Restarting Escitalopram 15mg After Missing Two Days
Direct Recommendation
Resume escitalopram 15mg immediately at your regular dose without any titration or dose adjustment. Missing two days (48 hours) of escitalopram does not require restarting at a lower dose or gradual re-titration 1, 2.
Evidence-Based Rationale
Pharmacokinetic Properties Support Immediate Resumption
- Escitalopram has an elimination half-life of 27-33 hours, meaning after missing two doses (48 hours), you still have approximately 25-37% of steady-state drug levels remaining in your system 2, 3.
- Steady-state concentrations are achieved within 7-10 days of continuous administration, so two missed doses represent only a partial decline from therapeutic levels rather than complete drug clearance 2.
- The long half-life of escitalopram provides a pharmacokinetic buffer that prevents abrupt discontinuation effects after brief interruptions 2.
FDA Labeling Guidance
- The FDA-approved prescribing information explicitly states: "If you miss a dose of Escitalopram tablets, take the missed dose as soon as you remember. If it is almost time for the next dose, skip the missed dose and take your next dose at the regular time. Do not take two doses of Escitalopram tablets at the same time." 1
- This guidance applies even when multiple doses have been missed—simply resume at your regular dose and schedule 1.
Clinical Algorithm for Resumption
Immediate Action (Today)
- Take your regular 15mg dose of escitalopram as soon as you remember, regardless of the time of day 1.
- If it is close to your next scheduled dose time (within 12 hours), take one dose now and resume your regular schedule tomorrow 1.
- Do not double your dose to "make up" for missed doses—this increases risk of side effects without therapeutic benefit 1.
Monitoring in the First Week
- Be aware that you may experience mild, transient symptoms during the first 3-7 days as drug levels re-stabilize, including:
- These symptoms typically resolve within 1-2 weeks as steady-state levels are re-established 4, 2.
When to Contact Your Provider
- If you experience severe anxiety, agitation, or mood destabilization that persists beyond 1 week 4.
- If you develop new or concerning symptoms such as confusion, muscle spasms, rapid heart rate, or high fever (signs of serotonin syndrome, though unlikely with resumption) 1.
- If depressive symptoms worsen significantly or suicidal thoughts emerge 1.
Important Caveats and Pitfalls to Avoid
Do Not Restart at a Lower Dose
- There is no clinical rationale for reducing your dose after a brief interruption—you were previously stable on 15mg, and your body has not "reset" after just 48 hours 2, 3.
- Restarting at a lower dose (e.g., 10mg) would unnecessarily delay return to therapeutic levels and prolong any withdrawal-related symptoms 2.
Distinguish Withdrawal from Relapse
- Symptoms appearing within the first 1-2 weeks after resumption are most likely transient re-equilibration effects, not relapse of your underlying condition 4.
- True relapse of depression typically develops more slowly (2-6 weeks after discontinuation) and does not improve spontaneously, whereas withdrawal symptoms resolve within 1-3 weeks 4.
Avoid Future Interruptions
- Escitalopram requires consistent daily dosing to maintain therapeutic efficacy—even brief interruptions can cause symptom fluctuations 2, 5.
- Set up medication reminders (phone alarms, pill organizers) to prevent future missed doses 5.
- If you anticipate difficulty with adherence, discuss long-term strategies with your provider, but do not alter your dosing schedule independently 5.
Expected Timeline for Re-Stabilization
- Days 1-3: You may notice mild withdrawal-like symptoms (anxiety, dizziness, nausea) as drug levels fluctuate 4, 2.
- Days 4-7: Symptoms should begin improving as steady-state levels are re-approached 2.
- Days 7-10: Full steady-state concentrations are re-established, and you should return to your baseline therapeutic response 2, 3.
Why Gradual Titration Is Not Necessary
- Gradual dose escalation is required when initiating escitalopram for the first time to minimize side effects and assess tolerability 3, 6.
- However, you have already demonstrated tolerance to 15mg daily, so your body does not need to "re-adapt" to this dose after a brief interruption 2, 3.
- The pharmacokinetic profile of escitalopram (long half-life, linear kinetics) supports immediate resumption without titration 2, 3.