Oskela
Get started

Drug Reference

escitalopram

Selective serotonin reuptake inhibitor (SSRI)· Brands: Cipralex, Lexapro, EscitalopramPO

Mechanism of action
Escitalopram is the active S-enantiomer of citalopram. It selectively inhibits the reuptake of serotonin (5-HT) at the presynaptic membrane by blocking the serotonin transporter (SERT), thereby increasing the concentration of serotonin in the synaptic cleft. This enhanced serotonergic neurotransmission is thought to underlie its antidepressant and anxiolytic effects. It has minimal affinity for adrenergic, dopaminergic, cholinergic, and histaminergic receptors, contributing to its favourable side effect profile.
Pharmacokinetics
Escitalopram is well absorbed after oral administration, with a bioavailability of approximately 80%. Peak plasma concentrations are reached in 4 to 5 hours. It undergoes hepatic metabolism primarily via CYP2C19, with some contribution from CYP3A4 and CYP2D6, forming inactive metabolites. The elimination half-life is about 27 to 32 hours, allowing once-daily dosing. Steady-state concentrations are achieved within a week. Excretion is mainly renal, with metabolites appearing in urine. Dose adjustment is not routinely required for renal impairment, but caution is advised in severe hepatic dysfunction.
Indications & dosing

Major depressive disorder (MDD)

Initiate at 10 mg/day; may increase to 20 mg/day after at least 1 week based on response. In elderly or hepatic impairment, max dose 10 mg/day. Continue for at least 6 months after remission to prevent relapse.

  • adult · PO: 10–20 mg once daily · Initiate at 10 mg/day; may increase to 20 mg/day after at least 1 week based on response. In elderly or hepatic impairment, max dose 10 mg/day. Continue for at least 6 months after remission to prevent relapse.

Generalized anxiety disorder (GAD)

Start 10 mg/day; may increase to 20 mg/day after 1 week. Taper gradually on discontinuation to avoid withdrawal symptoms.

  • adult · PO: 10–20 mg once daily · Start 10 mg/day; may increase to 20 mg/day after 1 week. Taper gradually on discontinuation to avoid withdrawal symptoms.

Panic disorder with or without agoraphobiaoff-label

Licensed in some regions (e.g., UK); off-label in US. Start 10 mg/day; may increase to 20 mg/day after 3 months. Consider starting at 5 mg/day for first week to reduce initial anxiety.

  • adult · PO: 10–20 mg once daily · Licensed in some regions (e.g., UK); off-label in US. Start 10 mg/day; may increase to 20 mg/day after 3 months. Consider starting at 5 mg/day for first week to reduce initial anxiety.

Social anxiety disorder (social phobia)off-label

Licensed in some regions (e.g., UK); off-label in US. Start 10 mg/day; may increase to 20 mg/day after 1 week. Be aware of potential for discontinuation symptoms.

  • adult · PO: 10–20 mg once daily · Licensed in some regions (e.g., UK); off-label in US. Start 10 mg/day; may increase to 20 mg/day after 1 week. Be aware of potential for discontinuation symptoms.

Major depressive disorder (MDD) in adolescents

Adolescents 12-17 years: start 10 mg/day; may increase to 20 mg/day after 3 weeks. Not recommended under 12 years.

  • pediatric · PO: 10–20 mg once daily · Adolescents 12-17 years: start 10 mg/day; may increase to 20 mg/day after 3 weeks. Not recommended under 12 years.
Contraindications & precautions
  • Concomitant use of MAOIs, including linezolid and methylthioninium chloride · Risk of serotonin syndrome; allow at least 14 days between stopping MAOIs and starting escitalopram.
  • Concomitant use of pimozide · Risk of QT prolongation and ventricular arrhythmias.
  • Hypersensitivity to escitalopram or any excipient · Angioedema and other allergic reactions reported.
  • Known QT prolongation or congenital long QT syndrome · Escitalopram can further prolong the QTc interval; avoid in these patients.
  • Monitor for suicidal ideation and self-harm, especially in patients under 25 years and during the first weeks of treatment.
  • Avoid abrupt discontinuation; taper gradually to reduce risk of withdrawal symptoms.
  • Use with caution in patients with epilepsy, cardiac disease, hepatic or renal impairment.
  • Caution in patients taking NSAIDs, antiplatelets or anticoagulants due to increased bleeding risk.
Adverse effects
  • Nausea
  • Headache
  • Insomnia or somnolence
  • Dry mouth
  • Sexual dysfunction
  • Increased risk of bleedingserious
  • Hyponatraemiaserious
  • QT interval prolongationserious
  • Serotonin syndromeserious
  • Mania or hypomaniaserious
Interactions
  • tramadolmajorAvoid concurrent use when possible. If the combination is considered necessary, use the lowest effective doses, and monitor patients closely for signs of serotonin syndrome, especially during dose escalation. Educate patients to seek immediate medical attention if they experience symptoms. Consider alternative analgesics with lower serotonergic activity.
  • linezolidcontraindicatedConcomitant use is contraindicated. If linezolid is essential, discontinue escitalopram at least 5 half-lives (approximately 1 week) before starting linezolid. After stopping linezolid, wait at least 1 week (or the product label's advised interval) before resuming escitalopram. Monitor for symptoms of serotonin syndrome if the interaction is unavoidable. Consider alternative antibiotics or alternative antidepressants with no serotonergic activity.
  • aspirinmajorBefore co-prescribing, assess the patient's overall bleeding risk and the necessity of each drug. For patients with existing risk factors, consider gastroprotective therapy (e.g., a proton pump inhibitor) and monitor closely for evidence of bleeding. Advise patients to report any unusual bleeding, easy bruising, or black stools. If pain relief is required, alternatives to aspirin (e.g., paracetamol) may be considered where appropriate, but the antiplatelet benefit of aspirin should not be discontinued without specialist advice.
Renal & hepatic adjustment
  • eGFR 30–300: No dose adjustment required
  • eGFR 0–29: Maximum dose 10 mg/day; use caution
  • Hepatic impairment (mild): