Weaning Options for Lexapro 20 mg
The FDA-approved approach is to gradually reduce the dose rather than abruptly stop, and if intolerable symptoms occur during dose reduction, resume the previous dose and then decrease more slowly. 1
Standard Tapering Protocol
Reduce the dose by 10-20% every 1-2 weeks to minimize discontinuation symptoms. 2 The FDA label specifically states that a gradual reduction is recommended whenever possible, and if intolerable symptoms emerge after a dose decrease, you should resume the previously prescribed dose and then continue decreasing at a more gradual rate. 1
Practical Tapering Schedule Options
Option 1: Standard Taper (4-6 weeks total)
- Week 1-2: Reduce to 15 mg daily 1
- Week 3-4: Reduce to 10 mg daily 1
- Week 5-6: Reduce to 5 mg daily 1
- Then discontinue 1
Option 2: Conservative Taper (8-10 weeks total)
- Weeks 1-2: Reduce to 17.5 mg daily (alternate 20 mg and 15 mg) 1
- Weeks 3-4: Reduce to 15 mg daily 1
- Weeks 5-6: Reduce to 12.5 mg daily (alternate 15 mg and 10 mg) 1
- Weeks 7-8: Reduce to 10 mg daily 1
- Weeks 9-10: Reduce to 5 mg daily 1
- Then discontinue 1
Key Pharmacokinetic Considerations
Escitalopram has a half-life of 27-33 hours and reaches steady-state in 7-10 days, which means each dose reduction requires at least 1-2 weeks for the body to equilibrate to the new level before further reduction. 3 This relatively long half-life actually makes escitalopram easier to taper than shorter half-life SSRIs like paroxetine. 4
Monitoring During Taper
Assess for discontinuation symptoms every 1-2 weeks during the taper. 1 Common discontinuation symptoms include:
- Dizziness, vertigo, or lightheadedness 1
- Nausea or gastrointestinal disturbances 1
- Headache 1
- Irritability or mood changes 1
- Sleep disturbances including vivid dreams 1
- Sensory disturbances (electric shock sensations or "brain zaps") 1
Management of Discontinuation Symptoms
If intolerable symptoms develop at any point, immediately return to the previous dose for 1-2 weeks, then resume tapering at a slower rate (reducing by 5 mg or less every 2-4 weeks). 1 The FDA label explicitly recommends this approach rather than pushing through severe symptoms. 1
Critical Pitfalls to Avoid
Do not abruptly discontinue escitalopram 20 mg without tapering. 2, 1 The guideline evidence indicates that discontinuing an antidepressant over 10-14 days limits withdrawal symptoms, but this applies to lower doses—at 20 mg, a longer taper is prudent. 2
Do not taper faster than every 1-2 weeks per dose reduction. 1, 3 Given escitalopram's 7-10 day time to steady-state, reducing doses more frequently doesn't allow adequate time to assess tolerance of each new level. 3
Do not discontinue if the patient still has active depression or anxiety symptoms requiring treatment. 1 The FDA label emphasizes that maintenance treatment should be periodically re-evaluated, but discontinuation should only occur when clinically appropriate. 1
Special Populations
For elderly patients or those with hepatic impairment, use an even more conservative taper (reducing by 5 mg or less every 2-4 weeks), as these populations may be more sensitive to dose changes. 1 The FDA recommends 10 mg/day as the standard dose for elderly patients, suggesting they may require slower tapers from higher doses. 1
Duration of Monitoring After Complete Discontinuation
Continue monitoring for discontinuation symptoms for at least 2-4 weeks after the final dose, as symptoms can emerge or persist during this period. 1 Escitalopram's relatively long half-life means complete elimination takes approximately 5-7 half-lives (roughly 6-10 days after the last dose), but neuroadaptive changes may take longer to resolve. 3