Embedded Files
Pharmacologic Category
Antidepressant, Selective Serotonin Reuptake Inhibitor
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 2020).
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 2020).
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 2020; 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 2020; 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 antidepressant treatment that has lasted for >3 weeks, gradually taper the dose (eg, over 2 to 4 weeks) to minimize withdrawal symptoms and detect reemerging symptoms (APA 2010; WFSBP [Bauer 2015]). Reasons for a slower taper (eg, over 4 weeks) include use of a drug with a half-life <24 hours (eg, paroxetine, venlafaxine), prior history of antidepressant withdrawal symptoms, or high doses of antidepressants (APA 2010; Hirsch 2019). If intolerable withdrawal symptoms occur, 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.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
* See Dosage and Administration in AHFS Essentials for additional information.
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 (level of hepatic dysfunction not specified). Some experts recommend initial doses of 5 mg/day for 2 weeks in patients with mild and moderate impairment (Child-Pugh A or B) (Mauri 2014).
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: Consider planning antidepressant discontinuation for lower-stress times, recognizing non-illness-related factors could cause stress or anxiety and be misattributed to antidepressant discontinuation (Hathaway 2018). Upon discontinuation of antidepressant therapy, gradually taper the dose to minimize the incidence of discontinuation syndromes (withdrawal) and allow for the detection of reemerging disease state symptoms (eg, relapse). Evidence supporting ideal taper rates after illness remission 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. After long-term (years) antidepressant treatment, WFSBP guidelines recommend tapering over 4 to 6 months, with close monitoring during and for 6 months after discontinuation. If intolerable discontinuation 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; Fenske 2009; Haddad 2001; NCCMH 2010; Schatzberg 2006; Shelton 2001; Warner 2006).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
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.
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
Calculations
- Creatinine Clearance by Cockcroft-Gault
- Creatinine Clearance by Cockcroft-Gault (SI units)
- Creatinine Clearance by Cockcroft-Gault with IBW
- Creatinine Clearance by Cockcroft-Gault with IBW (SI units)
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)
* See Uses in AHFS Essentials for additional information.
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
Class and Related Monographs
Selective Serotonin Reuptake Inhibitors
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
Depression:
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
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.
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:
• Nausea
• Dizziness
• Diarrhea
• Constipation
• Dry mouth
• Trouble sleeping
• Sweating a lot
• Flu-like signs
• Headache
• Loss of strength and energy
• Fatigue
• Runny nose
• Yawning
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:
• Depression like thoughts of suicide, anxiety, emotional instability, or confusion.
• Agitation
• Panic attacks
• Mood changes
• Behavioral changes
• Low sodium like headache, trouble focusing, trouble with memory, confusion, weakness, seizures, or change in balance.
• Bleeding like vomiting blood or vomit that looks like coffee grounds; coughing up blood; blood in the urine; 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 sex drive
• Vision changes
• Eye pain
• Eye redness
• Eye swelling
• Serotonin syndrome like dizziness, severe headache, agitation, sensing things that seem real but are not, fast heartbeat, abnormal heartbeat, flushing, tremors, sweating a lot, change in balance, severe nausea, or severe diarrhea.
• Erection that lasts more than 4 hours
• 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.
Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.
Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a limited summary of general information about the medicine's uses from the patient education leaflet and is not intended to be comprehensive. This limited summary does NOT include all information available about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not intended to provide medical advice, diagnosis or treatment and does not replace information you receive from the healthcare provider. For a more detailed summary of information about the risks and benefits of using this medicine, please speak with your healthcare provider and review the entire patient education leaflet.
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 thoughts/behavior: [US Boxed Warning]: Antidepressants increased the risk of suicidal thoughts and behaviors in pediatric and young adult patients (18 to 24 years of age) with major depressive disorder 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 of age. Closely monitor patients for clinical worsening and emergence of suicidal thoughts and behaviors, 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. Changing the therapeutic regimen or possible discontinuation of therapy should be considered in patients who experience emergent suicidal thoughts or behaviors or with worsening depression. 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 half-life and plasma concentrations are increased; a lower dosage may be needed. However, selective serotonin reuptake inhibitors such as escitalopram are considered the safest antidepressants to use in chronic liver disease because of their relative lack of side effects and high therapeutic index (Mauri 2014; Mullish 2014).
