What is the best way to taper off cipralex (escitalopram)?

Tapering Off Cipralex (Escitalopram)

Taper escitalopram gradually over weeks to months using dose reductions of approximately 10-25% of the current dose every 1-4 weeks, extending down to very low doses (well below the 10mg therapeutic minimum) before complete discontinuation to minimize withdrawal symptoms. 1, 2, 3

Critical Safety Framework

• Never stop escitalopram abruptly, as this causes discontinuation syndrome with symptoms including dysphoric mood, irritability, agitation, dizziness, sensory disturbances (electric shock sensations/paresthesias), anxiety, confusion, headache, lethargy, emotional lability, insomnia, and hypomania 1
• Withdrawal symptoms are generally self-limiting but can be severe and may last days to months, with different symptoms having different durations 1, 2
• These symptoms should not be automatically interpreted as relapse of the underlying depression or anxiety disorder 4

Recommended Tapering Protocol

Standard Taper Approach

• Reduce by 10-25% of the current dose (not the original dose) every 1-4 weeks, adjusting the rate based on patient tolerance 2, 3
• For patients on escitalopram longer than several months, consider slower tapers extending over months rather than the inadequate 2-4 week tapers recommended in older guidelines 3
• The taper rate must be determined by the patient's ability to tolerate reductions, not by a rigid schedule 2

Hyperbolic Tapering for Optimal Results

• Recent evidence supports hyperbolic (exponential) dose reductions rather than linear reductions, as this maintains more consistent serotonin transporter occupancy and minimizes withdrawal 3
• Taper down to doses much lower than the 10mg therapeutic minimum before complete cessation—this may mean reducing to 5mg, then 2.5mg, then 1.25mg or lower 3, 4
• The final stages of tapering (lowest doses) are when withdrawal symptoms most commonly emerge and should proceed most slowly 4

Practical Example

For a patient on escitalopram 10mg daily:

• Week 0-2: Reduce to 7.5mg daily (25% reduction)
• Week 3-6: Reduce to 5mg daily (33% of current dose)
• Week 7-10: Reduce to 3.75mg daily (25% of current dose)
• Week 11-14: Reduce to 2.5mg daily (33% of current dose)
• Week 15-18: Reduce to 1.25mg daily (50% of current dose)
• Week 19-22: Discontinue completely

This timeline may need to be extended to months depending on patient tolerance 2, 3

Managing Withdrawal Symptoms

Common Discontinuation Symptoms to Monitor

• Flu-like symptoms: fatigue, myalgias, headache 5
• Sensory disturbances: paresthesias, "electric shock" sensations (brain zaps) 5, 1
• Sleep disturbances: insomnia, vivid dreams 5
• Gastrointestinal symptoms: nausea, vomiting, diarrhea 5
• Mood changes: anxiety, irritability, dysphoria 1
• Dizziness and confusion 1, 2

Symptomatic Management

• Over-the-counter analgesics (NSAIDs, acetaminophen) for headache and myalgias 5
• Antiemetics for nausea 5
• Sleep hygiene measures for insomnia 5
• If symptoms become intolerable, restart the previous dose and taper even more slowly (reduce by smaller increments or extend the time between reductions) 2

Duration of Withdrawal

• Acute SSRI withdrawal symptoms typically resolve within 1-2 weeks after onset 5
• Protracted withdrawal syndrome can occur where symptoms (dysphoria, irritability, insomnia, anhedonia, vague sense of being unwell) persist for months after discontinuation 5
• Protracted withdrawal can be mistaken for psychiatric relapse—distinguish by timing and symptom pattern 5

Special Considerations

Risk Factors for Severe Withdrawal

• Longer duration of treatment increases likelihood and severity of discontinuation symptoms 5
• Patients on higher doses may experience more pronounced withdrawal 2
• Previous history of discontinuation symptoms predicts future difficulty 2

Monitoring Requirements

• Monitor for suicidal thoughts and behaviors, especially during initial tapering phases and at times of dosage changes, particularly in patients under age 25 1
• Assess for return of original psychiatric symptoms versus withdrawal symptoms 5
• Follow up regularly (at minimum every 2-4 weeks) during the taper, with more frequent contact during difficult phases 2

Patient Education

• Provide clear, balanced information about expected withdrawal symptoms to normalize the process and reduce nocebo effects 4
• Reassure patients that withdrawal symptoms, while uncomfortable, are not dangerous and will resolve 4
• Counsel patients that symptoms do not necessarily indicate relapse of their underlying condition 5, 4

Critical Pitfalls to Avoid

• Never use the outdated 2-4 week taper to therapeutic minimum doses—these show minimal benefit over abrupt discontinuation and are often not tolerated 3
• Do not reduce by fixed amounts (e.g., 5mg every week)—always reduce by a percentage of the current dose to avoid disproportionately large final reductions 3
• Do not stop at the 10mg therapeutic minimum—taper to much lower doses before complete cessation 3, 4
• Never abandon the patient if tapering is unsuccessful—maintain the therapeutic relationship and consider maintenance therapy at a reduced dose as a legitimate outcome 2

When to Refer to Specialist

• Patients with history of severe withdrawal symptoms from previous taper attempts 2
• Unstable psychiatric comorbidities or emergence of suicidal ideation during tapering 1
• Co-occurring substance use disorders 2
• Protracted withdrawal syndrome lasting beyond several months 5