Escitalopram (Lexi-Drugs)

ALERT: US Boxed Warning
  Suicidality and antidepressant drugs:
Pronunciation

(es sye TAL oh pram)

Brand Names: US

Lexapro

Brand Names: Canada

ACH-Escitalopram; ACT Escitalopram ODT; ACT Escitalopram [DSC]; AG-Escitalopram; APO-Escitalopram; Auro-Escitalopram; Cipralex; Cipralex Meltz [DSC]; JAMP-Escitalopram; M-Escitalopram; Mar-Escitalopram; MINT-Escitalopram; MYLAN-Escitalopram; NAT-Escitalopram; NRA-Escitalopram; PHARMA-Escitalopram; PMS-Escitalopram; Priva-Escitalopram; RAN-Escitalopram; RIVA-Escitalopram; SANDOZ Escitalopram; TEVA-Escitalopram

Dosing: Adult

Note: Some experts suggest lower starting doses of 5 mg/day and lower titration increments of 5 mg in patients sensitive to adverse effects, particularly in patients with anxiety who are generally more sensitive to overstimulation effects (eg, anxiety, insomnia) with antidepressants (Hirsch 2018c; WFSBP [Bandelow 2012]).

Binge eating disorder (off-label use): Based on limited data: Oral: Initial: 10 mg once daily; may increase based on response and tolerability in 10 mg increments at intervals ≥1 week up to 30 mg/day (Guerdjikova 2008).

Body dysmorphic disorder (off-label use): Based on limited data: Oral: Initial: 10 mg once daily; may increase dose gradually based upon response and tolerability in increments of 10 mg at intervals of every 2 to 3 weeks to 30 mg/day by week 6 to 10 (Phillips 2016; Phillips 2019). Some experts suggest usual doses of 40 mg/day and that in some patients for optimal response doses up to 60 mg/day may be necessary; however, ECGs are recommended at every 10 mg dosing increment above 30 mg/day (eg, at 40 mg/day, 50 mg/day, 60 mg/day) and then as clinically indicated (Phillips 2019). Note: An adequate trial for assessment of effect in BDD is 12 to 16 weeks, including maximum tolerated doses for at least 3 to 4 of those weeks (Phillips 2019).

Bulimia nervosa (alternative agent) (off-label use): Based on limited data; recommendations based on expert opinion: Oral: Initial: 10 mg once daily; may increase dose based on response and tolerability in increments of 10 mg at intervals ≥1 week. Maximum dose: 30 mg/day (Crow 2018).

Generalized anxiety disorder: Oral: Initial: 10 mg once daily; dose may be increased after ≥1 week based on response and tolerability to a maximum of 20 mg once daily.

Major depressive disorder (unipolar): Oral: Initial: 10 mg once daily; dose may be increased in 10 mg increments after ≥1 week based on response and tolerability up to a maximum dose of 20 mg once daily (according to the manufacturer’s labeling); however, doses up to 30 mg/day are used in practice and may provide further benefit (Wade 2011).

Obsessive-compulsive disorder (OCD) (off-label use): Oral: Initial: 10 mg once daily; dose may be increased in 10 mg increments at intervals ≥1 week up to 40 mg once daily (Fineberg 2007; Shim 2011). Higher doses up to ~60 mg/day have been evaluated in open-label trials and may be considered in refractory patients; however, adverse effects may be increased (Rabinowitz 2008; Shim 2011). Note: An adequate trial for assessment of effect in OCD is considered to be ≥6 weeks at maximum tolerated dose (Issari 2016).

Panic disorder (off-label use): Oral: Initial: 5 mg once daily for 3 to 7 days, then increase dose to 10 mg once daily (APA 2009; Stahl 2003). May further increase at intervals ≥1 week to 20 mg once daily based on response and tolerability; mean dose in a clinical trial was ~10 mg once daily (Stahl 2003).

Posttraumatic stress disorder (off-label use): Oral: Initial: 10 mg once daily; may gradually increase dose (4-week intervals used in some trials) based on response and tolerability up to 40 mg once daily (Qi 2017; Robert 2006). Some experts suggest dose titrations of 5 to 10 mg increments every 1 to 4 weeks (Hirsch 2018c).

Premature ejaculation (off-label use): Based on limited data; recommendations based on expert opinion: Oral: Initial: 10 mg once daily; may increase dose based on response and tolerability at intervals of ~3 to 4 weeks up to 20 mg once daily (Khera 2018).

Premenstrual dysphoric disorder (off-label use):

Continuous daily dosing regimen: Based on limited data; recommendations based on expert opinion: Oral: Initial: 5 to 10 mg once daily; over the first month, may increase dose based on response and tolerability to 20 mg once daily (Casper 2018).

Intermittent regimens:

Luteal phase dosing regimen: Oral: 5 to 10 mg once daily during the luteal phase of menstrual cycle (beginning therapy 14 days before anticipated onset of menstruation and continued to the onset of menses); over the first month, may increase dose to 20 mg once daily during the luteal phase (Casper 2018; Freeman 2005).

Symptom-onset dosing regimen: Oral: 5 to 10 mg once daily from the day of symptom-onset until a few days after the start of menses; over the first month, may increase dose based on response and tolerability to 20 mg once daily (Casper 2018; Freeman 2005).

Vasomotor symptoms associated with menopause (alternative agent) (off-label use): Note: Nonhormonal alternative in patients unable or unwilling to take estrogen (AACE [Goodman 2011]). Oral: Initial: 10 mg once daily, increase to 20 mg once daily after 4 weeks if symptoms not adequately controlled (Carpenter 2012; Freeman 2011; NAMS 2015).

Discontinuation of therapy:When discontinuing antidepressants, gradually taper the dose (eg, over 2 to 4 weeks) to minimize the incidence of withdrawal symptoms and allow for the detection of re-emerging symptoms (APA 2010; WFSBP [Bauer 2015]); antidepressants with a shorter half-life may need to be tapered more slowly (APA 2010) (eg, over 4 weeks [Hirsch 2018a]). If intolerable withdrawal symptoms occur following a dose reduction, resume the previously prescribed dose and/or decrease dose at a more gradual rate (Shelton 2001). Select patients (eg, those with a history of discontinuation syndrome) on long-term treatment (>6 months) may benefit from tapering over >3 months (WFSBP [Bauer 2015]). Evidence supporting ideal taper rates is limited (Shelton 2001; WFSBP [Bauer 2015]).

Switching antidepressants: Evidence for ideal antidepressant switching strategies is limited; strategies include cross-titration (gradually discontinuing the first antidepressant while at the same time gradually increasing the new antidepressant) and direct switch (abruptly discontinuing the first antidepressant and then starting the new antidepressant at an equivalent dose or lower dose and increasing it gradually). Cross-titration (eg, over 1 to 4 weeks depending upon sensitivity to discontinuation symptoms and adverse effects) is standard for most switches, but is contraindicated when switching to or from an MAOI. A direct switch may be an appropriate approach when switching to another agent in the same or similar class (eg, when switching between two SSRIs), when the antidepressant to be discontinued has been used for <1 week, or when the discontinuation is for adverse effects. When choosing the switch strategy, consider the risk of discontinuation symptoms, potential for drug interactions, other antidepressant properties (eg, half-life, adverse effects, and pharmacodynamics), and the degree of symptom control desired (Hirsch 2018b; Ogle 2013; WFSBP [Bauer 2013]).

Switching to or from an MAOI:

Allow 14 days to elapse between discontinuing an MAOI and initiation of escitalopram.

Allow 14 days to elapse between discontinuing escitalopram and initiation of an MAOI.

Dosing: Geriatric

Major depressive disorder (unipolar); generalized anxiety disorder: Oral: 10 mg once daily; lower initial doses of 5 mg once daily have been suggested for depression (VA/DoD 2016).

Discontinuation of therapy: Refer to adult dosing.

Switching antidepressants: Refer to adult dosing.

Dosing: Renal Impairment: Adult

Mild to moderate impairment: No dosage adjustment is necessary

Severe impairment: CrCl <20 mL/minute: Use with caution.

Dosing: Hepatic Impairment: Adult

10 mg once daily

Dosing: Pediatric

Depression: Oral:

Children <12 years: Limited data available; only one randomized, placebo-controlled trial has been published; efficacy was not demonstrated for children <12 years of age (Wagner 2006)

Children and Adolescents ≥12 years: Initial: 10 mg once daily; may be increased to 20 mg/day after at least 3 weeks

Autism and Pervasive Developmental Disorders (PDD): Limited data available: Oral: Children and Adolescents 6 to 17 years: Initial: 2.5 mg once daily; may increase if needed to 5 mg/day after 1 week; may then increase at weekly intervals by 5 mg/day if needed and as tolerated; maximum dose: 20 mg/day. Dosing based on a prospective, 10-week, open-labeled, forced dose-titration trial of 28 children and adolescents 6 to 17 years of age (mean age: 10.4 years) (Owley 2005). Mean severity outcome scores showed significant improvement; mean final dose: 11.1 ± 6.5 mg/day (range: 0 to 20 mg/day); no significant correlation between final tolerated dose and weight was shown; 10 of 28 treated subjects could not tolerate a 10 mg/day dose

Social anxiety disorder: Limited data available: Oral: Children and Adolescents 10-17 years: Initial: 5 mg once daily for 7 days, then 10 mg/day for 7 days; may then increase at weekly intervals by 5 mg/day if needed, based on clinical response and tolerability; maximum dose: 20 mg/day. Dosing based on a prospective, 12-week, open-labeled trial of 20 children and adolescents 10-17 years of age (mean age: 15 years) (Isolan 2007). At the end of the 12 weeks, 65% of patients met overall response criteria and all symptomatic and quality of life outcome measures showed significant improvements; mean final dose: 13 ± 4.1 mg/day

Discontinuation of therapy: Upon discontinuation of antidepressant therapy, gradually taper the dose to minimize the incidence of withdrawal symptoms and allow for the detection of reemerging symptoms. Evidence supporting ideal taper rates is limited. APA and NICE guidelines suggest tapering therapy over at least several weeks with consideration to the half-life of the antidepressant; antidepressants with a shorter half-life may need to be tapered more conservatively. In addition for long-term treated patients, WFSBP guidelines recommend tapering over 4 to 6 months. If intolerable withdrawal symptoms occur following a dose reduction, consider resuming the previously prescribed dose and/or decrease dose at a more gradual rate (APA 2010; Bauer 2002; Haddad 2001; NCCMH 2010; Schatzberg 2006; Shelton 2001; Warner 2006).

MAO inhibitor recommendations:

Switching to or from an MAO inhibitor intended to treat psychiatric disorders:

Allow 14 days to elapse between discontinuing an MAO inhibitor intended to treat psychiatric disorders and initiation of escitalopram.

Allow 14 days to elapse between discontinuing escitalopram and initiation of an MAO inhibitor intended to treat psychiatric disorders.

Use with other MAO inhibitors (linezolid or IV methylene blue):

Do not initiate escitalopram in patients receiving linezolid or IV methylene blue; consider other interventions for psychiatric condition.

If urgent treatment with linezolid or IV methylene blue is required in a patient already receiving escitalopram and potential benefits outweigh potential risks, discontinue escitalopram promptly and administer linezolid or IV methylene blue. Monitor for serotonin syndrome for 2 weeks or until 24 hours after the last dose of linezolid or IV methylene blue, whichever comes first. May resume escitalopram 24 hours after the last dose of linezolid or IV methylene blue.

Dosing: Renal Impairment: Pediatric

Children ≥12 years and Adolescents:

Mild-to-moderate impairment: No dosage adjustment needed.

Severe impairment: CrCl <20 mL/minute: Use with caution.

Dosing: Hepatic Impairment: Pediatric

Children ≥12 years and Adolescents: Depression: Maximum daily dose: 10 mg/day

Use: Labeled Indications

Major depressive disorder (unipolar): Acute and maintenance treatment of unipolar major depressive disorder (MDD)

Generalized anxiety disorder: Acute treatment of generalized anxiety disorder (GAD)

Use: Off-Label: Adult

  Binge eating disorderLevel of Evidence [C, G]

Data from a limited number of patients studied suggest that escitalopram may be beneficial to improve weight loss, severity of illness, binge frequency, and binge days in patients with binge eating disorder Ref.

