Is tapering required when switching from escitalopram (Lexapro) to bupropion (Wellbutrin)?

Switching from Escitalopram to Bupropion: Tapering Recommendations

Direct Answer

Yes, gradual tapering of escitalopram is required when switching to bupropion to minimize withdrawal symptoms and ensure safe transition. SSRIs like escitalopram should always be slowly tapered when discontinued due to the risk of withdrawal effects 1.

Recommended Cross-Tapering Protocol

Week 1-2: Initiate Taper

• Reduce escitalopram by 25% of the original dose (e.g., from 10mg to 7.5mg daily) 2
• Do not start bupropion yet during this initial reduction phase
• Monitor for early withdrawal symptoms including dizziness, anxiety, irritability, and nausea 2

Week 3-4: Continue Taper and Introduce Bupropion

• Reduce escitalopram by another 25% of the original dose (e.g., from 7.5mg to 5mg daily) 2
• Begin bupropion at low starting dose (typically 150mg SR once daily)
• This overlap period allows bupropion to begin taking effect while escitalopram is still providing some coverage

Week 5-6: Further Reduction

• Reduce escitalopram by another 25% of the original dose (e.g., from 5mg to 2.5mg daily) 2
• Increase bupropion to target therapeutic dose if tolerated (typically 300mg SR daily, maximum 450mg/day) 3

Week 7-8: Complete Discontinuation

• Discontinue escitalopram completely 2
• Maintain bupropion at therapeutic dose

Critical Evidence Supporting Gradual Tapering

Why Tapering Matters

• Abrupt discontinuation of SSRIs frequently causes withdrawal syndrome that can be severe and may compel patients to restart medication 4
• Short tapers of 2-4 weeks down to therapeutic minimum doses show minimal benefits over abrupt discontinuation and are often not tolerated 4
• Tapers over months and down to doses much lower than minimum therapeutic doses have shown greater success in reducing withdrawal symptoms 4

Specific Concerns with Escitalopram

• Escitalopram has a relatively short half-life compared to fluoxetine, making gradual tapering more important 5
• Alternate-day dosing (taking medication every other day) should be avoided as it causes pronounced increases in receptor occupancy variation and likely increases withdrawal risk 6
• Withdrawal symptoms may include dizziness, nausea, fatigue, sensory disturbances, anxiety, agitation, and irritability 5

Monitoring During Transition

Withdrawal Symptoms to Watch For

• Somatic symptoms: dizziness and light-headedness, nausea and vomiting, fatigue, myalgia, chills, flu-like symptoms, sensory and sleep disturbances 5
• Psychological symptoms: anxiety and/or agitation, crying spells, irritability 5
• Monitor for these symptoms at each clinical contact during the 4-6 week minimum transition period 2

Managing Withdrawal Symptoms

• If withdrawal symptoms become severe during tapering, slow the taper by returning to the previous dose before attempting a more gradual reduction 2
• Mild symptoms can often be managed by reassuring the patient that they are usually transient 5
• For more severe symptoms, it may be necessary to reinstitute the previous dosage and slow the rate of taper 5

Common Pitfalls to Avoid

Do Not Use Alternate-Day Dosing

• Avoid dosing escitalopram every other day when tapering, as this creates large fluctuations in serotonin transporter occupancy and increases withdrawal risk 6
• Instead, use daily dosing at progressively lower doses

Do Not Rush the Taper

• The American Academy of Child and Adolescent Psychiatry recommends a 4-6 week minimum transition period for most patients 2
• Abrupt discontinuation of escitalopram should be avoided as it can trigger severe withdrawal symptoms 2

Do Not Start Bupropion at Full Dose Too Early

• Starting bupropion at full therapeutic dose while still on higher doses of escitalopram should be avoided to reduce the risk of adverse effects 2
• Gradual introduction of bupropion allows for better tolerability assessment

Special Considerations

When Switching is Appropriate

• Guidelines indicate no significant differences in efficacy between various switch strategies, including switching from SSRIs to bupropion 1
• The decision to switch should be based on lack of response or tolerability issues with escitalopram

Serotonin Syndrome Risk

• While the risk of serotonin syndrome is low with this specific combination, monitor for confusion, agitation, muscle rigidity, and hyperthermia during the overlap period 2
• Bupropion does not significantly affect serotonin, making this combination relatively safe during cross-tapering

Alternative Approach for Severe Symptoms

• If the patient experiences severe depression symptoms during the taper, consider a longer overlap period where both medications are continued at therapeutic doses for 1-2 weeks before beginning the escitalopram taper
• This ensures continuous antidepressant coverage but requires careful monitoring