• Mania/hypomania: May precipitate a shift to mania or hypomania in patients with bipolar disorder. Monotherapy in patients with bipolar disorder should be avoided. Combination therapy with an antidepressant and a mood stabilizer may be effective for acute treatment of bipolar major depressive episodes but should be avoided in acute mania or mixed episodes, as well as maintenance treatment in bipolar disorder due to the mood-destabilizing effects of antidepressants (CANMAT [Yatham 2018]; WFSBP [Grunze 2018]). Screen all patients for any personal or family history of bipolar disorder, hypomania, or mania prior to initiating therapy. 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.
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.
* See Cautions in AHFS Essentials for additional information.
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
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%:
Gastrointestinal: Diarrhea (6% to 14%), nausea (15% to 18%)
Genitourinary: Ejaculatory disorder (9% to 14% [placebo: <1% to 2%])
Nervous system: Drowsiness (4% to 13%; literature suggests incidence is lower in children and adolescents compared to adults [Safer 2006]), headache (24%), insomnia (7% to 14%)
1% to 10%:
Dermatologic: Diaphoresis (3% to 8%)
Endocrine & metabolic: Decreased libido (3% to 7% [placebo: 1% to 2%]), menstrual disease (2%)
Gastrointestinal: Abdominal pain (2%), constipation (3% to 6%), decreased appetite (3%), dyspepsia (2% to 6%), flatulence (2%), toothache (2%), vomiting (3%; literature suggests incidence is higher in adolescents compared to adults, and is two- to threefold higher in children compared to adolescents [Safer 2006]), xerostomia (4% to 9%)
Genitourinary: Impotence (2% to 3% [placebo: <1%]), urinary tract infection (children ≥2%)
Nervous system: Abnormal dreams (3%), anorgasmia (2% to 6% [placebo: <1%]), dizziness (4% to 7%), fatigue (2% to 8%), lethargy (3%), paresthesia (2%), yawning (2%)
Neuromuscular & skeletal: Back pain (children ≥2%), neck pain (≤3%), shoulder pain (≤3%)
Respiratory: Flu-like symptoms (5%), nasal congestion (children ≥2%), rhinitis (5%), sinusitis (3%)
<1%:
Cardiovascular: Chest pain, hypertension, palpitations
Dermatologic: Skin rash
Endocrine & metabolic: Hot flash, weight gain
Gastrointestinal: Abdominal cramps, gastroenteritis, heartburn, increased appetite
Genitourinary: Dysmenorrhea, urinary frequency
Hypersensitivity: Hypersensitivity reaction
Nervous system: Irritability, lack of concentration, migraine
Neuromuscular & skeletal: Arthralgia, jaw tightness, limb pain, myalgia
Ophthalmic: Blurred vision
Otic: Tinnitus
Respiratory: Bronchitis, cough, paranasal sinus congestion, sinus headache
Miscellaneous: Fever
Postmarketing:
Cardiovascular: Acute myocardial infarction, atrial fibrillation, bradycardia, cardiac failure, cerebrovascular accident, deep vein thrombosis, edema, flushing, hypertensive crisis, hypotension, orthostatic hypotension, phlebitis, prolonged QT interval on ECG (Funk 2013), pulmonary embolism, syncope, tachycardia, thrombosis, torsades de pointes, ventricular arrhythmia, ventricular tachycardia
Dermatologic: Alopecia, dermatitis, ecchymoses, erythema multiforme, skin photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria
Endocrine & metabolic: Diabetes mellitus, heavy menstrual bleeding, hypercholesterolemia, hyperglycemia, hyperprolactinemia, hypoglycemia, hypokalemia, hyponatremia (Rawal 2017), SIADH (Raj 2018)
Gastrointestinal: Dysphagia, gastroesophageal reflux disease, gastrointestinal hemorrhage (Kumar 2009), pancreatitis
Genitourinary: Dysuria, erectile dysfunction, orgasm disturbance, priapism (Budak 2019), sexual disorder (Roy 2019), spontaneous abortion, urinary retention
Hematologic & oncologic: Agranulocytosis, anemia, aplastic anemia, hemolytic anemia, hypoprothrombinemia, immune thrombocytopenia, increased INR, leukopenia, rectal hemorrhage, thrombocytopenia
Hepatic: Hepatic failure, hepatic necrosis, hepatitis, increased liver enzymes, increased serum bilirubin
Hypersensitivity: Anaphylaxis, angioedema
Nervous system: Abnormal gait, aggressive behavior, agitated depression, agitation, akathisia, amnesia, anxiety, apathy, ataxia, choreoathetosis, delirium, delusion, depersonalization, dystonia, extrapyramidal reaction, hallucination, hypoesthesia, hypomania (Sharma 2009b), mania (Prapotnik 2004), myasthenia, myoclonus, neuroleptic malignant syndrome (Stevens 2008), nightmares, panic, paranoid ideation, parkinsonism, psychosis, restless leg syndrome, seizure, serotonin syndrome (Huska 2007; Sanyal 2010), suicidal ideation (Madsen 2019), suicidal tendencies, tardive dyskinesia, vertigo, withdrawal syndrome (De Berardis 2014)