Based on the World Federation of Societies of Biological Psychiatry guidelines for the pharmacological treatment of eating disorders, escitalopram may be effective and is recommended in the management of binge eating disorder.

  Body dysmorphic disorderLevel of Evidence [C]

Data from a limited number of patients studied suggest that escitalopram may be beneficial for the treatment of symptoms (including depression, insight, and psychosocial functioning) and prevention of relapse associated with body dysmorphic disorder Ref.

  Bulimia nervosaLevel of Evidence [G]

Based on the World Federation of Societies of Biological Psychiatry guidelines for the pharmacological treatment of eating disorders, SSRIs including fluoxetine and fluvoxamine are effective and recommended in the management of bulimia nervosa. Based on clinical experience some experts also recommend use of escitalopram as an alternative option for patients who do not respond to or tolerate fluoxetine Ref.

  Obsessive-compulsive disorder (OCD)Level of Evidence [A, G]

Data from a randomized, double-blind, placebo-controlled trial and a relapse prevention trial support the use of escitalopram in the treatment of OCD Ref.

Based on the American Psychiatric Association guidelines for the treatment of obsessive-compulsive disorder and the World Federation of Societies of Biological Psychiatry guidelines for the treatment of anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder, selective serotonin reuptake inhibitors (SSRIs) such as escitalopram are first-line for the treatment of OCD.

  Panic disorderLevel of Evidence [B, G]

Data from a double-blind, randomized, parallel-group, flexible-dose, placebo-controlled, multicenter study and an open-label trial support the use of escitalopram in the treatment of panic disorder Ref.

Based on the American Psychiatric Association guidelines for the treatment of panic disorder and the World Federation of Societies of Biological Psychiatry guidelines for the treatment of anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder, escitalopram is effective and recommended in the management of panic disorder.

  Posttraumatic stress disorder (PTSD)Level of Evidence [C, G]

Data from a limited number of patients suggest that escitalopram may be beneficial for the treatment of PTSD Ref.

Based on the American Psychiatric Association guidelines for the treatment of acute stress and PTSD, SSRIs are effective and recommended as first-line treatment for PTSD. The guidelines provide no recommendations specific to escitalopram because at the time of publication, no escitalopram studies were published; however, clinical consensus suggests SSRIs are equivalent in efficacy. Based on the World Federation of Societies of Biological Psychiatry guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder, and PTSD in primary care, SSRIs such as escitalopram are first-line for the treatment of PTSD. Access Full Off-Label Monograph

  Premature ejaculationLevel of Evidence [G]

According to the International Society for Sexual Medicine guidelines, SSRIs such as escitalopram are effective and recommended in the management of premature ejaculation; however, evidence supporting escitalopram is limited.

  Premenstrual dysphoric disorderLevel of Evidence [A, G]

Data from a randomized, placebo-controlled study support the use of escitalopram in the treatment of premenstrual dysphoric disorder during the luteal phase Ref. Data from a small randomized, parallel-group, double-blind trial also suggest benefits for symptom-based dosing Ref.

Based on the International Society for Premenstrual Disorders auditable standards for diagnosis and management of premenstrual disorder, SSRIs are effective and recommended in the management of premenstrual dysphoric disorder Ref.

  Vasomotor symptoms associated with menopauseLevel of Evidence [B, G]

Data from a randomized, double-blind, placebo-controlled trial support the use of escitalopram in the treatment of vasomotor symptoms (hot flashes) in peri- or postmenopausal women Ref.

Based on the American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE) position statement on menopause, the Endocrine Society guideline on the treatment of menopause symptoms, and the North American Menopause Society (NAMS) position statement on nonhormonal management of menopause-associated vasomotor symptoms, SSRIs (including escitalopram) are effective and recommended alternatives for the management of vasomotor symptoms associated with menopause in patients with contraindications to hormonal therapy or who prefer not to use hormonal therapy. Based on the American Cancer Society/American Society of Clinical Oncology (ACS/ASCO) breast cancer survivorship care guideline, SSRIs may be used to help mitigate vasomotor symptoms of premature menopause in women previously treated for breast cancer. Access Full Off-Label Monograph

Level of Evidence Definitions
  Level of Evidence Scale
Clinical Practice Guidelines

Anxiety Disorders:

American Psychiatric Association, “Practice Guideline for the Treatment of Patients with Panic Disorder,” 2009

World Federation of Societies of Biological Psychiatry (WFSBP), “Guidelines for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorders, First Revision,” 2008

World Federation of Societies of Biological Psychiatry (WFSBP), “Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder in primary care,” 2012

Bipolar Disorder:

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD), “Collaborative Update of CANMAT Guidelines for the Management of Patients with Bipolar Disorder – Update 2013,” February 2013

World Federation of Societies of Biological Psychiatry (WFSBP), “Guidelines for the Biological Treatment of Bipolar Disorders: Update 2009 on the Treatment of Acute Mania,” 2009

World Federation of Societies of Biological Psychiatry (WFSBP), “Guidelines for the Biological Treatment of Bipolar Disorders: Update 2010 on the Treatment of Acute Bipolar Depression,” 2010

World Federation of Societies of Biological Psychiatry (WFSBP), “Guidelines for the Biological Treatment of Bipolar Disorders: Update 2012 on the Long-term Treatment of Bipolar Disorder,” 2013

Depression:

American Academy of Child and Adolescent Psychiatry, Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders, 2007.

American Psychiatric Association, Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition, May 2010

Canadian Network for Mood and Anxiety Treatments (CANMAT), “Clinical Guidelines for the Management of Major Depressive Disorder in Adults,” October 2009

National Collaborating Centre for Mental Health (NCCMH), “Depression: The NICE Guideline on the Treatment and Management of Depression in Adults (Updated Edition).” 2010.

World Federation of Societies of Biological Psychiatry (WFSBP), “Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 1: Update 2013 on the Acute and Continuation Treatment of Unipolar Depressive Disorders,” 2013.

World Federation of Societies of Biological Psychiatry (WFSBP), “Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 2: Maintenance Treatment of Major Depressive Disorder and Treatment of Chronic Depressive Disorders and Subthreshold Depressions,” 2002.

Eating Disorders:

World Federation of Societies of Biological Psychiatry (WFSBP), “Guidelines for the Pharmacological Treatment of Eating Disorders,” 2011

Hot Flashes:

Endocrine Society (ES), Treatment of Symptoms of the Menopause, 2015

North American Menopause Society (NAMS), Nonhormonal management of menopause-associated vasomotor symptoms, 2015

Obsessive-Compulsive Disorder:

American Psychiatric Association, “Practice Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder,” 2007

World Federation of Societies of Biological Psychiatry (WFSBP), “Guidelines for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorders, First Revision,” 2008

World Federation of Societies of Biological Psychiatry (WFSBP), “Guidelines for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorder in Primary Care,” 2012

Premature Ejaculation:

International Society of Sexual Medicine, “An update of the International Society of Sexual Medicine’s guidelines for the diagnosis and treatment of premature ejaculation (PE),” 2014

Post Traumatic Stress Disorder (PTSD):

American Psychiatric Association, “Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder,” 2004

American Psychiatric Association, “Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder,” Guideline Watch (March 2009)

World Federation of Societies of Biological Psychiatry (WFSBP), “Guidelines for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorders, First Revision,” 2008

World Federation of Societies of Biological Psychiatry (WFSBP), “Guidelines for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorder in Primary Care,” 2012

Administration: Oral

Administer once daily (morning or evening), with or without food.

Administration: Pediatric

Oral: Administer once daily (morning or evening); may be administered with or without food.

Storage/Stability

Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F).

Medication Patient Education with HCAHPS Considerations

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience nausea, dizziness, diarrhea, constipation, dry mouth, insomnia, sweating a lot, flu-like signs, headache, loss of strength and energy, fatigue, rhinorrhea, or yawning. Have patient report immediately to prescriber signs of depression (suicidal ideation, anxiety, emotional instability, or confusion), agitation, panic attacks, mood changes, behavioral changes, signs of low sodium (headache, difficulty focusing, memory impairment, confusion, weakness, seizures, or change in balance), signs of bleeding (vomiting blood or vomit that looks like coffee grounds; coughing up blood; hematuria; black, red, or tarry stools; bleeding from the gums; abnormal vaginal bleeding; bruises without a reason or that get bigger; or any severe or persistent bleeding), seizures, chills, sexual dysfunction, decreased libido, vision changes, eye pain, eye redness, eye edema, signs of serotonin syndrome (dizziness, severe headache, agitation, hallucinations, tachycardia, abnormal heartbeat, flushing, tremors, sweating a lot, change in balance, severe nausea, or severe diarrhea), or priapism (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.

Medication Safety Issues
  Sound-alike/look-alike issues:
  Geriatric Patients: High-Risk Medication:
  International issues:
Medication Guide and/or Vaccine Information Statement (VIS)

An FDA-approved patient medication guide, which is available with the product information and at http://www.accessdata.fda.gov/drugsatfda_docs/label/2017/021323s047lbl.pdf#page=24, must be dispensed with this medication.

Contraindications

Hypersensitivity to escitalopram, citalopram, or any component of the formulation; use of MAO inhibitors intended to treat psychiatric disorders (concurrently or within 14 days of discontinuing either escitalopram or the MAO inhibitor); initiation of escitalopram in a patient receiving linezolid or intravenous methylene blue; concurrent use of pimozide

Canadian labeling: Additional contraindications (not in US labeling): Known QT-interval prolongation or congenital long QT syndrome

Warnings/Precautions

Major psychiatric warnings:

• Suicidal thinking/behavior: [US Boxed Warning]: Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 to 24 years of age) with major depressive disorder (MDD) and other psychiatric disorders; consider risk prior to prescribing. Short-term studies did not show an increased risk in patients >24 years of age and showed a decreased risk in patients ≥65 years. Closely monitor patients for clinical worsening, suicidality, or unusual changes in behavior, particularly during the initial 1 to 2 months of therapy or during periods of dosage adjustments (increases or decreases); the patient’s family or caregiver should be instructed to closely observe the patient and communicate condition with health care provider. A medication guide concerning the use of antidepressants should be dispensed with each prescription. Escitalopram is not FDA approved for use in children <12 years of age.

• The possibility of a suicide attempt is inherent in major depression and may persist until remission occurs. Worsening depression and severe abrupt suicidality that are not part of the presenting symptoms may require discontinuation or modification of drug therapy. Use caution in high-risk patients during initiation of therapy.

• Prescriptions should be written for the smallest quantity consistent with good patient care. The patient’s family or caregiver should be alerted to monitor patients for the emergence of suicidality and associated behaviors such as anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia, hypomania, and mania; patients should be instructed to notify their health care provider if any of these symptoms or worsening depression or psychosis occur.

Concerns related to adverse effects:

• Bleeding risk: Use with caution in patients who are hemodynamically unstable. May impair platelet aggregation resulting in increased risk of bleeding events (including GI bleeding), particularly if used concomitantly with aspirin, NSAIDs, warfarin, or other anticoagulants. Bleeding related to SSRI or SNRI use has been reported to range from relatively minor bruising and epistaxis to life-threatening hemorrhage.

• Cardiovascular effects: Use has been associated with dose-dependent QT interval prolongation with doses of 10 mg and 30 mg/day in healthy subjects (mean change from baseline: 4.3 msec and 10.7 msec, respectively); prolongation of QT interval and ventricular arrhythmia (including torsades de pointes) have been reported, particularly in females with preexisting QT prolongation or other risk factors (eg, hypokalemia, other cardiac disease).

• CNS depression: Has a low potential to impair cognitive or motor performance; caution operating hazardous machinery or driving.

