What is the recommended tapering schedule for discontinuing Lexapro (escitalopram) in an adult?

How to Taper Off Lexapro (Escitalopram)

Reduce escitalopram by 10% of the current dose every 2-4 weeks using a hyperbolic tapering schedule, extending the taper over several months to minimize withdrawal symptoms, and monitor closely after each reduction before proceeding further. 1

Recommended Tapering Protocol

Use a hyperbolic tapering approach where you reduce the dose by smaller absolute amounts as you approach lower doses, rather than linear reductions. 1, 2 This method accounts for the fact that serotonin transporter occupancy decreases hyperbolically with dose reductions, meaning small dose changes at lower doses have larger biological effects than the same absolute reduction at higher doses. 2

Specific Tapering Schedule

• Reduce by 10% of the current dose every 2-4 weeks as the standard approach. 1
• For patients on long-term therapy or those at higher risk for withdrawal, slow the taper to 10% reductions every 4-6 weeks or even monthly. 1, 3
• Continue tapering to doses well below the therapeutic minimum (below 5 mg) before complete discontinuation, as withdrawal symptoms can occur even when stopping very low doses. 2

Stabilization Between Reductions

• Wait 2-4 weeks at each new dose before proceeding with the next reduction to allow stabilization and assessment for withdrawal symptoms. 1
• Contact patients within 1 week of each dose reduction and schedule formal follow-up every 2-4 weeks during active tapering. 1

Managing Withdrawal Symptoms

Escitalopram discontinuation syndrome occurs frequently and can include dizziness (44% of cases), muscle tension (44%), chills (44%), confusion or trouble concentrating (40%), amnesia (28%), crying (28%), insomnia, flu-like symptoms, mood disturbances, and paresthesias. 4, 5

If Intolerable Symptoms Emerge

• Return to the previous well-tolerated dose immediately and stabilize for 2-4 weeks before attempting further reduction. 1, 6, 5
• Slow the taper further by reducing increments to smaller amounts (e.g., 5% of current dose) and extending time between reductions to 4-6 weeks or longer. 1
• Do not push forward with the taper if symptoms are severe—this approach leads to higher failure rates and unnecessary suffering. 5

Symptomatic Management

• For specific withdrawal symptoms, use adjunctive medications as needed (e.g., short-term non-benzodiazepine sleep aids for insomnia). 3
• Symptoms can last days to months, with different symptoms having different durations. 5

Duration of Tapering

• Minimum tapering duration: 2-3 months for patients on short-term therapy. 3
• Extended tapering: 6-12 months for patients on long-term therapy or those at higher risk. 1, 3, 2
• The FDA label recommends "a gradual reduction in the dose rather than abrupt cessation" whenever possible. 6
• Recent evidence demonstrates that slower tapering over months is associated with lower relapse rates compared to rapid tapers over weeks. 3, 2

High-Risk Patients Requiring Slower Tapers

Patients on higher doses and those with lower drug clearance are at significantly higher risk for discontinuation syndrome. 4

• Elderly patients: Consider even slower tapers with smaller dose reductions and more frequent monitoring due to altered drug clearance. 1
• Patients on doses above 10 mg: Higher treatment doses are associated with significantly increased risk of withdrawal symptoms. 4
• Long-duration users: Those on escitalopram for extended periods require longer taper durations. 1, 3

Monitoring Strategy

During Active Tapering

• Assess for withdrawal symptoms after each dose reduction before proceeding to the next step. 1, 6
• Schedule follow-up every 2-4 weeks during active tapering. 1
• Document at each visit: current dose and duration, presence and severity of withdrawal symptoms, patient's functional status and quality of life, and plan for next reduction or decision to pause. 1

After Complete Discontinuation

• Continue monitoring for 2-4 weeks after complete discontinuation, as symptoms can emerge late. 1
• If symptoms re-emerge after complete discontinuation, consider restarting at the last effective dose. 3

Common Pitfalls to Avoid

• Avoid rapid tapers over 2-4 weeks down to therapeutic minimum doses only—guidelines recommending this approach show minimal benefit over abrupt discontinuation and are often not tolerated. 2
• Do not stop at 5 mg or 10 mg as the final dose before discontinuation—taper to much lower doses (2.5 mg, 1.25 mg, or lower) before complete cessation. 2
• Do not confuse withdrawal symptoms with relapse of depression—withdrawal syndrome can be mistaken for recurrence, leading to unnecessary long-term medication. 2
• Do not use fixed-duration tapers for all patients—individualize based on risk factors, with higher-risk patients requiring slower approaches. 1, 4

Special Considerations

The elimination half-life of escitalopram is 27-33 hours, with steady-state achieved within 7-10 days, which informs the timing between dose reductions. 7 Escitalopram exhibits linear pharmacokinetics in the 10-30 mg/day dose range. 7