ess-sit-AL-o-pram

Therapeutic Classification: antidepressants

Pharmacologic Classification: selective serotonin reuptake inhibitors ssris

• Major depressive disorder.
• Generalized anxiety disorder.

Unlabeled Uses:

• Panic disorder.
• Obsessive-compulsive disorder.
• Post-traumatic stress disorder.
• Social anxiety disorder (social phobia).
• Premenstrual dysphoric disorder.

• Selectively inhibits the reuptake of serotonin in the CNS.

• Antidepressant action.

Absorption: 80% absorbed following oral administration.

Distribution: Widely distributed to tissues.

Metabolism/Excretion: Mostly metabolized by the liver, primarily by the CYP3A4 and CYP2C19 isoenzymes; 7% excreted unchanged by kidneys.

Half-life: 27–32 hr (↑ in older adults and hepatic impairment).

(antidepressant effect)

Contraindicated in:

• Hypersensitivity
• Concurrent use of pimozide
• Concurrent use of MAO inhibitors or MAO-like drugs (linezolid or methylene blue)
• Concurrent use of citalopram
• Angle-closure glaucoma.

Use Cautiously in:

• Personal or family history of bipolar disorder, mania, or hypomania (may activate mania/hypomania)
• History of seizures
• Patients at risk for suicide
• Hepatic impairment
• Severe renal impairment
• OB: Use during pregnancy only if potential maternal benefit justifies potential fetal risk
• Lactation: Use while breastfeeding only if potential maternal benefit justifies potential risk to infant
• Pedi: May ↑ risk of suicide attempt/ideation especially during early treatment or dose adjustment; safety not established in children <12 yr (major depressive disorder) or <7 yr (generalized anxiety disorder)
• Geri: Appears on Beers list. May worsen or cause syndrome of inappropriate antidiuretic hormone (SIADH) secretion and/or hyponatremia in older adults. Use with caution in older adults and closely monitor sodium concentrations when starting therapy or ↑ dose.

Derm: sweating.

Endo: SIADH.

F and E: hyponatremia.

GI: diarrhea, nausea, abdominal pain, constipation, dry mouth, indigestion.

GU: ↓libido, delayed/absent orgasm, ejaculatory delay/failure, erectile dysfunction.

Hemat: BLEEDING.

Metab: ↑appetite.

Neuro: insomnia, dizziness, drowsiness, fatigue, NEUROLEPTIC MALIGNANT SYNDROME, SUICIDAL THOUGHTS.
Misc: SEROTONIN SYNDROME.

Drug-Drug:

• May cause serious, potentially fatal reactions when used with MAO inhibitors; allow at least 14 days between escitalopram and MAO inhibitors.
• Concurrent use with MAO-inhibitor-like drugs, such as linezolid or methylene blue may ↑ risk of serotonin syndrome; concurrent use contraindicated; do not start therapy in patients receiving linezolid or methylene blue; if linezolid or methylene blue need to be started in a patient receiving escitalopram, immediately discontinue escitalopram and monitor for signs/symptoms of serotonin syndrome for 2 wk or until 24 hr after last dose of linezolid or methylene blue, whichever comes first (may resume escitalopram therapy 24 hr after last dose of linezolid or methylene blue).
• Concurrent use with pimozide may result in prolongation of the QT interval and is contraindicated.
• Use cautiously with other centrally acting drugs, including alcohol, antihistamines, opioid analgesics, and sedative/hypnotics; concurrent use with alcohol is not recommended.
• Drugs that affect serotonergic neurotransmitter systems, including tricyclic antidepressants, SNRIs, fentanyl, lithium, buspirone, tramadol, meperidine, methadone, amphetamines, and triptans, ↑ risk of serotonin syndrome.
• Cimetidine may ↑ levels.
• Serotonergic effects may be ↑ by lithium (concurrent use should be carefully monitored).
• Carbamazepine may ↓ levels.
• May ↑ levels of metoprolol.
• Use cautiously with tricyclic antidepressants due to unpredictable effects on serotonin and norepinephrine reuptake.
• ↑risk of bleeding with NSAIDs, aspirin, clopidogrel, prasugrel, ticagrelor, dabigatran, apixaban, edoxaban, rivaroxaban, or warfarin.