• Fractures: Bone fractures have been associated with antidepressant treatment. Consider the possibility of a fragility fracture if an antidepressant-treated patient presents with unexplained bone pain, point tenderness, swelling, or bruising (Rabenda 2013; Rizzoli 2012).

• Ocular effects: May cause mild pupillary dilation which in susceptible individuals can lead to an episode of narrow-angle glaucoma. Consider evaluating patients who have not had an iridectomy for narrow-angle glaucoma risk factors

• Serotonin syndrome: Potentially life-threatening serotonin syndrome (SS) has occurred with serotonergic agents (eg, SSRIs, SNRIs), particularly when used in combination with other serotonergic agents (eg, triptans, TCAs, fentanyl, lithium, tramadol, buspirone, St John’s wort, tryptophan) or agents that impair metabolism of serotonin (eg, MAO inhibitors intended to treat psychiatric disorders, other MAO inhibitors [ie, linezolid and intravenous methylene blue]). Monitor patients closely for signs of SS such as mental status changes (eg, agitation, hallucinations, delirium, coma); autonomic instability (eg, tachycardia, labile blood pressure, diaphoresis); neuromuscular changes (eg, tremor, rigidity, myoclonus); GI symptoms (eg, nausea, vomiting, diarrhea); and/or seizures. Discontinue treatment (and any concomitant serotonergic agent) immediately if signs/symptoms arise.

• Sexual dysfunction: May cause or exacerbate sexual dysfunction.

• SIADH and hyponatremia: SSRIs and SNRIs have been associated with the development of SIADH; hyponatremia has been reported rarely (including severe cases with serum sodium <110 mmol/L), predominately in the elderly. Hyponatremia is reversible with discontinuation of treatment. Volume depletion and/or concurrent use of diuretics likely increases risk.

Disease-related concerns:

• Cardiovascular disease: Patients with a recent history of MI or unstable heart disease were excluded from clinical trials; use with caution.

• Hepatic impairment: Use with caution in patients with hepatic impairment; clearance is decreased and plasma concentrations are increased; a lower dosage may be needed.

• Mania/hypomania: May precipitate a shift to mania or hypomania in patients with bipolar disorder. Monotherapy in patients with bipolar disorder should be avoided. Patients presenting with depressive symptoms should be screened for bipolar disorder. Escitalopram is not FDA approved for the treatment of bipolar depression.

• Metabolic disease: Use with caution; limited data in patients with altered metabolism.

• Renal impairment: Use with caution in patients with severe renal impairment.

• Seizure disorders: Use with caution in patients with a previous seizure disorder or condition predisposing to seizures such as brain damage or alcoholism.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• CYP2C19 poor metabolizers: Escitalopram systemic exposure may be increased in CYP2C19 poor metabolizers.

• Elderly: Bioavailability and half-life are increased by 50% in the elderly.

Dosage form specific issues:

• Propylene glycol: Some dosage forms may contain propylene glycol; large amounts are potentially toxic and have been associated hyperosmolality, lactic acidosis, seizures, and respiratory depression; use caution (AAP 1997; Zar 2007).

Other warnings/precautions:

• Discontinuation syndrome: Abrupt discontinuation or interruption of antidepressant therapy has been associated with a discontinuation syndrome. Symptoms arising may vary with antidepressant however commonly include nausea, vomiting, diarrhea, headaches, light-headedness, dizziness, diminished appetite, sweating, chills, tremors, paresthesias, fatigue, somnolence, and sleep disturbances (eg, vivid dreams, insomnia). Less common symptoms include electric shock-like sensations, cardiac arrhythmias (more common with tricyclic antidepressants), myalgias, parkinsonism, arthralgias, and balance difficulties. Psychological symptoms may also emerge such as agitation, anxiety, akathisia, panic attacks, irritability, aggressiveness, worsening of mood, dysphoria, mood lability, hyperactivity, mania/hypomania, depersonalization, decreased concentration, slowed thinking, confusion, and memory or concentration difficulties. Greater risks for developing a discontinuation syndrome have been associated with antidepressants with shorter half-lives, longer durations of treatment, and abrupt discontinuation. For antidepressants of short or intermediate half-lives, symptoms may emerge within 2 to 5 days after treatment discontinuation and last 7 to 14 days (APA 2010; Fava 2006; Haddad 2001; Shelton 2001; Warner 2006).

• Electroconvulsive therapy (ECT): Use with caution; no clinical studies have assessed the combined use of escitalopram and electroconvulsive therapy; may increase the risks (eg, cognitive adverse effects) associated with electroconvulsive therapy; consider discontinuing, when possible, prior to ECT treatment.

Geriatric Considerations

Bioavailability and half-life are increased by 50% in the elderly.

A systematic review and meta-analysis of antidepressant placebo-controlled trials in persons with depression and dementia found evidence “suggestive” of efficacy but not of sufficient strength to “confirm” efficacy (Nelson 2011). Older patients with depression being treated with an antidepressant should be closely monitored for response and adverse effects.

Warnings: Additional Pediatric Considerations

SSRI-associated behavioral activation (ie, restlessness, hyperkinesis, hyperactivity, agitation) is two- to threefold more prevalent in children compared to adolescents; it is more prevalent in adolescents compared to adults. Somnolence (including sedation and drowsiness) is more common in adults compared to children and adolescents (Safer, 2006). Escitalopram may impair cognitive or motor performance. SSRI-associated vomiting is two- to threefold more prevalent in children compared to adolescents and is more prevalent in adolescents compared to adults (Safer, 2006). A recent report describes five children (age: 8 to 15 years) who developed epistaxis (n=4) or bruising (n=1) while receiving SSRI therapy (sertraline) (Lake 2000).

Some dosage forms may contain propylene glycol; in neonates large amounts of propylene glycol delivered orally, intravenously (eg, >3,000 mg/day), or topically have been associated with potentially fatal toxicities which can include metabolic acidosis, seizures, renal failure, and CNS depression; toxicities have also been reported in children and adults including hyperosmolality, lactic acidosis, seizures, and respiratory depression; use caution (AAP, 1997; Shehab, 2009).

Pregnancy Considerations

Adverse events have been observed in animal reproduction studies. Escitalopram crosses the placenta and is distributed into the amniotic fluid. An increased risk of teratogenic effects, including cardiovascular defects, may be associated with maternal use of escitalopram or other SSRIs; however, available information is conflicting. Nonteratogenic effects in the newborn following SSRI/SNRI exposure late in the third trimester include respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypo- or hypertonia, hyper-reflexia, jitteriness, irritability, constant crying, and tremor. Symptoms may be due to the toxicity of the SSRIs/SNRIs or a discontinuation syndrome and may be consistent with serotonin syndrome associated with SSRI treatment. Persistent pulmonary hypertension of the newborn (PPHN) has also been reported with SSRI exposure. The long-term effects of in utero SSRI exposure on infant development and behavior are not known. Escitalopram is the S-enantiomer of the racemic derivative citalopram; also refer to the Citalopram monograph.

Due to pregnancy-induced physiologic changes, some pharmacokinetic parameters of escitalopram may be altered. The ACOG recommends that therapy with SSRIs or SNRIs during pregnancy be individualized; treatment of depression during pregnancy should incorporate the clinical expertise of the mental health clinician, obstetrician, primary health care provider, and pediatrician. According to the American Psychiatric Association (APA), the risks of medication treatment should be weighed against other treatment options and untreated depression. For women who discontinue antidepressant medications during pregnancy and who may be at high risk for postpartum depression, the medications can be restarted following delivery. Treatment algorithms have been developed by the ACOG and the APA for the management of depression in women prior to conception and during pregnancy.

Pregnant women exposed to antidepressants during pregnancy are encouraged to enroll in the National Pregnancy Registry for Antidepressants (NPRAD). Women 18 to 45 years of age or their health care providers may contact the registry by calling 844-405-6185. Enrollment should be done as early in pregnancy as possible.

Breast-Feeding Considerations

Escitalopram and its metabolite are present in breast milk.

The relative infant dose (RID) of escitalopram is ~3.9% and the RID of the metabolite is ~1.7% when calculated using average milk concentrations and compared to a weight-adjusted maternal dose of 10 to 20 mg/day. In general, breastfeeding is considered acceptable when the RID is <10% (Anderson 2016; Ito 2000); however, some sources note breastfeeding should only be considered if the RID is <5% for psychotropic agents (Larsen 2015). The calculations are based on mean milk concentrations of escitalopram 78 ng/mL (reported range: 37 to 168 ng/mL) and demethylescitalopram 27 ng/mL (reported range: 17 to 41 ng/mL). These milk concentrations were obtained following maternal administration of oral escitalopram 10 to 20 mg/day. Mean peak milk concentrations of escitalopram occurred ~5.5 hours after the maternal dose; the mean peak concentration of the metabolite was reported at ~4.8 hours (Rampono 2006). However, avoiding breastfeeding during the expected peak concentrations will generally not decrease infant exposure significantly for antidepressants with long half-lives (Berle 2011).

Adverse effects have been reported in breastfeeding infants exposed to SSRIs including escitalopram in some studies (Hale 2010). Infants of mothers using psychotropic medications should be monitored daily for changes in sleep, feeding patterns, and behavior (Bauer 2013), as well as infant growth and neurodevelopment (Sachs 2013; Sriraman 2015). Maternal use of an SSRI during pregnancy may cause delayed lactogenesis (Marshall 2010).

When first initiating an antidepressant in a breastfeeding woman, agents other than escitalopram are preferred. Women successfully treated with escitalopram during pregnancy may continue use while breastfeeding if there are no other contraindications (Berle 2011; Sriraman 2015). The manufacturer recommends caution be used if escitalopram is administered to a breastfeeding woman.

Escitalopram is the S-enantiomer of the racemic derivative citalopram; also refer to the Citalopram monograph.

Lexicomp Pregnancy & Lactation, In-Depth
Briggs’ Drugs in Pregnancy & Lactation
Adverse Reactions

>10%:

Central nervous system: Headache (24%), insomnia (7% to 14%), drowsiness (4% to 13%)

Gastrointestinal: Nausea (15% to 18%), diarrhea (6% to 14%)

Genitourinary: Ejaculatory disorder (9% to 14%)

1% to 10%:

Central nervous system: Fatigue (2% to 8%), dizziness (4% to 7%), anorgasmia (2% to 6%), abnormal dreams (3%), lethargy (3%), paresthesia (2%), yawning (2%)

Dermatologic: Diaphoresis (3% to 8%)

Endocrine & metabolic: Decreased libido (3% to 7%), menstrual disease (2%)

Gastrointestinal: Xerostomia (4% to 9%), constipation (3% to 6%), dyspepsia (2% to 6%), decreased appetite (3%), vomiting (3%), abdominal pain (2%), flatulence (2%), toothache (2%)

Genitourinary: Impotence (2% to 3%), urinary tract infection (children ≥2%)

Neuromuscular & skeletal: Neck pain (≤3%), shoulder pain (≤3%), back pain (children ≥2%)

Respiratory: Flu-like symptoms (5%), rhinitis (5%), sinusitis (3%), nasal congestion (children ≥2%)

