Escitalopram

Escitalopram

Lexapro Cipralex Lexamil Esipram

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Updated: December 06, 2025

Overview

Escitalopram is a selective serotonin reuptake inhibitor (SSRI) antidepressant widely used for the treatment of depression and anxiety disorders. As the S-enantiomer of citalopram, it demonstrates greater potency and selectivity for the serotonin transporter compared to the racemic mixture. Approved by the FDA in 2002, escitalopram has become a first-line treatment for major depressive disorder and generalized anxiety disorder due to its favorable efficacy and tolerability profile. It works by enhancing serotonergic neurotransmission in the central nervous system.

Drug Class

Selective Serotonin Reuptake Inhibitor (SSRI) Therapeutic Category: Antidepressant

Mechanism of Action

Escitalopram potently inhibits the serotonin transporter (SERT) by binding to the primary high-affinity binding site and an allosteric binding site. This dual action prevents presynaptic serotonin reuptake, increasing serotonin concentration in the synaptic cleft and enhancing serotonergic neurotransmission. Unlike other SSRIs, escitalopram has minimal affinity for histamine, muscarinic, or adrenergic receptors, contributing to its favorable side effect profile.

Pharmacokinetics

Absorption: Well absorbed after oral administration with 80% bioavailability (unaffected by food) Distribution: Extensive tissue distribution with 56% protein binding (primarily albumin) Metabolism: Hepatic metabolism via CYP2C19, CYP3A4, and CYP2D6 to S-demethylated and S-didemethylated metabolites Excretion: Renal (80%) and fecal (20%) excretion Half-life: 27-32 hours in healthy adults

Pharmacodynamics

• Increases synaptic serotonin levels within 3 hours of administration • Antidepressant effects typically manifest after 2-4 weeks • Downregulates 5-HT1A autoreceptors over time • Minimal effect on norepinephrine or dopamine reuptake

Indications

• Major Depressive Disorder (MDD): Treatment of acute and maintenance therapy for depression in adults and adolescents 12-17 years • Generalized Anxiety Disorder (GAD): Management of anxiety symptoms in adults • Off-label uses: Panic disorder, social anxiety disorder, OCD, and PTSD

Contraindications

Absolute: • Concurrent use with MAOIs or within 14 days of MAOI discontinuation • Known hypersensitivity to escitalopram or citalopram • Pimozide coadministration Relative: • Bipolar disorder (may induce manic episodes) • Seizure disorders • Uncontrolled angle-closure glaucoma

Dosage & Administration

Major Depressive Disorder: • Initial: 10 mg once daily • May increase to 20 mg after ≥1 week • Maintenance: 10-20 mg daily Generalized Anxiety Disorder: • Initial: 10 mg once daily • May increase to 20 mg after ≥1 week Elderly/Heptic Impaired: • Recommended maximum 10 mg daily

Special Populations

Pediatric: Safety established for MDD in adolescents 12-17 (10 mg initial, max 20 mg) Geriatric: Reduced clearance in elderly (max 10 mg/day recommended) Renal impairment: No dose adjustment needed for mild-moderate impairment Hepatic impairment: Half-life prolonged to 60 hours in cirrhosis (reduce dose by 50%)

Adverse Effects

Common (>10%): • Nausea (15-18%) • Insomnia (9-14%) • Somnolence (6-13%) • Dry mouth (6-9%) Serious (<1%): • Serotonin syndrome • QT prolongation • Suicidal ideation • Seizures • Hyponatremia/SIADH

Drug Interactions

• MAOIs: Risk of serotonin syndrome (contraindicated) • NSAIDs/anticoagulants: Increased bleeding risk • QTc-prolonging agents: Additive QT prolongation • CYP2C19 inhibitors: May increase escitalopram levels • Triptans: Increased serotonergic effects

Warnings & Precautions

• Black Box Warning: Increased risk of suicidal thoughts/behaviors in young adults • Serotonin syndrome risk with serotonergic drugs • QT prolongation at doses >20 mg/day • Discontinuation syndrome with abrupt cessation • Activation syndrome (anxiety/agitation) early in treatment

Pregnancy & Lactation

Pregnancy: Category C - Potential neonatal complications with third-trimester exposure Lactation: Excreted in breast milk (0.7-6.4% maternal dose); weigh benefits vs risks

Monitoring Parameters

• Mental status and suicidality • Serum sodium in elderly (SIADH risk) • ECG in patients with cardiac risk factors • Signs of serotonin syndrome • Height/weight in pediatric patients

Patient Counseling

• Take once daily (morning or evening) • May take 4-6 weeks for full effect • Do not stop abruptly • Report unusual behavior or suicidal thoughts • Avoid alcohol • Potential sexual side effects

Storage & Stability

Store at 25°C (77°F); excursions permitted to 15-30°C (59-86°F) Protect from light and moisture Stable in original packaging for 24 months

Clinical Pearls

• Most effective when taken consistently at same time daily • Consider lower starting doses in anxious patients • Taper over ≥1 week when discontinuing • Less weight gain than other antidepressants • Therapeutic drug monitoring not typically required

References

• Lexi-Drugs: Escitalopram. Lexicomp. 2023 • FDA Prescribing Information: Lexapro (escitalopram oxalate). 2022 • Stahl SM. Essential Psychopharmacology. 4th ed. Cambridge University Press; 2013

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