Drug-Natural Products:

• ↑risk of serotonin syndrome with St. John's wort and SAMe.

Major Depressive Disorder

• PO (Adults): 10 mg once daily, may ↑ to 20 mg once daily after 1 wk.
• PO (Geriatric Patients): 10 mg once daily.
• PO (Children 12 yr): 10 mg once daily, may ↑ to 20 mg once daily after 3 wk.

Generalized Anxiety Disorder

• PO (Adults): 10 mg once daily, may ↑ to 20 mg once daily after 1 wk.
• PO (Geriatric Patients): 10 mg once daily.
• PO (Children 7 yr): 10 mg once daily, may ↑ to 20 mg once daily after 2 wk.

(Generic available)

• Tablets: 5 mg; 10 mg; 20 mg;
• Orally disintegrating tablets: 10 mg; 20 mg;
• Oral solution (peppermint flavor): 1 mg/mL;

• Screen patient for a personal or family history of bipolar disorder, mania, or hypomania before starting therapy; may precipitate a mixed/manic episode.
• Monitor mood changes and level of anxiety during therapy.
• Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults 24 yr. After starting therapy, children, adolescents, and young adults should be seen by health care professional face-to-face at least weekly for 4 wk, then every other wk for next 4 wk, then at 12 wk, and then on advice of health care professional thereafter.
• Assess sexual function before starting escitalopram. Assess for changes in sexual function during treatment, including timing of onset; patient may not report.
• Assess for serotonin syndrome (mental changes [agitation, hallucinations, coma], autonomic instability [tachycardia, labile BP, hyperthermia], neuromuscular aberrations [hyperreflexia, incoordination], and/or GI symptoms [nausea, vomiting, diarrhea]), especially in patients taking other serotonergic drugs (SSRIs, SNRIs, triptans).

• Do not confuse escitalopram with citalopram.
• Do not administer escitalopram and citalopram concomitantly. When discontinuing therapy, taper to avoid potential withdrawal reactions (↓ dose by 50% for 3 days, then again by 50% for 3 days, then discontinue).
• PO: Administer as a single dose in the morning or evening without regard to meals.

• Instruct patient to take escitalopram as directed. Take missed doses on the same day as soon as remembered and consult health care professional. Resume regular dosing schedule next day. Do not double doses. Do not stop abruptly; should be discontinued gradually. Instruct patient to read Medication Guide before starting and with each Rx refill in case of changes.
• May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
• Advise patient, family, and caregivers to watch for suicidality, especially during early therapy or dose changes. Notify health care professional immediately if thoughts about suicide or dying, attempts to commit suicide, new or worse depression or anxiety, agitation or restlessness, panic attacks, insomnia, new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior or if rash or symptoms of serotonin syndrome occur.
• Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any other Rx, OTC, or herbal products, especially St. John's wort, alcohol, or other CNS depressants.
• Inform patient that escitalopram may cause symptoms of sexual dysfunction. In males, ejaculatory delay or failure, decreased libido, and erectile dysfunction may occur. In female patients, may result in decreased libido and delayed or absent orgasm. Advise patient to notify health care professional if symptoms occur.
• Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding. Use late in 3rd trimester may result in neonatal serotonin syndrome requiring prolonged hospitalization, respiratory support, and tube feeding; may occur immediately upon delivery. Symptoms include respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying. Use of escitalopram in last mo of pregnancy may ↑ risk of postpartum hemorrhage. Encourage pregnant patients to enroll in pregnancy exposure registry that monitors outcomes of women exposed to antidepressants during pregnancy by contacting National Pregnancy Registry for Antidepressants at 1-866-961-2388 or visiting online at womensmentalhealth.org/research/pregnancyregistry/antidepressants/. Monitor infants exposed to escitalopram via breastfeeding for sedation, poor feeding, and poor weight gain.
• Emphasize importance of follow-up exams to monitor progress.

• Increased sense of well-being.
  • Renewed interest in surroundings. May require 1–4 wk of therapy to obtain antidepressant effects. Full antidepressant effects occur in 4–6 wk.
• Decrease in anxiety.

Lexapro

Cipralex