<1%, postmarketing, and/or case reports: Abdominal cramps, abnormal gait, acute renal failure, aggressive behavior, agitated depression, agitation, agranulocytosis, akathisia, alopecia, amnesia, anaphylaxis, anemia, angioedema, angle-closure glaucoma, anxiety, apathy, aplastic anemia, arthralgia, ataxia, atrial fibrillation, blurred vision, bradycardia, bronchitis, cardiac failure, cerebrovascular accident, chest pain, choreoathetosis, cough, deep vein thrombosis, delirium, delusions, depersonalization, dermatitis, diabetes mellitus, diplopia, dyskinesia, dysmenorrhea, dysphagia, dyspnea, dystonia, dysuria, ecchymoses, edema, epistaxis, erythema multiforme, extrapyramidal reaction, fever, flushing, gastroenteritis, gastroesophageal reflux disease, gastrointestinal hemorrhage, hallucination, heartburn, hemolytic anemia, hepatic failure, hepatic necrosis, hepatitis, hot flash, hypercholesterolemia, hyperglycemia, hypermenorrhea, hyperprolactinemia, hypersensitivity reaction, hypertension, hypertensive crisis, hypoesthesia, hypoglycemia, hypokalemia, hyponatremia, hypoprothrombinemia, hypotension, immune thrombocytopenia, increased appetite, increased INR, increased liver enzymes, increased serum bilirubin, irritability, jaw tightness, lack of concentration, leukopenia, limb pain, migraine, myalgia, myasthenia, mydriasis, myocardial infarction, myoclonus, neuroleptic malignant syndrome (Stevens 2008), nightmares, nystagmus, orthostatic hypotension, palpitations, pancreatitis, panic, paranoia, Parkinsonian-like syndrome, phlebitis, priapism, prolonged Q-T interval on ECG, psychosis, pulmonary embolism, rectal hemorrhage, restless leg syndrome, rhabdomyolysis, seizure, serotonin syndrome, SIADH, sinus congestion, sinus headache, skin photosensitivity, skin rash, spontaneous abortion, Stevens-Johnson syndrome, suicidal ideation, suicidal tendencies, syncope, tachycardia, tardive dyskinesia, thrombocytopenia, thrombosis, tinnitus, torsades de pointes, toxic epidermal necrolysis, tremor, urinary frequency, urinary retention, urticaria, ventricular arrhythmia, ventricular tachycardia, vertigo, visual disturbance, weight gain, withdrawal syndrome

Allergy and Idiosyncratic Reactions
Metabolism/Transport Effects

Substrate of CYP2C19 (major), CYP3A4 (major); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential; Inhibits CYP2D6 (weak)

Drug Interactions 

Agents with Antiplatelet Properties (e.g., P2Y12 inhibitors, NSAIDs, SSRIs, etc.): May enhance the antiplatelet effect of other Agents with Antiplatelet Properties. Risk C: Monitor therapy

Alcohol (Ethyl): May enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Specifically, the risk of psychomotor impairment may be enhanced. Management: Patients receiving selective serotonin reuptake inhibitors should be advised to avoid alcohol. Monitor for increased psychomotor impairment in patients who consume alcohol during treatment with selective serotonin reuptake inhibitors. Risk D: Consider therapy modification

Anticoagulants: Agents with Antiplatelet Properties may enhance the anticoagulant effect of Anticoagulants. Risk C: Monitor therapy

Antiemetics (5HT3 Antagonists): May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Risk C: Monitor therapy

Antipsychotic Agents: Serotonin Modulators may enhance the adverse/toxic effect of Antipsychotic Agents. Specifically, serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotic Agents may enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Risk C: Monitor therapy

Apixaban: Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Apixaban. Specifically, the risk for bleeding may be increased. Management: Carefully consider risks and benefits of this combination and monitor closely. Risk C: Monitor therapy

ARIPiprazole: CYP2D6 Inhibitors (Weak) may increase the serum concentration of ARIPiprazole. Management: Monitor for increased aripiprazole pharmacologic effects. Aripiprazole dose adjustments may or may not be required based on concomitant therapy and/or indication. Consult full interaction monograph for specific recommendations. Risk C: Monitor therapy

Aspirin: Selective Serotonin Reuptake Inhibitors may enhance the antiplatelet effect of Aspirin. Risk C: Monitor therapy

Blood Glucose Lowering Agents: Selective Serotonin Reuptake Inhibitors may enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Risk C: Monitor therapy

Bosentan: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Bromopride: May enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Risk X: Avoid combination

BuPROPion: May enhance the adverse/toxic effect of Escitalopram. Specifically, the risk for seizures and serotonin syndrome may be increased. Risk C: Monitor therapy

BusPIRone: May enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This may cause serotonin syndrome. Selective Serotonin Reuptake Inhibitors may decrease the metabolism of BusPIRone. Management: The combination of a selective serotonin reuptake inhibitor and buspirone should be undertaken with great caution. When combined treatment is clinically indicated, monitor closely for signs of serotonin toxicity/serotonin syndrome. Risk D: Consider therapy modification

Cephalothin: Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Cephalothin. Specifically, the risk for bleeding may be increased. Risk C: Monitor therapy

Cimetidine: May increase the serum concentration of Escitalopram. Risk C: Monitor therapy

Citalopram: Escitalopram may enhance the QTc-prolonging effect of Citalopram. Escitalopram may enhance the serotonergic effect of Citalopram. This could result in serotonin syndrome. Risk X: Avoid combination

CNS Depressants: May enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Specifically, the risk of psychomotor impairment may be enhanced. Risk C: Monitor therapy

Collagenase (Systemic): Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Collagenase (Systemic). Specifically, the risk of injection site bruising and/or bleeding may be increased. Risk C: Monitor therapy

CYP2C19 Inducers (Moderate): May decrease the serum concentration of CYP2C19 Substrates (High risk with Inducers). Risk C: Monitor therapy

CYP2C19 Inducers (Strong): May increase the metabolism of CYP2C19 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Risk D: Consider therapy modification

CYP3A4 Inducers (Moderate): May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

CYP3A4 Inducers (Strong): May increase the metabolism of CYP3A4 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Risk D: Consider therapy modification

Cyproheptadine: May diminish the therapeutic effect of Selective Serotonin Reuptake Inhibitors. Risk C: Monitor therapy

Dabigatran Etexilate: Agents with Antiplatelet Properties may enhance the anticoagulant effect of Dabigatran Etexilate. Agents with Antiplatelet Properties may increase the serum concentration of Dabigatran Etexilate. This mechanism applies specifically to clopidogrel. Management: Carefully consider risks and benefits of this combination and monitor closely; Canadian labeling recommends avoiding prasugrel or ticagrelor. Risk C: Monitor therapy

Dabrafenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Seek alternatives to the CYP3A4 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). Risk D: Consider therapy modification

Dabrafenib: May decrease the serum concentration of CYP2C19 Substrates (High risk with Inducers). Management: Seek alternatives to the CYP2C19 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). Risk D: Consider therapy modification

Dapoxetine: May enhance the adverse/toxic effect of Serotonin Modulators. Risk X: Avoid combination

Deferasirox: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Deoxycholic Acid: Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Deoxycholic Acid. Specifically, the risk for bleeding or bruising in the treatment area may be increased. Risk C: Monitor therapy

Desmopressin: Selective Serotonin Reuptake Inhibitors may enhance the adverse/toxic effect of Desmopressin. Risk C: Monitor therapy

Dextromethorphan: Selective Serotonin Reuptake Inhibitors may enhance the serotonergic effect of Dextromethorphan. Selective Serotonin Reuptake Inhibitors may increase the serum concentration of Dextromethorphan. Management: Avoid the concurrent use of dextromethorphan and SSRIs, particularly fluoxetine and paroxetine, when possible. The risk for this interaction may persist for several weeks following discontinuation of fluoxetine or paroxetine. Risk D: Consider therapy modification

Domperidone: QT-prolonging Agents (Moderate Risk) may enhance the QTc-prolonging effect of Domperidone. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification

Dosulepin: Selective Serotonin Reuptake Inhibitors may increase the serum concentration of Dosulepin. Risk X: Avoid combination

Doxepin-Containing Products: Escitalopram may enhance the QTc-prolonging effect of Doxepin-Containing Products. Escitalopram may enhance the serotonergic effect of Doxepin-Containing Products. This could result in serotonin syndrome. Management: Monitor for QTc interval prolongation, ventricular arrhythmias, and serotonin syndrome when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy

Edoxaban: Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Edoxaban. Specifically, the risk of bleeding may be increased. Risk C: Monitor therapy

Enzalutamide: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Concurrent use of enzalutamide with CYP3A4 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP3A4 substrate should be performed with caution and close monitoring. Risk D: Consider therapy modification

Enzalutamide: May decrease the serum concentration of CYP2C19 Substrates (High risk with Inducers). Conversely, concentrations of active metabolites may be increased for those drugs activated by CYP2C19. Management: Concurrent use of enzalutamide with CYP2C19 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP2C19 substrate should be performed with caution and close monitoring. Risk D: Consider therapy modification

Fat Emulsion (Fish Oil Based): May enhance the adverse/toxic effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy

Gilteritinib: Escitalopram may enhance the QTc-prolonging effect of Gilteritinib. Gilteritinib may diminish the therapeutic effect of Escitalopram. Management: Avoid use of this combination if possible. If use is necessary, monitor for reduced response to escitalopram and for QTc prolongation and arrhythmias. Patients with other risk factors may be at greater risk for these serious toxicities. Risk D: Consider therapy modification

Glucosamine: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy

Haloperidol: QT-prolonging Antidepressants (Moderate Risk) may enhance the QTc-prolonging effect of Haloperidol. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy

Herbs (Anticoagulant/Antiplatelet Properties) (eg, Alfalfa, Anise, Bilberry): May enhance the adverse/toxic effect of Agents with Antiplatelet Properties. Bleeding may occur. Risk D: Consider therapy modification

Ibritumomab Tiuxetan: Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Ibritumomab Tiuxetan. Both agents may contribute to impaired platelet function and an increased risk of bleeding. Risk C: Monitor therapy

Ibrutinib: May enhance the adverse/toxic effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy

Inotersen: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy

Ioflupane I 123: Selective Serotonin Reuptake Inhibitors may diminish the diagnostic effect of Ioflupane I 123. Risk C: Monitor therapy

Limaprost: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy

Linezolid: May enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This could result in serotonin syndrome. Management: Consider alternatives to this combination whenever possible. If clinically acceptable, wait at least 2 weeks (5 weeks for fluoxetine) after SSRI discontinuation to initiate linezolid. Risk D: Consider therapy modification

Linezolid: May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Management: Due to a risk of serotonin syndrome/serotonin toxicity, discontinue serotonin modulators 2 weeks prior to the administration of linezolid. If urgent initiation of linezolid is needed, discontinue serotonin modulators immediately and monitor closely. Risk D: Consider therapy modification

Lithium: May enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This could increase the risk of serotonin toxicity/serotonin syndrome. Management: This combination should be undertaken with great caution. When combined treatment is clinically indicated, monitor closely for signs of serotonin toxicity/serotonin syndrome. Risk D: Consider therapy modification

Lofexidine: QT-prolonging Antidepressants (Moderate Risk) may enhance the QTc-prolonging effect of Lofexidine. Lofexidine may enhance the QTc-prolonging effect of QT-prolonging Antidepressants (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy

Lorlatinib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Avoid concurrent use of lorlatinib with any CYP3A4 substrates for which a minimal decrease in serum concentrations of the CYP3A4 substrate could lead to therapeutic failure and serious clinical consequences. Risk D: Consider therapy modification

Metaxalone: May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Risk C: Monitor therapy

Methylene Blue: Selective Serotonin Reuptake Inhibitors may enhance the serotonergic effect of Methylene Blue. This could result in serotonin syndrome. Risk X: Avoid combination

Methylene Blue: May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Risk X: Avoid combination

Methylphenidate: May enhance the adverse/toxic effect of Serotonin Modulators. Specifically, the risk of serotonin syndrome or serotonin toxicity may be increased. Risk C: Monitor therapy

Metoclopramide: May enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Management: Seek alternatives to this combination when possible. Monitor patients receiving metoclopramide with selective serotonin reuptake inhibitors for signs of extrapyramidal symptoms, neuroleptic malignant syndrome, and serotonin syndrome. Risk D: Consider therapy modification

MetyroSINE: May enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Risk C: Monitor therapy

Mexiletine: Selective Serotonin Reuptake Inhibitors may decrease the metabolism of Mexiletine. Risk D: Consider therapy modification

Mitotane: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Doses of CYP3A4 substrates may need to be adjusted substantially when used in patients being treated with mitotane. Risk D: Consider therapy modification

Monoamine Oxidase Inhibitors: May enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This may cause serotonin syndrome. While methylene blue and linezolid are expected to interact via this mechanism, management recommendations differ from other monoamine oxidase inhibitors. Refer to monographs specific to those agents for details. Exceptions: Linezolid; Methylene Blue; Tedizolid. Risk X: Avoid combination

