The question of how long before surgery should Lexapro be stopped does not have a single, universal answer. It requires a careful risk-benefit analysis performed by the patient in close consultation with their healthcare team, including the prescribing physician, surgeon, and anesthesiologist. For most surgeries, evidence often points toward continuing the medication, but this depends heavily on the type of procedure, the patient's overall health, and the severity of their mental health condition.
The Lexapro-Surgery Dilemma: Risk vs. Risk
For patients on long-term Lexapro (escitalopram), the decision involves weighing two primary risks: continuing the medication versus discontinuing it.
Risk of Continuing Lexapro
SSRI medications like Lexapro can potentially increase the risk of bleeding during and after surgery. This is because serotonin plays a role in platelet function, and SSRIs can reduce the amount of serotonin available in platelets, thereby inhibiting their aggregation. This anti-platelet effect has led to concerns about increased hemorrhage risk in surgical patients. However, studies on this topic have yielded inconsistent and often inconclusive results, and the magnitude of the risk is debated. A 2013 analysis of over 530,000 surgical patients found that SSRI use was associated with an approximate 10% increased risk of adverse outcomes like bleeding and transfusion, though the study acknowledged that patients on SSRIs often have other risk factors. For most common surgeries, many experts now believe this risk is relatively low.
Risk of Stopping Lexapro
Stopping Lexapro abruptly can be dangerous and lead to a set of symptoms known as Antidepressant Discontinuation Syndrome (ADS). The acronym FINISH summarizes common ADS symptoms: Flu-like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbances (e.g., "brain zaps"), and Hyperarousal. The sudden return or worsening of the underlying depression or anxiety is also a major concern, potentially compromising the patient's psychological stability before, during, and after a stressful event like surgery. A relapse of the psychiatric condition could severely impact the patient's ability to cope with recovery and follow post-operative instructions.
Expert Consensus: When to Continue or Pause
For many years, some physicians advised patients to stop SSRIs before surgery to mitigate bleeding risks. However, based on the current understanding of the risks, medical consensus has shifted. For most elective, non-invasive procedures, continuing Lexapro is often the safest and most recommended approach to avoid discontinuation syndrome and relapse.
Exceptions or special considerations may apply to specific situations:
- High-bleeding-risk procedures: For surgeries with a high potential for blood loss (e.g., major orthopedic or breast procedures), a physician may still recommend a pre-surgical taper.
- Specific drug combinations: If the patient is also on other blood-thinning medications like NSAIDs, warfarin, or anticoagulants, the overall bleeding risk increases.
- Individual patient factors: The patient's sensitivity to medication changes, the duration of their treatment, and the severity of their condition must all be taken into account.
The Importance of a Gradual Tapering Plan
Abruptly stopping Lexapro is universally discouraged due to the high risk of severe withdrawal symptoms. If discontinuation is deemed necessary, a gradual, medically supervised tapering plan is essential. The FDA label for Lexapro explicitly recommends a gradual reduction in dose. Your healthcare provider will create a personalized schedule based on your current dosage, duration of use, and response to previous medication adjustments.
A Shared Decision: Your Role in the Process
Making the right decision about your medication requires open communication with all members of your healthcare team. You should be prepared to discuss your complete medical history, including all prescription and over-the-counter medications, supplements, and herbal products. The following table compares the considerations involved:
| Consideration | Continuing Lexapro | Discontinuing Lexapro |
|---|---|---|
| Bleeding Risk | Potentially slightly increased risk, though magnitude is often inconclusive and procedure-dependent. | Risk of SSRI-related bleeding eliminated, but other factors may still increase risk. |
| Psychological Stability | Maintains mood stability and prevents relapse of depression or anxiety. | High risk of Antidepressant Discontinuation Syndrome (ADS) and relapse of underlying condition. |
| Perioperative Complications | Low risk of drug-drug interactions with standard anesthetics. | ADS symptoms like confusion, dizziness, and nausea could be misdiagnosed as other post-op issues. |
| Preparation | No special preparation required beyond a full medication history. | Requires a weeks-long tapering process to avoid withdrawal. |
Key Questions to Ask Your Doctors
- What are the specific risks of bleeding associated with my planned procedure and current Lexapro dose?
- Given my personal and medical history, is the risk of withdrawal syndrome a more significant concern than the potential for increased bleeding?
- What is the specific tapering schedule you recommend, if any?
- Who will be responsible for managing my mental health in the perioperative period?
- Are there any alternative methods, pharmacological or non-pharmacological, to manage my anxiety in the days leading up to surgery?
Conclusion
There is no fixed schedule for how long before surgery should Lexapro be stopped. Instead, it is a highly individualized decision that should be made collaboratively with your medical team. For most patients and procedures, the risks associated with abrupt discontinuation and potential relapse of mental illness often outweigh the minimal bleeding risks linked to continued use. Always communicate transparently with your healthcare providers and follow their guidance on whether to continue, taper, or stop your medication. The patient's well-being—both physical and mental—is the ultimate priority.
For more information on the management of medications before surgery, patients can refer to trusted medical resources like the American College of Surgeons guidance on medication and surgery.
