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meds:antidepressants:ssri:escitalopram [on April 21, 2020]
meds:antidepressants:ssri:escitalopram [on February 20, 2021] (current)
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-====== Escitalopram (Cipralex) ======+====== Escitalopram (Cipralex/Lexapro) ====== 
 +{{INLINETOC}} 
 ===== Primer ===== ===== Primer =====
-**Escitalopram** (Tradename: //Cipralex/////Lexapro//) is a medication ​in the [[meds:​antidepressants:​ssri:​home|]] class.+<WRAP group> 
 +<WRAP half column>​ 
 +**Escitalopram** (Trade name: //​Cipralex/​Lexapro//​) is an [[meds:​antidepressants:​home|antidepressant]] ​in the [[meds:​antidepressants:​ssri:​home|selective serotonin reuptake inhibitor (SSRI)]] class commonly used in the treatment of [[mood:​1-depression:​home|major depressive disorder]]. 
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +<catlist meds:​antidepressants:​ssri -columns:1 -noAddPageButton -sortAscending -noNSInBold>​ 
 +</​WRAP>​ 
 +</​WRAP>​
  
-===== Metabolism ​===== +===== Pharmacokinetics ​===== 
-Metabolized by CYP2C19, 3A4+<WRAP group> 
 +<WRAP half column>​ 
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See also article: **[[meds:​pharmacology:​home|]]** 
 +</​alert>​ 
 +<panel type="​info"​ title="​Pharmacokinetics of Escitalopram"​ subtitle=""​ no-body="​true"​ footer="">​ 
 +^ [[meds:​pharmacology:​home#​absorption|Absorption]] ​            ​| ​  | 
 +^ [[meds:​pharmacology:​home#​distribution|Distribution]] ​        ​| ​  | 
 +^ [[meds:​pharmacology:​home#​metabolism|Metabolism]] ​            ​| ​  | 
 +^ [[meds:​pharmacology:​home#​excretionelimination|Elimination]] ​ |   | 
 +^ [[meds:​pharmacology:​home#​half-life|Half-life]] ​              ​| ​  | 
 +</​panel>​ 
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See also article: **[[meds:​cytochrome-p450|]]** 
 +</​alert>​ 
 +<panel title="​Escitalopram:​ Cytochrome P450 Metabolism"​ no-body="​true">​ 
 +^ Substrate of (Metabolized by)  | 2C19, 3A4 
 +^ Induces ​        ​| ​ | 
 +^ Inhibits ​       |  | 
 +</​panel>​ 
 +</​WRAP>​ 
 +</​WRAP>​ 
 + 
 +===== Pharmacodynamics ===== 
 +==== Mechanism of Action ==== 
 +==== Toxicity ==== 
 + 
 +===== Indications ===== 
 +===== Escitalopram vs. Citalopram ===== 
 +<panel type="​info"​ title="​Recommended daily dose ranges for citalopram and escitalopram"​ subtitle=""​ no-body="​true"​ footer="​*Omeprazole increases plasma levels of citalopram and escitalopram,​ 
 +increasing the risk of QT prolongation and hyponatraemia.">​ 
 +^ Population ​                                       ^ [[meds:​antidepressants:​ssri:​citalopram|Citalopram]] ​ ^ [[meds:​antidepressants:​ssri:​escitalopram|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                      | 
 +</​panel>​
  