Multivitamins/Fluoride (with ADE): May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy

Multivitamins/Minerals (with ADEK, Folate, Iron): May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy

Multivitamins/Minerals (with AE, No Iron): May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy

Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective): Selective Serotonin Reuptake Inhibitors may enhance the antiplatelet effect of Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective). Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective) may diminish the therapeutic effect of Selective Serotonin Reuptake Inhibitors. Risk C: Monitor therapy

Nonsteroidal Anti-Inflammatory Agents (Nonselective): Selective Serotonin Reuptake Inhibitors may enhance the antiplatelet effect of Nonsteroidal Anti-Inflammatory Agents (Nonselective). Nonsteroidal Anti-Inflammatory Agents (Nonselective) may diminish the therapeutic effect of Selective Serotonin Reuptake Inhibitors. Management: Consider using alternative analgesics, when appropriate, and/or addition of a gastroprotective agent. Monitor patients closely for signs/symptoms of bleeding, and for evidence of diminished SSRI effectiveness with concurrent use. Risk D: Consider therapy modification

Obinutuzumab: Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Obinutuzumab. Specifically, the risk of serious bleeding-related events may be increased.Risk C: Monitor therapy

Omega-3 Fatty Acids: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy

Omeprazole: May increase the serum concentration of Escitalopram. Management: Monitor for increased escitalopram toxicity with concomitant use of omeprazole. Recommendations for management of this interaction found in product labeling may differ by country. Consult appropriate labeling. Risk D: Consider therapy modification

Ondansetron: May enhance the QTc-prolonging effect of QT-prolonging Antidepressants (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy

Opioid Agonists: May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Risk C: Monitor therapy

Pentamidine (Systemic): May enhance the QTc-prolonging effect of QT-prolonging Antidepressants (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy

Pentosan Polysulfate Sodium: May enhance the adverse/toxic effect of Agents with Antiplatelet Properties. Specifically, the risk of bleeding may be increased by concurrent use of these agents. Risk C: Monitor therapy

Pentoxifylline: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy

Perhexiline: CYP2D6 Inhibitors (Weak) may increase the serum concentration of Perhexiline. Risk C: Monitor therapy

Pimozide: May enhance the QTc-prolonging effect of QT-prolonging Agents (Moderate Risk). Risk X: Avoid combination

Pitolisant: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Combined use of pitolisant with a CYP3A4 substrate that has a narrow therapeutic index should be avoided. Other CYP3A4 substrates should be monitored more closely when used with pitolisant. Risk D: Consider therapy modification

Prostacyclin Analogues: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy

QT-prolonging Agents (Highest Risk): May enhance the QTc-prolonging effect of Escitalopram. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification

QT-prolonging Antipsychotics (Moderate Risk): May enhance the QTc-prolonging effect of QT-prolonging Antidepressants (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Exceptions: Pimozide. Risk C: Monitor therapy

QT-prolonging Class IC Antiarrhythmics (Moderate Risk): May enhance the QTc-prolonging effect of QT-prolonging Antidepressants (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy

QT-prolonging Kinase Inhibitors (Moderate Risk): QT-prolonging Antidepressants (Moderate Risk) may enhance the QTc-prolonging effect of QT-prolonging Kinase Inhibitors (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Exceptions: Gilteritinib. Risk C: Monitor therapy

QT-prolonging Miscellaneous Agents (Moderate Risk): QT-prolonging Antidepressants (Moderate Risk) may enhance the QTc-prolonging effect of QT-prolonging Miscellaneous Agents (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Exceptions: Domperidone; Lofexidine. Risk C: Monitor therapy

QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk): QT-prolonging Antidepressants (Moderate Risk) may enhance the QTc-prolonging effect of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). Risk C: Monitor therapy

QT-prolonging Quinolone Antibiotics (Moderate Risk): May enhance the QTc-prolonging effect of QT-prolonging Antidepressants (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy

QT-prolonging Strong CYP3A4 Inhibitors (Moderate Risk): May enhance the QTc-prolonging effect of QT-prolonging Antidepressants (Moderate Risk). Risk C: Monitor therapy

Rivaroxaban: Agents with Antiplatelet Properties may enhance the anticoagulant effect of Rivaroxaban. Management: Carefully consider risks and benefits of this combination and monitor closely; Canadian labeling recommends avoiding prasugrel or ticagrelor. Risk C: Monitor therapy

Salicylates: Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Salicylates. Increased risk of bleeding may result. Risk C: Monitor therapy

Sarilumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Serotonin Modulators: May enhance the adverse/toxic effect of other Serotonin Modulators. The development of serotonin syndrome may occur. Exceptions: Nicergoline; Tedizolid.Risk C: Monitor therapy

Serotonin Reuptake Inhibitor/Antagonists: Selective Serotonin Reuptake Inhibitors may enhance the serotonergic effect of Serotonin Reuptake Inhibitor/Antagonists. This may cause serotonin syndrome. Management: Consider alternatives, and use conservative initial dosing. Monitor patients receiving these combinations for signs/symptoms of serotonin toxicity. Risk D: Consider therapy modification

Siltuximab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Simeprevir: Escitalopram may decrease the serum concentration of Simeprevir. Risk C: Monitor therapy

St John’s Wort: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Risk D: Consider therapy modification

Tedizolid: May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Risk C: Monitor therapy

Thiazide and Thiazide-Like Diuretics: Selective Serotonin Reuptake Inhibitors may enhance the hyponatremic effect of Thiazide and Thiazide-Like Diuretics. Risk C: Monitor therapy

Thrombolytic Agents: Agents with Antiplatelet Properties may enhance the anticoagulant effect of Thrombolytic Agents. Risk C: Monitor therapy

Thyroid Products: Selective Serotonin Reuptake Inhibitors may diminish the therapeutic effect of Thyroid Products. Thyroid product dose requirements may be increased. Risk C: Monitor therapy

Tipranavir: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy

Tocilizumab: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

TraMADol: Serotonin Modulators may enhance the adverse/toxic effect of TraMADol. The risk of seizures may be increased. TraMADol may enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Risk C: Monitor therapy

Tricyclic Antidepressants: May enhance the adverse/toxic effect of Escitalopram. Escitalopram may increase the serum concentration of Tricyclic Antidepressants. Management: Consider alternatives to this combination when possible. Monitor for adverse effects of tricyclic antidepressants (TCAs), including serotonin syndrome and QT-interval prolongation, when a TCA is being used in combination with escitalopram. Exceptions: Doxepin (Systemic); Doxepin (Topical). Risk D: Consider therapy modification

Tryptophan: May enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This may cause serotonin syndrome. Risk X: Avoid combination

Urokinase: Agents with Antiplatelet Properties may enhance the anticoagulant effect of Urokinase. Risk X: Avoid combination

Vitamin E (Systemic): May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy

Vitamin K Antagonists (eg, warfarin): Selective Serotonin Reuptake Inhibitors may enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy

Monitoring Parameters

ECG (in patients at increased risk for QT-prolonging effects); electrolytes (potassium and magnesium concentrations at baseline and as clinically indicated); liver and renal function tests (baseline; as clinically indicated); serum sodium in at-risk populations (as clinically indicated); CBC (as clinically indicated); suicidal ideation (baseline and with dose changes).

Advanced Practitioners Physical Assessment/Monitoring

Assess patient for signs of clinical worsening, suicide ideation, mania, hypomania, anxiety, or panic attacks. Assess for signs and symptoms of serotonin syndrome. Taper dosage slowly when discontinuing Consider obtaining an eye exam prior to starting therapy. Assess other medicines patient may be taking; alternate therapy or dosage adjustments may be needed.

Nursing Physical Assessment/Monitoring

Monitor for therapeutic effectiveness (mental status for depression, suicide ideation, social functioning, mania, or panic attacks). Monitor for signs of clinical worsening or hypomania. Instruct patient to taper dosage slowly when discontinuing. Instruct patient to determine if this drug makes them too sleepy to perform tasks that require mental alertness, such as driving or operating machinery. Educate patient on signs and symptoms of serotonin syndrome and to report any signs to healthcare provider.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution, Oral:

Lexapro: 5 mg/5 mL (240 mL [DSC]) [contains methylparaben, propylene glycol, propylparaben; peppermint flavor]

Generic: 5 mg/5 mL (10 mL, 240 mL)

Tablet, Oral:

Lexapro: 5 mg, 10 mg [DSC]

Lexapro: 10 mg [scored]

Lexapro: 20 mg [DSC]

Lexapro: 20 mg [scored]

Generic: 5 mg, 10 mg, 20 mg

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Tablet, Oral:

Cipralex: 10 mg, 20 mg

Generic: 10 mg, 20 mg

Tablet Disintegrating, Oral:

Cipralex Meltz: 10 mg [DSC], 20 mg [DSC]

Generic: 10 mg, 20 mg

Anatomic Therapeutic Chemical (ATC) Classification
  • N06AB10
Generic Available (US)

Yes

Pricing: US

Solution (Escitalopram Oxalate Oral)

5 mg/5 mL (per mL): $0.79 – $0.96

Tablets (Escitalopram Oxalate Oral)

5 mg (per each): $0.26 – $4.51

10 mg (per each): $0.27 – $4.72

20 mg (per each): $0.29 – $4.92

Tablets (Lexapro Oral)

5 mg (per each): $13.17

10 mg (per each): $13.77

20 mg (per each): $14.37

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer’s AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Mechanism of Action

Escitalopram is the S-enantiomer of the racemic derivative citalopram, which selectively inhibits the reuptake of serotonin with little to no effect on norepinephrine or dopamine reuptake. It has no or very low affinity for 5-HT1-7, alpha- and beta-adrenergic, D1-5, H1-3, M1-5, and benzodiazepine receptors. Escitalopram does not bind to or has low affinity for Na+, K+, Cl, and Ca++ ion channels.

Pharmacodynamics/Kinetics

Onset of action: Depression: The onset of action is within a week; however, individual response varies greatly and full response may not be seen until 8 to 12 weeks after initiation of treatment.

Distribution: Vd: ~20 L/kg (Søgaard 2005)

Protein binding: ~56% to plasma proteins

Metabolism: Hepatic via CYP2C19 and 3A4 to S-desmethylcitalopram (S-DCT); S-DCT is metabolized to S-didesmethylcitalopram (S-DDCT) via CYP2D6; in vitro data suggest metabolites do not contribute significantly to the antidepressant effects of escitalopram

Bioavailability: 80%; tablets and oral solution are bioequivalent

Half-life elimination: Mean: Adolescents: 19 hours; Adults: ~27 to 32 hours (increased ~50% in the elderly and doubled in patients with hepatic impairment)

Time to peak: Escitalopram: Adolescents: 2.9 hours; Adults: ~5 hours

Excretion: Urine (8% as unchanged drug; S-DCT 10%)

Clearance (citalopram):

Hepatic impairment: Decreased by 37%

Mild to moderate renal impairment: Decreased by 17%

Severe renal impairment (CrCl <20 mL/minute): No information available.

Pharmacodynamics/Kinetics: Additional Considerations

Geriatric: AUC and half-life increased ~50%.

Local Anesthetic/Vasoconstrictor Precautions

Although caution should be used in patients taking tricyclic antidepressants, no interactions have been reported with vasoconstrictors and escitalopram, a nontricyclic antidepressant which acts to increase serotonin; no precautions appear to be needed

Escitalopram is one of the drugs confirmed to prolong the QT interval and is accepted as having a risk of causing torsade de pointes. The risk of drug-induced torsade de pointes is extremely low when a single QT interval prolonging drug is prescribed. In terms of epinephrine, it is not known what effect vasoconstrictors in the local anesthetic regimen will have in patients with a known history of congenital prolonged QT interval or in patients taking any medication that prolongs the QT interval. Until more information is obtained, it is suggested that the clinician consult with the physician prior to the use of a vasoconstrictor in suspected patients, and that the vasoconstrictor (epinephrine, mepivacaine, and levonordefrin [Carbocaine® 2% with Neo-Cobefrin®]) be used with caution.

