Escitalopram (Cipralex/Lexapro)

Primer

Escitalopram (Trade name: Cipralex/Lexapro) is an antidepressant in the selective serotonin reuptake inhibitor (SSRI) class commonly used in the treatment of major depressive disorder.

Pharmacokinetics

Pharmacokinetics of Escitalopram

Absorption
Distribution
Metabolism
Elimination
Half-life

Escitalopram: Cytochrome P450 Metabolism

Substrate of (Metabolized by) 2C19, 3A4
Induces
Inhibits

Pharmacodynamics

Mechanism of Action

Toxicity

Indications

Escitalopram vs. Citalopram

Recommended daily dose ranges for citalopram and escitalopram

Population Citalopram Escitalopram
Adult 18-65 years
without risk factors 		• Starting: 20mg
• Maximum: 40mg 		• Starting: 10mg
• Maximum: 20mg
Adult >65 years or
impaired hepatic
function 		• Starting: 10mg
• Maximum: 20mg 		• Starting: 5mg
• Maximum: 10mg
Taking omeprazole* • Starting: 20mg
• Maximum: 20mg 		• Starting: 5mg
• Maximum: 10mg
*Omeprazole increases plasma levels of citalopram and escitalopram, increasing the risk of QT prolongation and hyponatraemia.

Dosing

Dosing for Escitalopram

Starting 10 mg PO daily
Titration Increase by 5 to 10 mg every 1 to 2 weeks, depending on tolerability
Maximum 20 mg per day (10 mg in adults >65), due to QTc concerns[1]
Taper Tapering/Switching Antidepressants

Formulations

  • Escitalopram comes in

Monitoring

Contraindications

Absolute

Relative

Drug-Drug Interactions

Side Effects

Adverse Events

QTc prolongation

Citalopram and escitalopram both have a dose-dependent QTc prolongation, but this effect is greater in citalopram than escitalopram (due to escitalopram only having S-enantiomer).[2][3]

Clinical Pearls

  • eScitalopram is the S-enantiomer of the racemic SSRI citalopram
    • Compared to citalopram, escitalopram is thought to be a more potent and selective serotonin reuptake inhibitor (though the clinical significance is unclear)[4]
  • A good first line choice for medically complex patients due to fewer drug-drug interactions
  • May be sedating for some patients, and activating for others

Special Populations

Geriatric

Pediatric

Obstetric and Fetal

Medically Ill

  • Dose should be reduced in patients with hepatic impairment and/or age > 65.

Resources

References

1) Do, A., Noohi, S., Elie, D., Mahdanian, A. A., Yu, C., Segal, M., ... & Rej, S. (2016). Health Canada warning on citalopram and escitalopram—its effects on prescribing in consultation-liaison psychiatry. Psychosomatics, 57(1), 57-63.
2) Lam, R. W. (2013). Psychopharmacology for the Clinician. Journal of psychiatry & neuroscience: JPN, 38(2), E5.
3) Hasnain, M., Howland, R. H., & Lam, R. W. (2013). Escitalopram and QTc prolongation/Author response. Journal of psychiatry & neuroscience: JPN, 38(4), E11.
4) Burke, W. J., & Kratochvil, C. J. (2002). Stereoisomers in psychiatry: the case of escitalopram. Primary care companion to the Journal of clinical psychiatry, 4(1), 20.