2.

Alternative Slower Taper for Long-Term Users

For patients who have been on escitalopram for years or who are particularly sensitive to dose changes, consider an even slower taper of 10% per month:

• This may require several months to a year to complete 2
• Each reduction should be 10% of the most recent dose, not the original dose 2
• Some patients may prefer to taper at 5-10% of their most recent dose each month 4

Monitoring and Managing Withdrawal Symptoms

Monitor for withdrawal symptoms at each dose reduction:

• Acute withdrawal symptoms include anxiety, insomnia, tremor, irritability, nausea, headache, dizziness, and sensory disturbances 1, 2
• Protracted withdrawal may include dysphoria, irritability, insomnia, anhedonia, or a vague sense of being unwell that can persist for months after complete discontinuation 3

If intolerable symptoms occur:

• Resume the previously prescribed dose and allow symptoms to stabilize 1
• Subsequently, decrease the dose at a more gradual rate 1
• Consider extending the time between dose reductions to 4-6 weeks 5
• Consider smaller dose reductions (5% instead of 10%) 5

Adjunctive Medications for Withdrawal Symptoms

Consider symptomatic treatments as needed:

• Trazodone or mirtazapine for insomnia 6
• NSAIDs or acetaminophen for headaches and muscle aches 6
• Anti-nausea medications for gastrointestinal symptoms 6

Critical Pitfalls to Avoid

• Do not taper too quickly - the standard 2-4 week taper recommended in many older guidelines is often insufficient 2, 7
• Do not use fixed-dose reductions - percentage-based reductions are more physiologically appropriate 2, 4
• Do not mistake withdrawal symptoms for relapse - withdrawal can mimic the original condition and may lead to unnecessary long-term medication 2, 7
• Do not abandon the patient - if they struggle with the taper, consider pausing at a stable dose rather than pushing forward 5
• Do not stop at the "minimum therapeutic dose" - tapering should continue to very small doses before complete cessation 2

Follow-Up Schedule

• Schedule appointments every 2-4 weeks during the taper to assess for withdrawal symptoms and potential relapse 5
• Document baseline symptoms and functioning before initiating the taper 5
• Continue monitoring for several months after complete discontinuation for protracted withdrawal symptoms 6
• Be prepared to adjust the tapering schedule based on individual patient response 5, 1

Special Considerations

• Escitalopram has a half-life of 27-33 hours, which means steady-state changes occur within 7-10 days of each dose adjustment 8
• The elimination half-life supports the feasibility of once-daily dosing adjustments during tapering 8
• Patient agreement and collaboration are essential - ensure the patient understands the plan and knows they can request slower tapering if needed 5