Switching from Lexapro 20mg to Zoloft
Use a direct cross-taper approach: start sertraline at 50mg daily while continuing escitalopram 20mg, then after 1-2 weeks reduce escitalopram to 10mg for 1-2 weeks, and finally discontinue escitalopram completely. 1, 2
Why This Approach Works
Escitalopram's pharmacokinetic profile makes switching straightforward. Unlike shorter-acting SSRIs such as paroxetine, escitalopram has minimal discontinuation syndrome risk and can be tapered relatively quickly without significant withdrawal symptoms. 3 The drug has a half-life that provides natural buffering against abrupt discontinuation effects, though not as long as fluoxetine's 4-6 day half-life. 1
Step-by-Step Switching Protocol
Week 1-2: Initiate Cross-Taper
- Start sertraline 50mg once daily while maintaining escitalopram 20mg daily. 1, 2
- Monitor for initial sertraline side effects including nausea, dizziness, increased sweating, and insomnia during this overlap period. 1
- This overlap allows sertraline to begin exerting therapeutic effects before reducing escitalopram. 2
Week 3-4: Reduce Escitalopram
- Decrease escitalopram from 20mg to 10mg daily (50% reduction) while continuing sertraline 50mg. 1
- Continue monitoring for discontinuation symptoms, though these are less common with escitalopram than with paroxetine or sertraline itself. 3
- Assess tolerability of sertraline at this dose before proceeding. 1
Week 5: Complete the Switch
- Discontinue escitalopram completely while maintaining sertraline 50mg. 1
- After 1-2 weeks at sertraline 50mg monotherapy, the dose can be titrated upward by 50mg increments at weekly intervals based on clinical response and tolerability, up to a maximum of 200mg daily. 3, 4
Critical Monitoring Parameters
Watch for serotonin syndrome during the overlap period, particularly in the first 24-48 hours after any dose changes, as both medications are serotonergic agents. 3 Signs include agitation, confusion, tremor, hyperreflexia, diaphoresis, and in severe cases, hyperthermia and muscle rigidity. 5
Monitor for sertraline-specific side effects including gastrointestinal symptoms (nausea, diarrhea), sexual dysfunction, and potential drug interactions via CYP2D6 inhibition, though this is less pronounced than with paroxetine. 3, 6
Assess for discontinuation symptoms from escitalopram including dizziness, fatigue, headaches, irritability, and sensory disturbances, though these are significantly less common than with paroxetine or sertraline discontinuation. 3
Dosing Considerations
The typical therapeutic range for sertraline is 50-200mg daily, with most patients responding to 100-150mg daily. 4, 7 In comparative trials, sertraline at mean doses of 144-150mg daily showed equivalent efficacy to escitalopram 10mg daily. 4
Sertraline has a shorter half-life than escitalopram, requiring once-daily dosing but making it more susceptible to discontinuation syndrome if later stopped abruptly. 3 This is an important counseling point for future medication management.
Common Pitfalls to Avoid
Do not stop escitalopram abruptly before starting sertraline. While escitalopram has lower discontinuation syndrome risk than paroxetine, abrupt cessation can still cause withdrawal symptoms and leaves a gap in antidepressant coverage. 3, 1
Do not rush the titration of sertraline. Starting at 50mg allows assessment of tolerability before increasing to higher therapeutic doses. 3, 4
Do not ignore the potential for drug-drug interactions. Sertraline inhibits CYP2D6 (though less than paroxetine) and should be used cautiously with other medications metabolized by this pathway. 3, 6
Avoid combining with MAOIs or other highly serotonergic agents during the switch, as this significantly increases serotonin syndrome risk. 3
Expected Timeline for Response
Clinical improvement should be evident within 4-6 weeks of reaching therapeutic sertraline doses. 2 Both escitalopram and sertraline have comparable efficacy profiles, with response rates of 70-75% and remission rates of 65-77% in head-to-head trials. 4, 7