Dental Health Professional Considerations

Problems with SSRI-induced bruxism have been reported and may preclude their use; clinicians attempting to evaluate any patient with bruxism or involuntary muscle movement, who is simultaneously being treated with an SSRI drug, should be aware of the potential association (see Local Anesthetic/Vasoconstrictor Precautions)

Effects on Dental Treatment

Key adverse event(s) related to dental treatment: Xerostomia (normal salivary flow resumes upon discontinuation) and toothache (see Effects on Bleeding and Dental Health Professional Considerations)

Effects on Bleeding

Selective serotonin reuptake inhibitors such as escitalopram may impair platelet aggregation due to platelet serotonin depletion, possibly increasing the risk of a bleeding complication. The risk of a bleeding complication can be increased by coadministration of other antiplatelet agents such as NSAIDs and aspirin.

Index Terms

Escitalopram Oxalate; Lu-26-054; S-Citalopram

FDA Approval Date
August 14, 2002
References

Aigner M, Treasure J, Kaye W, Kasper S; WFSBP Task Force on Eating Disorders. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of eating disorders. World J Biol Psychiatry. 2011;12(6):400-443. doi: 10.3109/15622975.2011.602720.[PubMed 21961502]

Althof SE, McMahon CG, Waldinger MD, et al. An update of the International Society of Sexual Medicine’s guidelines for the diagnosis and treatment of premature ejaculation (PE). Sex Med. 2014;2(2):60-90. doi: 10.1002/sm2.28.[PubMed 25356302]

American Academy of Pediatrics Committee on Drugs. “Inactive” ingredients in pharmaceutical products: update (subject review). Pediatrics. 1997;99(2):268-278.[PubMed 9024461]

American College of Obstetricians and Gynecologists, ACOG Practice Bulletin: Clinical Management Guidelines for Obstetricians-Gynecologists No. 92 April 2008 (Replaces Practice Bulletin Number 87, November 2007), “Use of Psychiatric Medications During Pregnancy and Lactation,” Obstet Gynecol, 2008, 111(4):1001-20.[PubMed 18378767]

American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-2246. doi:10.1111/jgs.13702.[PubMed 26446832]

American Psychiatric Association (APA). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd.pdf. Published November 2004. Accessed February 2016.

American Psychiatric Association (APA). Practice guideline for the treatment of patients with obsessive-compulsive disorder. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ocd.pdf. Published July 2007.

American Psychiatric Association (APA). Practice guideline for the treatment of patients with panic disorder. 2nd ed. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf. Published January 2009. Accessed August 16, 2018.

American Psychiatric Association (APA). Practice guideline for the treatment of patients with major depressive disorder. 3rd ed. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Published May 2010.

Anderson PO, Sauberan JB. Modeling drug passage into human milk. Clin Pharmacol Ther. 2016;100(1):42-52.[PubMed 27060684]

Bandelow B, Sher L, Bunevicius R, et al; WFSBP Task Force on Mental Disorders in Primary Care; WFSBP Task Force on Anxiety Disorders, OCD and PTSD. Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder in primary care [published corrections appear in Int J Psychiatry Clin Pract. 2012;16(3):242; Int J Psychiatry Clin Pract. 2013;17(1):76]. Int J Psychiatry Clin Pract. 2012;16(2):77-84.[PubMed 22540422]

Bauer M, Whybrow PC, Anst J, et al. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 2: Maintenance treatment of major depressive disorder and treatment of chronic depressive disorders and subthreshold depressions. World J Biol Psychiatry. 2002;3(2):69-86.[PubMed 12479080]

Bauer M, Pfennig A, Severus E, Whybrow PC, Angst J, Möller HJ; World Federation of Societies of Biological Psychiatry Task Force on Unipolar Depressive Disorders. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders. World J Biol Psychiatry. 2013;14(5):334-385. doi: 10.3109/15622975.2013.804195.[PubMed 23879318]

Bauer M, Severus E, Köhler S, Angst J, Möller HJ; WFSBP Task Force on Treatment Guidelines for Unipolar Depressive Disorders. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders. Part 2: maintenance treatment of major depressive disorder-update 2015. World J Biol Psychiatry. 2015;16(2):76-95. doi: 10.3109/15622975.2014.1001786.[PubMed 25677972]

Berle JO, Spigset O. Antidepressant use during breastfeeding. Curr Womens Health Rev. 2011;7(1):28-34.[PubMed 22299006]

Bernard L, Stern R, Lew D, et al, “Serotonin Syndrome After Concomitant Treatment With Linezolid and Citalopram,” Clin Infect Dis, 2003, 36(9):1197.[PubMed 12715317]

Boyer EW and Shannon M, “The Serotonin Syndrome,” N Engl J Med, 2005, 352:1112-20.[PubMed 15784664]

Carpenter JS, Guthrie KA, Larson JC, et al. Effect of escitalopram on hot flash interference: a randomized, controlled trial. Fertil Steril. 2012;97(6):1399-1404.e1.[PubMed 22480818]

Casper RF, Yonkers KA. Treatment of premenstrual syndrome and premenstrual dysphoric disorder. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 16, 2018.

Chambers CD, Hernandez-Diaz S, Van Marter LJ, et al, “Selective Serotonin-Reuptake Inhibitors and Risk of Persistent Pulmonary Hypertension of the Newborn,” N Engl J Med, 2006, 354(6):579-87.[PubMed 16467545]

Cipralex [product monograph]. Montreal, QC, Canada: Lundbeck Canada Inc; June 2016.

Cobin RH, Goodman NF; AACE Reproductive Endocrinology Scientific Committee. American Association of Clinical Endocrinologists and American College of Endocrinology position statement on menopause–2017 update. Endocr Pract. 2017;23(7):869-880. doi: 10.4158/EP171828.PS.[PubMed 28703650]

Crow SJ. Bulimia nervosa in adults: Pharmacotherapy. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed January 9, 2019.

Defronzo Dobkin R, Menza M, Allen LA, et al, “Escitalopram Reduces Hot Flashes in Nondepressed Menopausal Women: A Pilot Study,” Ann Clin Psychiatry, 2009, 21(2):70-6.[PubMed 19439155]

Dunkley EJ, Isbister GK, Sibbritt D, et al, “The Hunter Serotonin Toxicity Criteria: Simple and Accurate Diagnostic Decision Rules for Serotonin Toxicity,” QJM, 2003, 96(9):635-42.[PubMed 12925718]

Eriksson E, Ekman A, Sinclair S, et al. Escitalopram administered in the luteal phase exerts a marked and dose-dependent effect in premenstrual dysphoric disorder. J Clin Psychopharmacol. 2008;28(2):195-202. doi: 10.1097/JCP.0b013e3181678a28.[PubMed 18344730]

Escitalopram [prescribing information]. Philadelphia, PA: Lannett Company Inc; June 2017.

Fava M. Prospective studies of adverse events related to antidepressant discontinuation. J Clin Psychiatry. 2006;67(Suppl 4):14-21.[PubMed 16683858]

Fineberg NA, Tonnoir B, Lemming O, Stein DJ. Escitalopram prevents relapse of obsessive-compulsive disorder. Eur Neuropsychopharmacol. 2007;17(6-7):430-439. doi: 10.1016/j.euroneuro.2006.11.005.[PubMed 17240120]

Freeman EW, Sondheimer SJ, Sammel MD, Ferdousi T, Lin H. A preliminary study of luteal phase versus symptom-onset dosing with escitalopram for premenstrual dysphoric disorder. J Clin Psychiatry. 2005;66(6):769-773.[PubMed 15960573]

Freeman EW, Guthrie KA, Caan B, et al. Efficacy of escitalopram for hot flashes in healthy menopausal women: a randomized controlled trial. JAMA. 2011;305(3):267-274.[PubMed 21245182]

Goodman NF, Cobin RH, Ginzburg SB, Katz IA, Wood DE; American Association of Clinical Endocrinologists. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of menopause: executive summary of recommendations. Endocr Pract. 2011;17(6):949-954.[PubMed 22193145]

Guerdjikova AI, McElroy SL, Kotwal R, et al. High-dose escitalopram in the treatment of binge-eating disorder with obesity: a placebo-controlled monotherapy trial. Hum Psychopharmacol. 2008;23(1):1-11. doi: 10.1002/hup.899.[PubMed 18058852]

Haddad PM. Antidepressant discontinuation syndromes. Drug Saf. 2001;24(3):183-197.[PubMed 11347722]

Hale TW, Kendall-Tackett K, Cong Z, et al, “Discontinuation Syndrome in Newborns Whose Mothers Took Antidepressants While Pregnant or Breastfeeding,” Breastfeed Med, 2010, 5(6):283-8.[PubMed 20807106]

Hirsch M, Birnbaum RJ. Discontinuing antidepressant medications in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed May 11, 2018a.

Hirsch M, Birnbaum RJ. Switching antidepressant medications in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed May 11, 2018b.

Hirsch M, Birnbaum RJ. Selective serotonin reuptake inhibitors: Pharmacology, administration, and side effects. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 16, 2018c.

Huezo-Diaz, P, Perroud N, Spencer EP, et al. CYP2C19 genotype predicts steady state escitalopram concentration in GENDEP. J Psychopharmacol. 2012;26(3):398-407.[PubMed 21926427]

“Inactive” ingredients in pharmaceutical products: update (subject review). American Academy of Pediatrics Committee on Drugs. Pediatrics. 1997;99(2):268-278.[PubMed 9024461]

Ismaili E, Walsh S, O’Brien PMS, et al; Consensus Group of the International Society for Premenstrual Disorders. Fourth consensus of the International Society for Premenstrual Disorders (ISPMD): auditable standards for diagnosis and management of premenstrual disorder. Arch Womens Ment Health. 2016;19(6):953-958. doi: 10.1007/s00737-016-0631-7.[PubMed 27378473]

Issari Y, Jakubovski E, Bartley CA, Pittenger C, Bloch MH. Early onset of response with selective serotonin reuptake inhibitors in obsessive-compulsive disorder: a meta-analysis. J Clin Psychiatry. 2016;77(5):e605-e611. doi: 10.4088/JCP.14r09758.[PubMed 27249090]

Ito S. Drug therapy for breast-feeding women. N Engl J Med. 2000;343(2):118-126.[PubMed 10891521]

Khera M, Cunningham GR. Treatment of male sexual dysfunction. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 7, 2018.

Larsen ER, Damkier P, Pedersen LH, et al. Use of psychotropic drugs during pregnancy and breast-feeding. Acta Psychiatr Scand Suppl. 2015;(445):1-28.[PubMed 26344706]

Lexapro (escitalopram) [prescribing information]. Irvine, CA: Allergan USA Inc; January 2019.

Mahlberg R, Kunz D, Sasse J, et al, “Serotonin Syndrome With Tramadol and Citalopram,” Am J Psychiatry, 2004, 161(6):1129.

Marshall AM, Nommsen-Rivers LA, Hernandez LL, et al, “Serotonin Transport and Metabolism in the Mammary Gland Modulates Secretory Activation and Involution,” J Clin Endocrinol Metab, 2010, 95(2):837-46.[PubMed 19965920]

Mokhlesi B, Leikin JB, Murray P, et al, “Adult Toxicology in Critical Care: Part II: Specific Poisonings,” Chest, 2003, 123(3):897-922.[PubMed 12628894]

Montgomery SA, Loft H, Sanchez C, et al, “Escitalopram (S-Enantiomer of Citalopram): Clinical Efficacy and Onset of Action Predicted From a Rat Model,” Pharmacol Toxicol, 2001, 88(5):282-6.[PubMed 11393591]

Nelson JC and Devanand DP, “A Systematic Review and Meta-Analysis of Placebo-Controlled Antidepressant Studies in People With Depression and Dementia,” J Am Geriatr Soc, 2011, 59(4):577-85.[PubMed 21453380]

North American Menopause Society (NAMS). Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015;22(11):1155-1172. doi: 10.1097/GME.0000000000000546.[PubMed 26382310]

Ogle NR, Akkerman SR. Guidance for the discontinuation or switching of antidepressant therapies in adults. J Pharm Pract. 2013;26(4):389-396. doi: 10.1177/0897190012467210.[PubMed 23459282]

Pass SE and Simpson RW, “Discontinuation and Reinstitution of Medications During the Perioperative Period,” Am J Health Syst Pharm, 2004, 61(9):899-912.[PubMed 15156966]

Phillips KA, Keshaviah A, Dougherty DD, et al. Pharmacotherapy relapse prevention in body dysmorphic disorder: a double-blind, placebo-controlled trial. Am J Psychiatry.2016;173(9):887-895. doi: 10.1176/appi.ajp.2016.15091243.[PubMed 27056606]

Phillips KA. Body dysmorphic disorder: Treatment and prognosis. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 16, 2018.

Qi W, Gevonden M, Shalev A. Efficacy and tolerability of high-dose escitalopram in posttraumatic stress disorder. J Clin Psychopharmacol. 2017;37(1):89-93. doi: 10.1097/JCP.0000000000000626.[PubMed 27977469]

Rabenda V, Nicolet D, Beaudart C, et al. Relationship between use of antidepressants and risk of fractures: a meta-analysis. Osteoporos Int. 2013;24(1):121-137.[PubMed 22638709]

Rabinowitz I, Baruch Y, Barak Y. High-dose escitalopram for the treatment of obsessive-compulsive disorder. Int Clin Psychopharmacol. 2008;23(1):49-53.[PubMed 18090508]

Rabins PV, Blacker D, Rovner BW, et al, “American Psychiatric Association Practice Guideline for the Treatment of Patients With Alzheimer’s Disease and Other Dementias. Second Edition,” Am J Psychiatry, 2007, 164(12 Suppl):5-56.[PubMed 18340692]

Rampello L, Alvano A, Raffaele R, Malaguarnera M, Vecchio I. New possibilities of treatment for panic attacks in elderly patients: escitalopram versus citalopram. J Clin Psychopharmacol. 2006;26(1):67-70.[PubMed 16415709]

Rampono J, Hackett LP, Kristensen JH, et al. Transfer of escitalopram and its metabolite demethylescitalopram into breastmilk. Br J Clin Pharmacol. 2006;62(3):316-322. doi: 10.1111/j.1365-2125.2006.02659.x.[PubMed 16415709]

Rizzoli R, Cooper C, Reginster JY, et al. Antidepressant medications and osteoporosis. Bone. 2012;51(3):606-613.[PubMed 22659406]

Robert S, Hamner MB, Ulmer HG, Lorberbaum JP, Durkalski VL. Open-label trial of escitalopram in the treatment of posttraumatic stress disorder. J Clin Psychiatry. 2006;67(10):1522-1526.[PubMed 17107242]

Runowicz CD, Leach CR, Henry NL, et al. American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline. J Clin Oncol. 2016;34(6):611-635. doi: 10.1200/JCO.2015.64.3809.[PubMed 26644543]

Sachs HC, Committee On Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics. 2013;132(3):e796-809.[PubMed 23979084]

Shelton RC. Steps following attainment of remission: discontinuation of antidepressant therapy. Prim Care Companion J Clin Psychiatry. 2001;3(4):168-174.[PubMed 15014601]

Shim G, Park HY, Jang JH, et al. What is the optimal dose of escitalopram for the treatment of obsessive-compulsive disorder? A naturalistic open-label study. Int Clin Psychopharmacol. 2011;26(5):284-290. doi: 10.1097/YIC.0b013e32834a5c09.[PubMed 21829108]

Søgaard B, Mengel H, Rao N, et al, “The Pharmacokinetics of Escitalopram After Oral and Intravenous Administration of Single and Multiple Doses to Healthy Subjects,” J Clin Pharmacol, 2005, 45(12):1400-6.[PubMed 16291715]

Sriraman NK, Melvin K, Meltzer-Brody S. ABM clinical protocol #18: use of antidepressants in breastfeeding mothers. Breastfeed Med. 2015;10(6):290-299.[PubMed 26204124]

Stahl SM, Gergel I, Li D. Escitalopram in the treatment of panic disorder: a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry. 2003;64(11):1322-1327.[PubMed 14658946]

Stein DJ, Andersen EW, Tonnoir B, Fineberg N. Escitalopram in obsessive-compulsive disorder: a randomized, placebo-controlled, paroxetine-referenced, fixed-dose, 24-week study. Curr Med Res Opin. 2007;23(4):701-711. doi: 10.1185/030079907X178838.[PubMed 17407626]

Stein MB, Goin MK, Pollac MH, et al; American Psychiatric Association. Practice guideline for the treatment of patients with panic disorder. 2009. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf. Published January 2009. Accessed March 11, 2015.

Stevens DL. Association between selective serotonin-reuptake inhibitors, second-generation antipsychotics, and neuroleptic malignant syndrome. Ann Pharmacother. 2008;42(9):1290-1297.

Stuenkel CA, Davis SR, Gompel A, et al. Treatment of symptoms of the menopause: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100(11):3975-4011. doi: 10.1210/jc.2015-2236.[PubMed 26444994]

Tahir N. Serotonin Syndrome as a Consequence of Drug-Resistant Infections: An Interaction Between Linezolid and Citalopram. J Am Med Dir Assoc. 2004;5(2):111-3.[PubMed 20351036]

Tsai MH, Lin KM, Hsiao MC, et al. Genetic polymorphisms of cytochrome P450 enzymes influence metabolism of the antidepressant escitalopram and treatment response. Pharmacogenomics. 2010;11(4):537-546.[PubMed 20351036]

Tseng PT, Lee Y, Lin YE, et al, “Low-Dose Escitalopram for 2 Days Associated With Corrected QT Interval Prolongation in a Middle-Aged Woman: A Case Report and Literature Review,” Gen Hosp Psychiatry, 2012, 34(2):210.[PubMed 22133983]

Ursano RJ, Bell C, Eth S, et al; Work Group on ASD and PTSD. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. http://psychiatryonline.org/guidelines. Published November 2004. Accessed August 14, 2008.

US Department of Veterans Affairs/Department of Defense (VA/DoD). VA/DoD clinical practice guideline for the management of major depressive disorder. https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFINAL82916.pdf. Updated April 2016. Accessed August 2, 2018.

Von Moltke LL, Greenblatt DJ, Giancarlo GM, et al, “Escitalopram (S-Citalopram) and its Metabolites in vitro: Cytochromes Mediating Biotransformation, Inhibitory Effects, and Comparison to R-Citalopram,” Drug Metab Dispos, 2001, 29(8):1102-9.[PubMed 11454728]

Wade AG, Crawford GM, Yellowlees A. Efficacy, safety and tolerability of escitalopram in doses up to 50 mg in major depressive disorder (MDD): an open-label, pilot study. BMC Psychiatry. 2011;11:42. doi: 10.1186/1471-244X-11-42.[PubMed 21410960]

Warner, CH, Bobo W, Warner C, et al. Antidepressant discontinuation syndrome. Am Fam Physician. 2006;74:449-456.[PubMed 16913164]

Yang LP and Scott LJ, “Escitalopram in the Treatment of Major Depressive Disorder in Adolescent Patients,” Paediatr Drugs, 2010, 12(3):155-63[PubMed 20481645]

Yonkers KA, Wisner KL, Stewart DE, et al, “The Management of Depression During Pregnancy: A Report From the American Psychiatric Association and the American College of Obstetricians and Gynecologists,” Obstet Gynecol, 2009, 114(3):703-13.[PubMed 19701065]

Zar T, Graeber C, Perazella MA. Recognition, treatment, and prevention of propylene glycol toxicity. Semin Dial. 2007;20(3):217-219.[PubMed 17555487]

Brand Names: International

Antidex (CR, DO, GT, HN, NI, PA, SV); Celtium (EC); Cilentra (LK, ZW); Cipralex (AE, AT, BG, BH, CH, CY, CZ, DE, DK, EE, ES, FI, GB, GR, HR, HU, IE, IL, IN, IQ, IR, IS, IT, JO, KW, LB, LT, LY, MT, NO, OM, PK, PL, PT, QA, RO, RU, SA, SE, SI, SK, SY, TR, UA, YE); Citalam (BD); Citalo (KR); Citao (TW); Citaplex (KR); Clomentin (TR); Conjupram (PH); Depram (ID); Depresan (UA); Depsit (LK); E-Zentius (PE); Ecinil (LK); Edpa (KR); Elapram (ID); Elxion (ID); Epram (BD, TW, UY); Esciprex (IE); Escital (KR); Escitalpro (IE); Escitam (UA); Escivex (PH); Esidep (TH); Esipram (AU); Esitalo (AU, HK, PH); Eslopran (CO); Esopam (TH); Esoplex (LB); Esopram (UA); Esram (HR); Estimex (PY); Esto (IL); Estoram (KR); Etalopro (IE); Feliz S (PH); Feliz S 10 (ZW); Feliz S 20 (ZW); Feliz-20 (TZ); Ipran (CL, CO); Isolift (ZW); Jovia (PH); L-Xapam (KR); Leeyo (TW); Lepax (TW); Lexacure (KR); Lexam (AU); Lexapam (KR); Lexapro (AR, AU, BB, BM, BR, BS, BZ, CN, EC, GY, HK, IE, JM, JP, KR, MY, NL, NZ, PE, PH, PR, SG, SR, TH, TT, TW, VE); Lexapro Meltz (KR); Lexatin (KR); Lexcitam (KR); Lexdin (PH); Loxalate (AU); Neolexa (LK); Neopra (HK); Newpram (KR); Nexito (PH); Nodep (LK); Oxapro (LK); Pramokline (MY); Recita (IN); Reformex (EG); S-Celepra (PH); S-Oropram (HK, MT); Saropram (KR); Seropam (BD); Seroplex (FR); Sipralexa (BE); Spador (BD); Sycopanaxin (EG); Talopram (PY); Taloscito (EG); Zelax (LB, QA); Zytapram (PH)

Escitalopram (Patient Education – Adult Medication)
You must carefully read the “Consumer Information Use and Disclaimer” below in order to understand and correctly use this information
Pronunciation

(es sye TAL oh pram)

