Escitalopram (Cipralex)

Primer

Escitalopram (Tradename: Cipralex/Lexapro) is a medication in the Selective Serotonin Reuptake Inhibitors (SSRI) class.

Metabolism

Metabolized by CYP2C19, 3A4

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

  • Start at 10mg
  • Maximum dose is 20mg per day, due to QTc concerns[1]
Adult Dosing
  • Max dose is 20mg
Geriatric Dosing
  • Start at 5mg and increase to 10mg, max dose is 10mg in geriatric population

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)[2]
  • 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

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

QT prolongation

See main article: QT (QTc) Prolongation and Monitoring

Citalopram and escitalopram both have a dose-dependent QTc prolongation. This effect is greater in citalopram than 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.[3][4]

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) 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.
3) Lam, R. W. (2013). Psychopharmacology for the Clinician. Journal of psychiatry & neuroscience: JPN, 38(2), E5.
4) Hasnain, M., Howland, R. H., & Lam, R. W. (2013). Escitalopram and QTc prolongation/Author response. Journal of psychiatry & neuroscience: JPN, 38(4), E11.