Neuromuscular & skeletal: Bone fracture (fragility) (Khanassov 2018), dyskinesia, rhabdomyolysis, tremor
Ophthalmic: Acute angle-closure glaucoma (AlQuorain 2016; Zelefsky 2006), diplopia, mydriasis, nystagmus disorder, subconjunctival hemorrhage (Sharma 2009a), visual disturbance
Renal: Acute renal failure
Respiratory: Dyspnea, epistaxis (Lake 2000)
* See Cautions in AHFS Essentials for additional information.
Allergy and Idiosyncratic Reactions
Toxicology
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 Open Interactions
Acalabrutinib: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
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
Agents with Blood Glucose Lowering Effects: Selective Serotonin Reuptake Inhibitors may enhance the hypoglycemic effect of Agents with Blood Glucose Lowering Effects. 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
Almotriptan: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy
Alosetron: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy
Amisulpride (Oral): May enhance the QTc-prolonging effect of QT-prolonging Agents (Moderate Risk). Risk C: Monitor therapy
Amphetamines: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability). Initiate amphetamines at lower doses, monitor frequently, and adjust doses as needed. Risk C: Monitor therapy
Anticoagulants: Agents with Antiplatelet Properties may enhance the anticoagulant effect of Anticoagulants. Exceptions: Bemiparin; Enoxaparin; Heparin. Risk C: Monitor therapy
Antiemetics (5HT3 Antagonists): May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Exceptions: Alosetron; Ondansetron; Ramosetron. Risk C: Monitor therapy
Antipsychotic Agents: Serotonergic Agents (High Risk) may enhance the adverse/toxic effect of Antipsychotic Agents. Specifically, serotonergic agents may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotic Agents may enhance the serotonergic effect of Serotonergic Agents (High Risk). 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
Aspirin: Selective Serotonin Reuptake Inhibitors may enhance the antiplatelet effect of Aspirin. Risk C: Monitor therapy
Bemiparin: Agents with Antiplatelet Properties may enhance the anticoagulant effect of Bemiparin. Management: Avoid concomitant use of bemiparin with antiplatelet agents. If concomitant use is unavoidable, monitor closely for signs and symptoms of bleeding. Risk D: Consider therapy modification
Brexanolone: Selective Serotonin Reuptake Inhibitors may enhance the CNS depressant effect of Brexanolone. 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. Risk C: Monitor therapy
BusPIRone: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy
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: May enhance the antiplatelet effect of Escitalopram. 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
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
Cyclobenzaprine: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy
CYP2C19 Inhibitors (Moderate): May increase the serum concentration of Escitalopram. Exceptions: FLUoxetine; FluvoxaMINE; Moclobemide; Voriconazole. Risk C: Monitor therapy
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
Dapoxetine: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Do not use serotonergic agents (high risk) with dapoxetine or within 7 days of serotonergic agent discontinuation. Do not use dapoxetine within 14 days of monoamine oxidase inhibitor use. Dapoxetine labeling lists this combination as contraindicated. 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
Dexmethylphenidate-Methylphenidate: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy
Dextromethorphan: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy
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
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
DULoxetine: Selective Serotonin Reuptake Inhibitors may enhance the antiplatelet effect of DULoxetine. Selective Serotonin Reuptake Inhibitors may enhance the serotonergic effect of DULoxetine. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, mental status changes) when these agents are combined. In addition, monitor for signs and symptoms of bleeding. 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
Eletriptan: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy
Enoxaparin: Agents with Antiplatelet Properties may enhance the anticoagulant effect of Enoxaparin. Management: Discontinue antiplatelet agents prior to initiating enoxaparin whenever possible. If concomitant administration is unavoidable, monitor closely for signs and symptoms of bleeding. Risk D: Consider therapy modification
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
Erdafitinib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy
Ergot Derivatives: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Exceptions: Lisuride; Nicergoline. Risk C: Monitor therapy
Esomeprazole: May increase the serum concentration of Escitalopram. Risk C: Monitor therapy
Fat Emulsion (Fish Oil Based): May enhance the adverse/toxic effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Fenfluramine: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Risk C: Monitor therapy
Fexinidazole [INT]: May enhance the QTc-prolonging effect of QT-prolonging Agents (Moderate Risk). Risk X: Avoid combination
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
Heparin: Agents with Antiplatelet Properties may enhance the anticoagulant effect of Heparin. Management: Decrease the dose of heparin or agents with antiplatelet properties if coadministration is required. Risk D: Consider therapy modification
Herbs (Anticoagulant/Antiplatelet Properties) (eg, Alfalfa, Anise, Bilberry): May enhance the adverse/toxic effect of Agents with Antiplatelet Properties. Bleeding may occur. Management: Avoid combination when possible. If used, monitor more closely for evidence of bleeding. Discontinue herbal products with anticoagulant or antiplatelet actions 2 weeks prior to surgical, dental, or invasive procedures. Risk D: Consider therapy modification
Hydroxychloroquine: Escitalopram may enhance the hypoglycemic effect of Hydroxychloroquine. Hydroxychloroquine may enhance the QTc-prolonging effect of Escitalopram. Risk C: Monitor therapy
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
Icosapent Ethyl: May enhance the antiplatelet 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
Lasmiditan: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy
Levomethadone: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. 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. Risk X: Avoid combination
Lofexidine: May enhance the QTc-prolonging effect of QT-prolonging Antidepressants (Moderate Risk). QT-prolonging Antidepressants (Moderate Risk) may enhance the QTc-prolonging effect of Lofexidine. 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
Lorcaserin (Withdrawn From US Market): May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy
Lumacaftor and Ivacaftor: May decrease the serum concentration of Escitalopram. Risk C: Monitor therapy
Metaxalone: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. 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
MetyroSINE: May enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Risk C: Monitor therapy
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 (Antidepressant): Selective Serotonin Reuptake Inhibitors may enhance the serotonergic effect of Monoamine Oxidase Inhibitors (Antidepressant). This could result in serotonin syndrome. 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
Nefazodone: May enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. 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 alternatives to NSAIDs. Monitor for evidence of bleeding and diminished antidepressant effects. It is unclear whether COX-2-selective NSAIDs reduce risk. Risk D: Consider therapy modification
Nonsteroidal Anti-Inflammatory Agents (Topical): May enhance the antiplatelet effect of Selective Serotonin Reuptake Inhibitors. Risk C: Monitor therapy
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. Risk C: Monitor therapy
Ondansetron: May enhance the QTc-prolonging effect of QT-prolonging Antidepressants (Moderate Risk). Ondansetron may enhance the serotonergic effect of QT-prolonging Antidepressants (Moderate Risk). 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 or serotonin syndrome may be at even higher risk. Risk C: Monitor therapy
Opioid Agonists: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Exceptions: Alfentanil; Benzhydrocodone; Buprenorphine; Butorphanol; Codeine; Dihydrocodeine; FentaNYL; HYDROcodone; Levomethadone; Meperidine; Methadone; Oliceridine; OxyCODONE; SUFentanil; TraMADol. Risk C: Monitor therapy