Brand Names: US

Lexapro

Brand Names: Canada

Cipralex

Warning
  • For all patients taking this drug:
  • Drugs like this one have raised the chance of suicidal thoughts or actions in children and young adults. The risk may be greater in people who have had these thoughts or actions in the past. All people who take this drug need to be watched closely. Call the doctor right away if signs like low mood (depression), nervousness, restlessness, grouchiness, panic attacks, or changes in mood or actions are new or worse. Call the doctor right away if any thoughts or actions of suicide occur.
  • Children:
  • This drug is not approved for use in all children. Talk with the doctor to be sure that this drug is right for your child.
  • If your child has been given this drug, talk with the doctor about the benefits and risks. Talk with the doctor if you have questions or concerns about giving this drug to your child.
What is this drug used for?
  • It is used to treat low mood (depression).
  • It is used to treat anxiety.
  • It may be given to you for other reasons. Talk with the doctor.
What do I need to tell my doctor BEFORE I take this drug?
  • If you have an allergy to escitalopram or any other part of this drug.
  • If you are allergic to any drugs like this one, any other drugs, foods, or other substances. Tell your doctor about the allergy and what signs you had, like rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other signs.
  • If you are taking any of these drugs: Linezolid or methylene blue.
  • If you are taking any of these drugs: Citalopram or pimozide.
  • If you have taken certain drugs used for low mood (depression) like isocarboxazid, phenelzine, or tranylcypromine or drugs used for Parkinson’s disease like selegiline or rasagiline in the last 14 days. Taking this drug within 14 days of those drugs can cause very bad high blood pressure.
  • This is not a list of all drugs or health problems that interact with this drug.
  • Tell your doctor and pharmacist about all of your drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe for you to take this drug with all of your drugs and health problems. Do not start, stop, or change the dose of any drug without checking with your doctor.
What are some things I need to know or do while I take this drug?
  • For all patients taking this drug:
  • Tell all of your health care providers that you take this drug. This includes your doctors, nurses, pharmacists, and dentists.
  • Avoid driving and doing other tasks or actions that call for you to be alert until you see how this drug affects you.
  • Do not stop taking this drug all of a sudden without calling your doctor. You may have a greater risk of side effects. If you need to stop this drug, you will want to slowly stop it as ordered by your doctor.
  • Avoid drinking alcohol while taking this drug.
  • Talk with your doctor before you use other drugs and natural products that slow your actions.
  • In depression, sleep and appetite may get better soon after starting this drug. Other low mood signs may take up to 4 weeks to get better.
  • This drug may raise the chance of bleeding. Sometimes, bleeding can be life-threatening. Talk with the doctor.
  • Some people may have a higher chance of eye problems with this drug. Your doctor may want you to have an eye exam to see if you have a higher chance of these eye problems. Call your doctor right away if you have eye pain, change in eyesight, or swelling or redness in or around the eye.
  • This drug can cause low sodium levels. Very low sodium levels can be life-threatening, leading to seizures, passing out, trouble breathing, or death. Talk with the doctor.
  • If you are 65 or older, use this drug with care. You could have more side effects.
  • Tell your doctor if you are pregnant, plan on getting pregnant, or are breast-feeding. You will need to talk about the benefits and risks to you and the baby.
  • Taking this drug in the third trimester of pregnancy may lead to some health problems in the newborn. Talk with the doctor.
  • Children:
  • Use with care in children. Talk with the doctor.
  • This drug may affect growth in children and teens in some cases. They may need regular growth checks. Talk with the doctor.
What are some side effects that I need to call my doctor about right away?
  • WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:
  • Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
  • Signs of low sodium levels like headache, trouble focusing, memory problems, feeling confused, weakness, seizures, or change in balance.
  • Signs of bleeding like throwing up blood or throw up that looks like coffee grounds; coughing up blood; blood in the urine; black, red, or tarry stools; bleeding from the gums; vaginal bleeding that is not normal; bruises without a reason or that get bigger; or any bleeding that is very bad or that you cannot stop.
  • Seizures.
  • Fever or chills.
  • Sex problems like lowered interest in sex or ejaculation problems.
  • Erection that lasts more than 4 hours.
  • A very bad and sometimes deadly health problem called serotonin syndrome may happen. The risk may be greater if you take this drug with drugs for depression, migraines, or certain other drugs. Call your doctor right away if you have agitation; change in balance; confusion; hallucinations; fever; fast or abnormal heartbeat; flushing; muscle twitching or stiffness; seizures; shivering or shaking; sweating a lot; very bad diarrhea, upset stomach, or throwing up; or very bad headache.
What are some other side effects of this drug?
  • All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:
  • Dizziness.
  • Upset stomach.
  • Diarrhea.
  • Constipation.
  • Dry mouth.
  • Trouble sleeping.
  • Sweating a lot.
  • Flu-like signs.
  • Feeling tired or weak.
  • Feeling sleepy.
  • Runny nose.
  • Headache.
  • Yawning.
  • These are not all of the side effects that may occur. If you have questions about side effects, call your doctor. Call your doctor for medical advice about side effects.
  • You may report side effects to your national health agency.
How is this drug best taken?
  • Use this drug as ordered by your doctor. Read all information given to you. Follow all instructions closely.
  • All products:
  • Take with or without food.
  • To gain the most benefit, do not miss doses.
  • Keep taking this drug as you have been told by your doctor or other health care provider, even if you feel well.
  • Oral solution:
  • Measure liquid doses carefully. Use the measuring device that comes with this drug. If there is none, ask the pharmacist for a device to measure this drug.
What do I do if I miss a dose?
  • Take a missed dose as soon as you think about it.
  • If it is close to the time for your next dose, skip the missed dose and go back to your normal time.
  • Do not take 2 doses at the same time or extra doses.
How do I store and/or throw out this drug?
  • Store at room temperature.
  • Store in a dry place. Do not store in a bathroom.
  • Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets.
  • Throw away unused or expired drugs. Do not flush down a toilet or pour down a drain unless you are told to do so. Check with your pharmacist if you have questions about the best way to throw out drugs. There may be drug take-back programs in your area.
General drug facts
  • If your symptoms or health problems do not get better or if they become worse, call your doctor.
  • Do not share your drugs with others and do not take anyone else’s drugs.
  • Keep a list of all your drugs (prescription, natural products, vitamins, OTC) with you. Give this list to your doctor.
  • Talk with the doctor before starting any new drug, including prescription or OTC, natural products, or vitamins.
  • Some drugs may have another patient information leaflet. If you have any questions about this drug, please talk with your doctor, nurse, pharmacist, or other health care provider.
  • If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.
Escitalopram (Patient Education – Pediatric Medication)
You must carefully read the “Consumer Information Use and Disclaimer” below in order to understand and correctly use this information
Pronunciation

(es sye TAL oh pram)

Brand Names: US

Lexapro

Brand Names: Canada

Cipralex

Warning
  • Drugs like this one have raised the chance of suicidal thoughts or actions in children and young adults. The risk may be greater in people who have had these thoughts or actions in the past. All people who take this drug need to be watched closely. Call the doctor right away if signs like low mood (depression), nervousness, restlessness, grouchiness, panic attacks, or changes in mood or actions are new or worse. Call the doctor right away if any thoughts or actions of suicide occur.
  • This drug is not approved for use in all children. Talk with the doctor to be sure that this drug is right for your child.
  • If your child has been given this drug, talk with the doctor about the benefits and risks. Talk with the doctor if you have questions or concerns about giving this drug to your child.
What is this drug used for?
  • It is used to treat low mood (depression).
  • It is used to treat anxiety.
  • It may be given to your child for other reasons. Talk with the doctor.
What do I need to tell the doctor BEFORE my child takes this drug?
  • If your child has an allergy to this drug or any part of this drug.
  • If your child is allergic to any drugs like this one or any other drugs, foods, or other substances. Tell the doctor about the allergy and what signs your child had, like rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other signs.
  • If your child is taking any of these drugs: Linezolid or methylene blue.
  • If your child is taking any of these drugs: Citalopram or pimozide.
  • If your child has taken certain drugs used for low mood (depression) like isocarboxazid, phenelzine, or tranylcypromine or drugs used for certain other health problems in the last 14 days. Taking this drug within 14 days of those drugs can cause very bad high blood pressure.
  • This is not a list of all drugs or health problems that interact with this drug.
  • Tell the doctor and pharmacist about all of your child’s drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe for your child to take this drug with all of his/her drugs and health problems. Do not start, stop, or change the dose of any drug your child takes without checking with the doctor.
What are some things I need to know or do while my child takes this drug?
  • Tell all of your child’s health care providers that your child is taking this drug. This includes your child’s doctors, nurses, pharmacists, and dentists.
  • Have your child avoid tasks or actions that call for alertness until you see how this drug affects your child. These are things like riding a bike, playing sports, or using items such as scissors, lawnmowers, electric scooters, toy cars, or motorized vehicles.
  • Do not stop giving this drug to your child all of a sudden without calling the doctor. Your child may have a greater risk of side effects. If your child needs to stop this drug, you will want to slowly stop it as told by the doctor.
  • Alcohol may interact with this drug. Be sure your child does not drink alcohol.
  • Talk with the doctor before giving your child other drugs and natural products that may slow your child’s actions.
  • In depression, sleep and appetite may get better soon after starting this drug. Other low mood signs may take up to 4 weeks to get better.
  • This drug may raise the chance of bleeding. Sometimes, bleeding can be life-threatening. Talk with the doctor.
  • Some people may have a higher chance of eye problems with this drug. The doctor may want your child to have an eye exam to see if your child has a higher chance of these eye problems. Call the doctor right away if your child has eye pain, change in eyesight, or swelling or redness in or around the eye.
  • This drug can cause low sodium levels. Very low sodium levels can be life-threatening, leading to seizures, passing out, trouble breathing, or death. Talk with the doctor.
  • Use with care in children. Talk with the doctor.
  • This drug may affect growth in children and teens in some cases. They may need regular growth checks. Talk with the doctor.
  • If your child is pregnant or breast-feeding a baby:
  • Talk with the doctor if your child is pregnant, becomes pregnant, or is breast-feeding a baby. You will need to talk about the benefits and risks to your child and the baby.
  • Taking this drug in the third trimester of pregnancy may lead to some health problems in the newborn. Talk with the doctor.
What are some side effects that I need to call my child’s doctor about right away?
  • WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your child’s doctor or get medical help right away if your child has any of the following signs or symptoms that may be related to a very bad side effect:
  • Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
  • Signs of low sodium levels like headache, trouble focusing, memory problems, feeling confused, weakness, seizures, or change in balance.
  • Signs of bleeding like throwing up blood or throw up that looks like coffee grounds; coughing up blood; blood in the urine; black, red, or tarry stools; bleeding from the gums; vaginal bleeding that is not normal; bruises without a reason or that get bigger; or any bleeding that is very bad or that you cannot stop.
  • Seizures.
  • Fever or chills.
  • Erection that lasts more than 4 hours.
  • A very bad and sometimes deadly health problem called serotonin syndrome may happen. The risk may be greater if your child takes this drug with drugs for depression, migraines, or certain other drugs. Call your child’s doctor right away if your child has agitation; change in balance; confusion; hallucinations; fever; a fast or abnormal heartbeat; flushing; muscle twitching or stiffness; seizures; shivering or shaking; sweating a lot; very bad diarrhea, upset stomach, or throwing up; or very bad headache.
  • If your child is or may be sexually active:
  • Sex problems like lowered interest in sex or ejaculation problems.
What are some other side effects of this drug?
  • All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your child’s doctor or get medical help if any of these side effects or any other side effects bother your child or do not go away:
  • Dizziness.
  • Headache.
  • Upset stomach.
  • Trouble sleeping.
  • Dry mouth.
  • Diarrhea.
  • Constipation.
  • Sweating a lot.
  • Flu-like signs.
  • Feeling tired or weak.
  • Feeling sleepy.
  • Runny nose.
  • Yawning.
  • These are not all of the side effects that may occur. If you have questions about side effects, call your child’s doctor. Call your child’s doctor for medical advice about side effects.
  • You may report side effects to your national health agency.
How is this drug best given?
  • Give this drug as ordered by your child’s doctor. Read all information given to you. Follow all instructions closely.
  • All products:
  • Give this drug with or without food.
  • To gain the most benefit, do not miss giving your child doses.
  • Keep giving this drug to your child as you have been told by your child’s doctor or other health care provider, even if your child feels well.
  • Oral solution:
  • Measure liquid doses carefully. Use the measuring device that comes with this drug. If there is none, ask the pharmacist for a device to measure this drug.
What do I do if my child misses a dose?
  • Give a missed dose as soon as you think about it.
  • If it is close to the time for your child’s next dose, skip the missed dose and go back to your child’s normal time.
  • Do not give 2 doses at the same time or extra doses.
How do I store and/or throw out this drug?
  • Store at room temperature.
  • Store in a dry place. Do not store in a bathroom.
  • Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets.
  • Throw away unused or expired drugs. Do not flush down a toilet or pour down a drain unless you are told to do so. Check with your pharmacist if you have questions about the best way to throw out drugs. There may be drug take-back programs in your area.
General drug facts
  • If your child’s symptoms or health problems do not get better or if they become worse, call your child’s doctor.
  • Do not share your child’s drug with others and do not give anyone else’s drug to your child.
  • Keep a list of all your child’s drugs (prescription, natural products, vitamins, OTC) with you. Give this list to your child’s doctor.
  • Talk with your child’s doctor before giving your child any new drug, including prescription or OTC, natural products, or vitamins.
  • Some drugs may have another patient information leaflet. If you have any questions about this drug, please talk with your child’s doctor, nurse, pharmacist, or other health care provider.
  • If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.