Escitalopram

1. Introduction

Escitalopram is a selective serotonin reuptake inhibitor (SSRI) used to treat depression and anxiety disorders. It works by increasing serotonin levels in the brain, improving mood and reducing symptoms of anxiety. Escitalopram is favoured for its high selectivity for serotonin transporters and relatively fewer side effects compared to other antidepressants.

2. Indications

  • Approved Indications:
    • Major depressive disorder (MDD).
    • Generalised anxiety disorder (GAD).
    • Panic disorder.
    • Social anxiety disorder (social phobia).
    • Obsessive-compulsive disorder (OCD).
  • Off-Label Uses:
    • Premenstrual dysphoric disorder (PMDD).
    • Post-traumatic stress disorder (PTSD).

3. Dosage

  • Adults:
    • Major depressive disorder and GAD: Start with 10 mg once daily; increase to 20 mg daily after 1–2 weeks if needed. Maximum: 20 mg/day.
    • Panic disorder: Start with 5 mg once daily for the first week, then increase to 10 mg daily. Maximum: 20 mg/day.
  • Elderly:
    • Start with 5 mg once daily; maximum dose: 10 mg/day.
  • Children and Adolescents (≥12 years):
    • Start with 10 mg once daily; increase to 20 mg/day if necessary for major depressive disorder.

4. Administration

  • Take orally once daily, with or without food.
  • Preferably take at the same time each day (morning or evening).

5. Forms Available

  • Tablets: 5 mg, 10 mg, 20 mg.
  • Oral solution: 5 mg/5 mL.

6. Side Effects

6.1. Common Side Effects

  • Nausea.
  • Dry mouth.
  • Insomnia or somnolence.
  • Dizziness.
  • Fatigue.

6.2. Less Common Side Effects

  • Decreased libido or sexual dysfunction.
  • Increased sweating.
  • Weight changes (typically weight gain).

6.3. Rare but Serious Side Effects

  • Suicidal ideation or behaviour (especially in young adults during the initial weeks of treatment).
  • Serotonin syndrome (e.g., confusion, agitation, rapid heart rate, high blood pressure).
  • QT prolongation (dose-dependent).

7. Warnings

  • Suicidal Risk: Increased risk of suicidal thoughts and behaviours in children, adolescents, and young adults during the first few weeks of therapy. Monitor closely.
  • QT Prolongation: Risk increases at higher doses (e.g., 20 mg/day) or in patients with predisposing factors.
  • Serotonin Syndrome: Can occur when combined with serotonergic drugs (e.g., other SSRIs, MAOIs, or triptans).

8. Precautions

  • Avoid abrupt discontinuation to prevent withdrawal symptoms such as irritability, dizziness, and headache.
  • Use cautiously in patients with bipolar disorder to avoid triggering mania.
  • Monitor for worsening anxiety or restlessness during initial treatment, as activation symptoms may occur.

9. Interactions

  • Drug-Drug Interactions:
    • Monoamine oxidase inhibitors (MAOIs): Contraindicated; risk of serotonin syndrome.
    • NSAIDs and anticoagulants: Increased risk of bleeding.
    • CYP2C19 inhibitors (e.g., omeprazole): May increase escitalopram levels.
    • Alcohol: May worsen side effects such as drowsiness.
  • Drug-Food Interactions:
    • No significant interactions, but avoid alcohol to minimise adverse effects.

10. Monitoring Parameters

  • Monitor mood improvement and reduction in anxiety symptoms.
  • Check for suicidal thoughts or behaviours, especially during the first few weeks.
  • Monitor ECG for QT prolongation in patients at risk.
  • Assess for signs of serotonin syndrome in patients on serotonergic drugs.

11. Use in Children

  • Approved for major depressive disorder in children aged 12 years and older. Monitor closely for suicidal ideation and behavioural changes.

12. Use in Pregnancy

  • Category C: Use only if benefits outweigh risks. SSRIs, including escitalopram, are associated with potential risks such as neonatal withdrawal syndrome and persistent pulmonary hypertension of the newborn (PPHN).

13. Use in Elderly

  • Start at the lowest effective dose (5 mg daily) due to increased sensitivity to side effects like hyponatraemia and QT prolongation.

14. Use in Kidney Disease

  • No dose adjustment required in mild to moderate renal impairment.
  • Use with caution in severe renal impairment (eGFR <15 mL/min).

15. Use in Liver Disease

  • Start with 5 mg once daily in patients with hepatic impairment; maximum dose: 10 mg/day.

16. Patient Counselling Points

  • Take escitalopram daily as prescribed, even if you feel better. Do not skip doses.
  • Inform your doctor if you experience worsening depression, suicidal thoughts, or unusual changes in behaviour.
  • Avoid alcohol while taking escitalopram, as it can increase drowsiness and other side effects.
  • Report symptoms of serotonin syndrome, such as confusion, rapid heartbeat, or fever, immediately.
  • Be patient, as it may take 2–4 weeks to notice improvement in symptoms.

17. Table of Brand Names, Manufacturers, and Prices

Brand NameManufacturerPrice (USD)
LexaproLundbeck/Forest Labs$200–250 (30 tablets, 10 mg)
CipralexLundbeck$150–200 (30 tablets, 10 mg)
Generic EscitalopramVarious$10–30 (30 tablets, 10 mg)

18. FAQs (15 Questions)

  1. What is escitalopram used for?
    It is used to treat depression, anxiety, panic disorders, and other related conditions.
  2. How does escitalopram work?
    It increases serotonin levels in the brain by inhibiting its reuptake, improving mood and reducing anxiety.
  3. How long does escitalopram take to work?
    Symptom improvement may be seen within 1–2 weeks, but full effects may take 4–6 weeks.
  4. Can escitalopram cause weight changes?
    It may cause weight gain or, less commonly, weight loss.
  5. What are the common side effects of escitalopram?
    Nausea, dizziness, dry mouth, and fatigue are common side effects.
  6. Can I stop taking escitalopram abruptly?
    No, stopping suddenly may cause withdrawal symptoms. Taper off gradually under medical supervision.
  7. Can escitalopram cause sexual dysfunction?
    Yes, decreased libido and difficulty achieving orgasm are possible side effects.
  8. Is escitalopram safe during pregnancy?
    It should only be used if the benefits outweigh the risks. Consult your doctor before use.
  9. Does escitalopram interact with alcohol?
    Alcohol can worsen side effects like drowsiness and should be avoided.
  10. What should I do if I miss a dose?
    Take it as soon as you remember, but skip it if it’s close to the next dose. Do not double up.
  11. Can escitalopram cause suicidal thoughts?
    It may increase the risk of suicidal thoughts, especially in young adults during the initial weeks.
  12. Does escitalopram cause drowsiness?
    It may cause drowsiness in some individuals, while others may experience insomnia.
  13. How should escitalopram be stored?
    Store at room temperature, away from moisture and heat.
  14. Can children take escitalopram?
    Yes, it is approved for major depressive disorder in children aged 12 and older, but they should be monitored closely.
  15. How long can escitalopram be taken?
    It can be taken long-term under medical supervision, as required by the condition being treated.