Salient Features of Escitalopram (Lexapro)
Escitalopram (Lexapro) is the mirror image molecule of citalopram and is the most recent agent approved for the treatment of major depressive disorder in the United States, having been introduced in 2002. It is a second-generation antidepressant, belonging to the group of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It is available under the brand-name Lexapro in the US.
A meta-analysis that compared 12 second-generation antidepressants from 117 published trials that collectively included almost 26,000 participants, ranked escitalopram as one of the top four antidepressants for efficacy, although escitalopram and sertraline were preferred when tolerability and efficacy rankings were combined. Escitalopram is one of the most widely used for treatment of major depressive disorder. Antidepressant actions are similar in efficacy and time course to tricyclic antidepressants (TCAs). But, acute toxicity (especially cardiotoxicity) is less than that of monoamine oxidase inhibitors (MAOIs) or TCAs, so overdose risk is reduced.
Escitalopram is also effective in the treatment of generalized anxiety disorder, phobias, social anxiety disorder, post-traumatic stress disorder and obsessive-compulsive disorder. It is one of the first-line agents for pharmacological treatment of significant OCD, anxiety disorders, and mood symptoms.
Side effects include nausea, insomnia and sexual dysfunction. It is less sedating than the older TCAs.
Escitalopram (Lexapro) is only one of the two SSRIs that have FDA approval for acute and maintenance treatment of major depression in children and adolescents (>12 years old), the other being fluoxetine (>8 years old), with the greatest amount of data supporting their safety and efficacy in the pediatric population. Escitalopram exhibits an age-dependent decrease in metabolism and should be dosed with care in elderly patients.
Uses of Escitalopram
Escitalopram is prescribed for major depressive disorder, obsessive-compulsive disorder, panic disorder, generalized anxiety disorder, fibromyalgia and neuropathic pain, among other disorders.
- Depression or major depressive disorder (MDD): The dosage of escitalopram should be increased gradually. The starting daily dosage is 5 to 10 mg. For some patients, daily dosage of 10 mg is sufficient, although higher dosages may be required. The maximum daily dose is 20 mg.
- Anxiety disorders: The anxiolytic effect of escitalopram is not immediate but takes days or weeks to develop after commencing drug therapy, suggesting that adaptive responses to the initial effects of these drugs that develop over time are important. Escitalopram (Lexapro) is beneficial in specific anxiety conditions, such as generalized anxiety disorder, social phobias, obsessive-compulsive disorder, and panic disorder. These effects appear to be related to the capacity of serotonin to regulate the activity of brain structures, such as the amygdala and locus ceruleus, that are thought to be involved in the genesis of anxiety. Interestingly, escitalopram often will produce some increases in anxiety in the short term that dissipate with time. Therefore, the maxim “start low and go slow” is indicated with anxious patients; however, many patients with anxiety disorders ultimately will require doses that are about the same as those required for the treatment of depression. The SSRIs citalopram, escitalopram, and sertraline may be particularly effective treatments for anxiety in the elderly based on their low propensity for drug interactions and short half-lives. If started at too high a dose, it may initially exacerbate symptoms of anxiety and, therefore, a lower starting dose of 2.5 mg/day of escitalopram is often indicated in elderly anxious individuals. Once it has been established that the patient is tolerating the starting dose, the dose should then be gradually increased to the usual therapeutic range of 5 mg/day, not exceeding 10 mg/day. Both citalopram and escitalopram have been associated with dose-dependent prolongation of the QT interval on EKG and, as a result, it is recommended not to exceed 10 mg/day of escitalopram in persons 65 years or older.
- Generalized Anxiety Disorders (GAD): People with GAD suffer from a combination of both physical symptoms and psychic anxiety. Large RCTs, as well as systematic reviews and meta-analyses, confirm the benefit of escitalopram as one of the first-line choices. The longer-term maintenance studies clearly suggest that patients continue to improve and are more likely to achieve remission from their symptoms of GAD if they are continued at full dose of their treatment over a period of at least 1 year. Open-label trials support the potential utility of escitalopram for comorbid depression and GAD in older adults. Escitalopram is a reasonable first-line choice for the treatment of GAD in later life, given that it has FDA approval for this condition and there are efficacy and tolerability data specific to the elderly.
- Social Anxiety Disorder: This has been treated successfully with escitalopram 20 mg, which was significantly more effective than placebo or paroxetine 20 mg on five of six symptom dimensions of the Liebowitz Social Anxiety Scale (LSAS).
- Panic Disorder: Meta-analyses and RCTs have confirmed the benefit of several classes of antidepressants, including escitalopram, in this condition. Escitalopram is often one of the antidepressants recommended as initial therapy.
- Specific Phobia: Escitalopram (and paroxetine) may be useful as second-line treatment if patients do not respond to psychotherapy.
- Obsessive-compulsive disorder OCD: Although escitalopram is not FDA-approved for OCD at this time escitalopram is found to be quite effective at higher doses, say, 30 mg. A combination of escitalopram and bupropion is also found effective. In pediatric cases of OCD, the dose range is 5-20 mg/day. Several studies have investigated escitalopram efficacy in OCD treatment. Escitalopram 20 mg/day was found superior to the others in total Y-BOCS score improvement and in remission rates. Higher dose escitalopram was also associated with a significantly earlier response, separating from the other treatments as early as week 6.