Opioid Agonists (metabolized by CYP3A4 and CYP2D6): May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy
Opioid Agonists (metabolized by CYP3A4): May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Exceptions: Levomethadone; Methadone. Risk C: Monitor therapy
Oxitriptan: Serotonergic Agents (High Risk) may enhance the serotonergic effect of Oxitriptan. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy
Ozanimod: May enhance the adverse/toxic effect of Serotonergic Agents (High Risk). Management: Concomitant use of ozanimod with serotonergic agents is not recommended. If combined, monitor patients closely for the development of hypertension, including hypertensive crises. Risk D: Consider therapy modification
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
Pimozide: May enhance the QTc-prolonging effect of QT-prolonging Agents (Moderate Risk). Risk X: Avoid combination
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
Ramosetron: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy
Rasagiline: Selective Serotonin Reuptake Inhibitors may enhance the serotonergic effect of Rasagiline. This could result in serotonin syndrome. Risk X: Avoid combination
RifAMPin: May decrease the serum concentration of Escitalopram. 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
Safinamide: May enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This could result in serotonin syndrome. Management: Use the lowest effective dose of SSRIs in patients treated with safinamide and monitor for signs and symptoms of serotonin syndrome/serotonin toxicity. Risk D: Consider therapy modification
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
Selective Serotonin Reuptake Inhibitors: May enhance the antiplatelet effect of other Selective Serotonin Reuptake Inhibitors. Selective Serotonin Reuptake Inhibitors may enhance the serotonergic effect of other Selective Serotonin Reuptake Inhibitors. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, mental status changes) when these agents are combined. In addition, monitor for signs and symptoms of bleeding. Exceptions: Citalopram; Dapoxetine; Vortioxetine. Risk C: Monitor therapy
Selegiline: Selective Serotonin Reuptake Inhibitors may enhance the serotonergic effect of Selegiline. This could result in serotonin syndrome. Risk X: Avoid combination
Selumetinib: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Serotonergic Agents (High Risk, Miscellaneous): May enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy
Serotonergic Non-Opioid CNS Depressants: Selective Serotonin Reuptake Inhibitors may enhance the serotonergic effect of Serotonergic Non-Opioid CNS Depressants. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy
Serotonergic Opioids (High Risk): May enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) if these agents are combined. Exceptions: TraMADol. Risk C: Monitor therapy
Serotonin 5-HT1D Receptor Agonists (Triptans): May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Exceptions: Almotriptan; Eletriptan. Risk C: Monitor therapy
Serotonin/Norepinephrine Reuptake Inhibitors: Selective Serotonin Reuptake Inhibitors may enhance the antiplatelet effect of Serotonin/Norepinephrine Reuptake Inhibitors. Selective Serotonin Reuptake Inhibitors may enhance the serotonergic effect of Serotonin/Norepinephrine Reuptake Inhibitors. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, mental status changes) when these agents are combined. In addition, monitor for signs and symptoms of bleeding. Exceptions: DULoxetine. Risk C: Monitor therapy
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 enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. St John's Wort may decrease the serum concentration of Serotonergic Agents (High Risk). Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy
Syrian Rue: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. 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: May enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Specifically, the risk for serotonin syndrome/serotonin toxicity and seizures may be increased. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) and seizures when these agents are combined. Risk C: Monitor therapy
Tricyclic Antidepressants: May enhance the serotonergic effect of Escitalopram. Escitalopram may increase the serum concentration of Tricyclic Antidepressants. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) and increased TCA concentrations/effects if these agents are combined. Exceptions: Doxepin (Systemic); Doxepin (Topical). Risk C: Monitor therapy