 ===== Dosing ===== ===== Dosing =====
-  * Start at 10mg +<panel type="​info"​ title="​Dosing for Escitalopram"​ no-body="​true">​ 
-  ​Maximum ​dose is 20mg per day, due to QTc concerns[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​26633294|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.]])]+^ 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[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​26633294|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.]])] | 
 +^ Taper     | [[meds:​antidepressants:​tapering-switching|]] | 
 +</​panel>​ 
 + 
 + 
 + 
 +==== Formulations ==== 
 +  * Escitalopram comes in  
 + 
 +==== Monitoring ==== 
 + 
 +===== Contraindications ===== 
 +==== Absolute ==== 
 +==== Relative ==== 
 + 
 +===== Drug-Drug Interactions ===== 
 + 
 +===== Side Effects ===== 
 + 
 +===== Adverse Events ===== 
 +  * [[meds:​antidepressants:​serotonin|Serotonin syndrome]] 
 + 
 +==== QTc prolongation ==== 
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See main article: **[[meds:​qtc]]** 
 +</​alert>​ 
 + 
 +Citalopram and escitalopram both have a dose-dependent QTc prolongation,​ but this effect is greater in [[meds:​antidepressants:​ssri:​citalopram|citalopram]] than [[meds:​antidepressants:​ssri:​escitalopram|escitalopram]] (due to escitalopram only having S-enantiomer).[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3581598/​|Lam,​ R. W. (2013). Psychopharmacology for the Clinician. Journal of psychiatry & neuroscience:​ JPN, 38(2), E5.]])][([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3692726/​|Hasnain,​ M., Howland, R. H., & Lam, R. W. (2013). Escitalopram and QTc prolongation/​Author response. Journal of psychiatry & neuroscience:​ JPN, 38(4), E11.]])]
  
-== Adult Dosing == 
-  * Max dose is 20mg 
-== Geriatric Dosing == 
-  * Start at 5mg and increase to 10mg, max dose is 10mg in geriatric population 
  
-===== Pearls =====+===== Clinical ​Pearls =====
   * e__**S**__citalopram is the __**S**__-enantiomer of the racemic SSRI [[meds:​antidepressants:​ssri:​citalopram|citalopram]]   * e__**S**__citalopram is the __**S**__-enantiomer of the racemic SSRI [[meds:​antidepressants:​ssri:​citalopram|citalopram]]
     * Compared to citalopram, escitalopram is thought to be a more potent and selective serotonin reuptake inhibitor (though the clinical significance is unclear)[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC314378/​|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.]])]     * Compared to citalopram, escitalopram is thought to be a more potent and selective serotonin reuptake inhibitor (though the clinical significance is unclear)[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC314378/​|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.]])]
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   * May be sedating for some patients, and activating for others   * May be sedating for some patients, and activating for others
  
 +===== Special Populations =====
 +==== Geriatric ====
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​
 +See main article: **[[meds:​pharmacology:​geri|]]**
 +</​alert>​
  
-==== Special Populations ​==== +==== Pediatric ​==== 
-Dose should be reduced in patients with hepatic impairment and/or age 65.+<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See main article: **[[meds:​pharmacology:​pediatric|]]** 
 +</alert>
  
-==== QT prolongation ​==== +==== Obstetric and Fetal ==== 
-<callout type="success">​{{fa>arrow-circle-right?color=green}} ​See main article: **[[meds:qtc]]**</callout>+<alert icon="​fa ​fa-arrow-circle-right ​fa-lg fa-fw" type="​success">​ 
 +See main article: **[[meds:pharmacology:​obstetric-and-fetal|]]** 
 +</alert>
  
-Citalopram and escitalopram both have a dose-dependent QTc prolongation. This effect is greater in [[meds:antidepressants:​ssri:​citalopram|citalopram]] than [[meds:antidepressants:ssri:​escitalopram|escitalopram]] (due to escitalopram only having S-enantiomer). The threshold for clinical significance of the QTc interval is an absolute duration of 500 ms or longer or a change from baseline of 60 ms or more.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3581598/​|Lam, R. W. (2013). Psychopharmacology for the Clinician. Journal of psychiatry & neuroscience:​ JPN, 38(2), E5.]])][([[https:​//​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3692726/​|Hasnain,​ M., Howland, R. H., & Lam, R. W. (2013). Escitalopram ​and QTc prolongation/Author responseJournal of psychiatry & neuroscience:​ JPN, 38(4), E11.]])]+==== Medically Ill ==== 
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See main article**[[meds:pharmacology:psychotropic-rx-medically-ill|]]** 
 +</alert> 
 +  * Dose should be reduced in patients with hepatic impairment ​and/or age > 65. 
 +===== Resources =====