- Alcohol use disorder (AUD): Although SSRIs have not been shown to be effective treatments for AUD in patients without a comorbid mental disorder, SSRIs like escitalopram and other antidepressants may decrease intake when AUD and depression co-occur; if alcohol use occurs as a consequence of depression, treating the underlying problem can decrease drinking.
- Escitalopram is effective in post-stroke depression, given in the dose of 5 mg/day in those over age 65, and 10 mg/day under age 65, over 1 year.
- Cancer-related fatigue: Escitalopram 5–10 mg/day is the starting dose, going up to the dose range of 5–20 mg/day.
- Agitation in dementia: Escitalopram (Lexapro) is an option for the treatment of persistent agitation and aggression in dementia (neurocognitive disorder) not responding to psychosocial environmental interventions. With regard to depression, consideration may be given to an SSRI such as escitalopram or citalopram.
- Premature ejaculation: Delay in ejaculation occurs with escitalopram 10-20 mg/day.
- Depression in cardiac patients: Good results with respect to patient satisfaction, mood, and quality of life outcomes, in patients with depression following admission for coronary artery disease or heart failure, in patients with recent acute coronary syndromes, and in post-bypass patients (Bypassing the Blues Trial).
- Psychocutaneous disorders: Escitalopram is considered first-line treatment for obsessive-compulsive and related disorders like body-focused repetitive behaviors: dermatitis artefacta, trichotillomania, skin picking disorder, and body dysmorphic disorder.
- Premenstrual dysphoric disorder (PMDD) and severe premenstrual syndrome (PMS): Treatment of PMDD and Severe PMS is with escitalopram 10–20 mg daily.
- Postpartum depression (PPD): In small, open trials, escitalopram was effective for the treatment of PPD.
- Perimenopausal Vasomotor and Depressive Symptoms: Escitalopram may improve distress tolerance of hot flashes via symptomatic improvement of coexisting mild insomnia, anxiety, dysphoria, and/or irritability.
- Tourette and tic disorders: Starting dose of escitalopram is 2.5 mg/day, going up to 2.5-20 mg/day, with a maximum dose of 20 mg/day.
- Transplant patients: Escitalopram is preferred due to a lack of drug-drug interactions.
Dosage of Lexapro (Escitalopram)
Escitalopram is available in 10- and 20-mg-size tablets, both of which are scored. An oral solution of 5 mg/5 mL is available as well.
Many patients are observed to do well if citalopram or escitalopram is taken after meals for the first few days. After that period, they can take the medication with or without food. Peak serum levels of escitalopram are seen approximately 5 hours after ingestion.
The recommended starting dose of escitalopram is 10 mg per day. In clinical trials, the 20-mg-per-day dose did not offer any added benefit, but individual patients are often observed to benefit from the higher dose. If the dose is to be increased to 20 mg, this should generally occur no sooner than after 1 week on the initial dose. Because the 10-mg tablet is scored, 5 mg as a starting dose, if required, is available. 10 mg is the recommended daily dose in the geriatric population.
In Children and Adolescents, typical starting dose (mg) is 5 mg/day, and in adolescents it is 10 mg/day, with a target dose of 10-20 mg/day.
Side Effects of Lexapro (Escitalopram)
Common side effects of escitalopram include:
- Delayed ejaculation
- Lack of appetite
Less common side effects include:
- Decreased libido
- Excessive sweating
- Dry mouth
- Trouble sleeping
- Allergic reaction, including rash, itching/ /swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.
Interactions of Lexapro
Escitalopram does not affect hepatic metabolizing enzymes and may be less likely to cause drug interactions.
Like other SSRIs, escitalopram can cause the serious serotonin syndrome when combined with a monoamine oxidase inhibitor (MAOI). Hence, escitalopram should not be started until at least 14 days following discontinuation of treatment with an MAOI; this allows for the synthesis of the new MAO. At least 14 days should pass prior to beginning treatment with an MAOI following the end of treatment with escitalopram.
Escitalopram (20 mg per day) for 21 days resulted in increases in plasma levels of metoprolol given as a single dose of 100 mg. Likewise, escitalopram (20 mg per day) for 21 days resulted in increases in plasma levels of desipramine given as a single dose of 50 mg.
Taking certain migraine drugs called triptans with escitalopram could increase your risk of side effects.
Cimetidine may increase levels of escitalopram in your body and increase your risk of side effects.
Certain diuretics (water pills – drugs to get rid of excess water in your body) can decrease sodium levels in your body. Escitalopram may also decrease sodium. Taking water pills with these drugs may increase your risk of low sodium levels.
Your risk of bleeding is increased if you take escitalopram along with blood-thinning drugs, such as warfarin and nonsteroidal anti-inflammatory drugs like aspirin.
Brunton, L., 2018. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 13th ed. New York: McGraw Hill.
Ritter, J. et al., 2020. Rang and Dale’s Pharmacology. 9th ed. Edinburgh: Elsevier.
Sadock, B. J., Sadock, V. A. & Ruiz, P., 2017. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 10th ed. Philadelphia: Wolters Kluwer.
Tasman, A. et al. eds., 2015. Psychiatry. 4th ed. Oxford: Wiley Blackwell.