Escitalopram

# Escitalopram ## Overview - **Classification**: Selective Serotonin Reuptake Inhibitor (SSRI) - **Mechanism**: Potent and selective inhibition of serotonin (5-HT) reuptake in the central nervous system (CNS), leading to increased serotonin concentrations in the synaptic cleft. ## Primary Indications 1. **Major Depressive Disorder (MDD)** - Treatment of acute and maintenance phases. 2. **Generalized Anxiety Disorder (GAD)** - Treatment of acute and maintenance phases. ## Adult Dosing ### Standard Dosing **Major Depressive Disorder (MDD)** - **Dose**: Initiate **10 mg** - **Frequency**: Once daily - **Route**: Oral - **Maximum dose**: May increase to **20 mg** once daily after at least 1 week. **Generalized Anxiety Disorder (GAD)** - **Dose**: Initiate **10 mg** - **Frequency**: Once daily - **Route**: Oral - **Maximum dose**: May increase to **20 mg** once daily after at least 1 week. ### Dose Adjustments - **Renal Impairment**: No dosage adjustment is generally needed for mild to moderate impairment. Use with caution in severe impairment. - **Hepatic Impairment**: Max dose **10 mg** once daily for patients with mild to moderate impairment. Not studied in severe impairment. - **Elderly Patients (≥65 years)**: Initiate **10 mg** once daily. Max dose **10 mg** once daily. ## Pediatric Dosing ### Neonates (0-28 days) - **Special Notes**: Not recommended. SSRI exposure late in pregnancy linked to persistent pulmonary hypertension of the newborn (PPHN). ### Infants (1-12 months) - **Special Notes**: Not recommended. Safety and efficacy not established. ### Children (1-12 years) - **Special Notes**: Not FDA approved for this age group for MDD or GAD. Safety and efficacy not established. ### Adolescents (13-18 years) **Major Depressive Disorder (MDD) & Generalized Anxiety Disorder (GAD)** - **Dose**: Initiate **10 mg** - **Frequency**: Once daily - **Route**: Oral - **Maximum dose**: May increase to **20 mg** once daily after at least 1 week. - **Special Notes**: Monitor closely for suicidality, especially at initiation and with dose changes. ## Safety Information ### Contraindications - **Absolute**: Concomitant use with MAOIs (risk of serotonin syndrome). - **Absolute**: Concomitant use with pimozide (risk of QTc prolongation). - **Absolute**: Hypersensitivity to escitalopram or citalopram. - **Absolute**: Concomitant use with linezolid or intravenous methylene blue (MAOI activity). ### Common Adverse Effects - **Very Common (>10%)**: Nausea, insomnia, ejaculation disorder, somnolence, sweating. - **Common (1-10%)**: Dry mouth, fatigue, dizziness, decreased libido, anorgasmia, diarrhea. - **Serious but Rare**: Serotonin syndrome, QTc prolongation, hyponatremia, suicidal ideation. ### Key Drug Interactions - **MAOIs**: Risk of **serotonin syndrome**. Separate by at least **14 days**. - **Pimozide**: **Contraindicated** due to risk of QTc prolongation. - **Other Serotonergic Drugs (e.g., triptans, tramadol, lithium, St. John's Wort)**: Increased risk of **serotonin syndrome**. Monitor closely. - **Anticoagulants/Antiplatelets (e.g., warfarin, NSAIDs)**: Increased risk of **bleeding**. Monitor INR for warfarin. - **Drugs that Prolong QT Interval**: Increased risk of **Torsades de Pointes**. Avoid co-administration if possible. ## Monitoring & Follow-up - **Before Treatment**: Assess for personal/family history of bipolar disorder or suicidal ideation. Consider baseline ECG if cardiac risk factors are present. - **During Treatment**: Monitor for worsening depression, emergence of suicidal thoughts/behaviors, changes in mood/behavior, and adverse effects (especially during dose titration). - **Clinical Signs**: Watch for symptoms of serotonin syndrome (e.g., agitation, hyperthermia, rapid heart rate, muscle rigidity). ## Clinical Pearls - 💡 **Onset of Action**: Clinical effect typically begins within **2-4 weeks**, full effect may take longer. - 💡 **Administration**: Can be taken with or without food. - 💡 **Discontinuation**: Taper gradually over several weeks to avoid withdrawal symptoms (e.g., dizziness, sensory disturbances). - 💡 **Suicidality Warning**: All antidepressants carry a **Black Box Warning** for increased risk of suicidal thoughts/behaviors in children, adolescents, and young adults (18-24 years). > **⚠️ Important**: This information is for educational purposes only. Always consult current prescribing information, local guidelines, and clinical judgment before prescribing.