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
Vortioxetine: May enhance the antiplatelet effect of Selective Serotonin Reuptake Inhibitors. Vortioxetine may enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, mental status changes) when these agents are combined. In addition, monitor for signs and symptoms of bleeding. Risk C: Monitor therapy
Zanubrutinib: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Gene Testing May Be Considered
Genes of Interest
- Brain-Derived Neurotropic Factor
- Cytochrome P450 3A4
- FK506 Binding Protein 5
- G protein beta subunit 3
- Monoamine Oxidase A
- Serotonin Receptor 2A
- Solute Carrier 6A4
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); screen all patients for any personal or family history of bipolar disorder, hypomania, or mania (prior to initiating therapy); 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]
Generic: 5 mg/5 mL (10 mL, 240 mL)
Tablet, Oral:
Lexapro: 5 mg
Lexapro: 10 mg, 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): $4.14 - $4.51
10 mg (per each): $4.33 - $4.72
20 mg (per each): $4.51 - $4.92
Tablets (Lexapro Oral)
5 mg (per each): $13.83
10 mg (per each): $14.46
20 mg (per each): $15.09
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:
Anxiety disorders (generalized anxiety, obsessive-compulsive, panic, and posttraumatic stress disorder): Initial effects may be observed within 2 weeks of treatment, with continued improvements through 4 to 6 weeks (Issari 2016; Varigonda 2016; WFSBP [Bandelow 2012]); some experts suggest up to 12 weeks of treatment may be necessary for response, particularly in patients with obsessive-compulsive disorder and posttraumatic stress disorder (BAP [Baldwin 2014]; Katzman 2014; WFSBP [Bandelow 2012]).
Body dysmorphic disorder: Initial effects may be observed within 2 weeks; some experts suggest up to 12 to 16 weeks of treatment may be necessary for response in some patients (Phillips 2008).
Depression: Initial effects may be observed within 1 to 2 weeks of treatment, with continued improvements through 4 to 6 weeks (Papakostas 2006; Posternak 2005; Szegedi 2009; Taylor 2006).
Premenstrual dysphoric disorder: Initial effects may be observed within the first few days of treatment, with response at the first menstrual cycle of treatment (ISPMD [Nevatte 2013]).
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
Hepatic function impairment: Patients with mild and moderate hepatic impairment had a 51% and 69% increase in AUC, respectively. Additionally, the clearance of those with moderate impairment was 16 L/hour compared to a 25 L/hour clearance in healthy patients (Areberg 2006).
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.
Related Information
- Antidepressant Receptor Profile
- Beers Criteria 2019: Potentially Inappropriate Medication Use in Older Adults ≥65 Years of Age
- Comparison of Antidepressant Adverse Effects
- Drug-Induced Prolongation of the QT Interval and Torsades de Pointes
- Drugs With Actionable Pharmacogenomic Recommendations
- Relative Infant Dose
- Selective Serotonin Reuptake Inhibitors (SSRIs) Pharmacokinetics
- Selective Serotonin Reuptake Inhibitors (SSRIs) Receptor Profile
Pharmacotherapy Pearls
The tablet and oral solution dosage forms are bioequivalent.
Clinically, escitalopram 20 mg is equipotent to citalopram 40 mg. Do not coadminister with citalopram.
Index Terms
Escitalopram Oxalate; Lu-26-054
FDA Approval Date
August 14, 2002
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Brand Names: International
Afya (CR, DO, GT, HN, NI, PA, SV); Bitalofar (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, ID, 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); Depresan (UA); Depresinal (RO); Depsit (LK); E-Zentius (PE); Ecinil (LK); Edpa (KR); Elapram (ID); Elicea (MY, RO); Elxion (ID); Epram (BD, TW, UY); Esciprex (IE); Escital (KR); Escitalpro (IE); Escitam (UA); Escivex (PH); Esidep (TH); Esipram (AU); Esitalo (AU, HK, PH); Eslo (MY); Eslopran (CO); Esopam (HK, TH); Esoplex (LB); Esopram (UA); Esram (HR); Estan (RO); 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); Jovia 20 (TH); L-Xapam (KR); Leeyo (TW); Lepax (TW); Lexacure (KR); Lexam (AU); Lexapam (KR); Lexapro (AR, AU, BB, BM, BR, BS, BZ, CN, CR, DO, EC, GT, GY, HK, HN, IE, JM, JP, KR, MY, NI, NL, NZ, PA, PE, PH, PR, SG, SR, SV, 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)
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