Escitalopram (Lexapro, Cipralex, Esertia)

Escitalopram is a highly selective serotonin reuptake inhibitor (SSRI) used to treat depression and anxiety. Escitalopram was developed collaboratively by Forest Pharmaceuticals and Lundbeck, the developer of citalopram and was approved for use in the US in 2003.

Some people assert that escitalopram is an example of "lifecycle management"-finding new ways to use or market a drug to preserve the patent or the market share of the drug. Because escitalopram is an isomer of citalopram, it took less time and money to develop and was ready for marketing by the time the patent on citalopram expired. Some people assert that the two drugs are virtually identical and that escitalopram should not be patented. In court challenges, however, Forest Pharmaceuticals demonstrated that there are significant differences between the drugs, and the patent for escitalopram has been upheld.

The Bottom Line: What You Really Need to Know

Uses of escitalopram

Escitalopram is approved for the treatment of Major Depressive Disorder (MDD) and General Anxiety Disorder (GAD) in adults. It is also used to treat other anxiety disorders and obsessive compulsive disorder. It may be helpful in treating other problems such as body dysmorphic disorder and pervasive developmental disorder.

Dosage and instructions

The usual dose of escitalopram is 10 mg/day for depression and 10-20 mg/day for anxiety. The dose may need to be decreased in the elderly and in people with liver problems. Escitalopram is taken once a day and can be taken either in the morning or evening, with or without food.

How escitalopram works

Although no one is certain what causes depression and anxiety, one probable cause is an imbalance of chemicals called neurotransmitters, which help carry messages between nerve cells. Neurotransmitters are found at the junction between two nerve cells; they are released by one cell and absorbed by the other one. Some serotonin is also reabsorbed by the first cell.

SSRI medications block the reabsorption of neurotransmitters by the first cell, which allows them to accumulate and restores chemical balance. Dopamine, norepinephrine and serotonin are the neurotransmitters most often affected by SSRI medications.

Serotonin is thought to be the neurotransmitter most responsible for depression and anxiety, and pharmaceutical companies have been trying to develop drugs that only block serotonin reuptake without affecting dopamine or norepinephrine. Escitalopram is the most serotonin selective medication that has been developed to date.

Neurotransmitters and other biochemicals work by binding to receptor sites on cells. It works much like a lock and key-the receptor site is the lock, and only the right key will fit into it. When the key is in the lock, the site is blocked and no other key can access that lock.

Most neurotransmitters, medications and other organic chemicals have different isomers. Isomers are different forms, or shapes, of the molecules of a chemical. Because they are shaped differently, they may react with receptor sites differently. That's what makes escitalopram different from other SSRIs, including it's parent medication, citalopram. Escitalopram contains only one isomer of the compound-the one that fits best into the receptor. That's why it is more powerful than citalopram and has fewer side effects and drug interactions than other SSRI medications.

Side effects of escitalopram

In studies that compared escitalopram to other medications, it had fewer side effects than either paroxetine or venlafaxine. Still, many people experience mild to moderate side effects when taking escitalopram. Most resolve after taking the medication for a few weeks. The most common side effects are dry mouth, nausea, sleep difficulties, sweating, fatigue and sexual problems.

Sexual problems are a common problem with antidepressants. Escitalopram is associated with decreased libido, ejaculatory dysfunction and female anorgasmia (inability to experience orgasm). If you experience sexual side effects while taking escitalopram, it is important to discuss them with your doctor to determine what treatment options are available. Do not discontinue taking the medication; abrupt discontinuation can cause withdrawal symptoms.

Less frequently experienced side effects of escitalopram include:

Drug interactions

There are few direct interactions between escitalopram and other medications, but many interactions related to co-action and co-metabolism. Make sure your doctor and pharmacist know what medications you take, including over the counter drugs, herbal and naturopathic remedies, vitamins and minerals, supplements and medications you only take occasionally. Some medications that interact with escitalopram are:

Sometimes you can continue to take escitalopram while taking other medications, but will need to have the dose adjusted.

Escitalopram interacts with some herbal treatments, including grapefruit extract or juice, St. John's Wort and kava kava.

Amphetamines and other recreational drugs may also interact with escitalopram.

Withdrawal

Like other SSRI medications, escitalopram must be withdrawn gradually. Abrupt discontinuation can cause severe symptoms such as:

Warnings, precautions and contraindications

Suicide risk: SSRI medications have been implicated in increased suicide risk in children, adolescents and young adults. Anyone who starts taking these medications should be monitored closely during the first several weeks of therapy. This includes at least weekly appointments with a physician or therapist and daily monitoring by friends or family. Friends and family should be instructed to ask the individual if he or she is having thoughts of harming or killing himself. The patient or family member should notify the doctor immediately if they notice:

Pregnancy risk: Escitalopram has not been tested in pregnant or lactating women. The drug does cross the placental barrier and is excreted in breast milk. SSRI medications have been implicated in birth defects, including heart defects and pulmonary hypertension of the newborn. Babies born to mothers who are taking SSRIs have exhibited symptoms of SSRI withdrawal and serotonin syndrome. SSRIs are not recommended for women who are pregnant or who wish to become pregnant.

Serotonin Syndrome: Serotonin syndrome is a toxic syndrome. It occasionally occurs with SSRI overdose, but is more common when SSRIs are taken with other "serotoninergic" medications. Symptoms can be mild, moderate or severe.

The symptoms of serotonin syndrome come on quickly, within minutes or hours of taking a serotonergic medication. Self-medicating with over-the-counter drugs, alternative therapies or recreational drugs can cause serotonin syndrome. Serotonin syndrome is very similar to neuroleptic malignant syndrome (NMS) and may be difficult to differentiate from it.

MAOIs and escitalopram: MAOI antidepressants have a serotoninergic effect and should not be taken with SSRIs. Both MAOIs and SSRIs are highly bound to plasma and remain in the body for days to weeks after you stop taking them. You should not start taking one type of medication for at least two weeks after stopping the other one to make sure the first medication has been completely eliminated from your body.

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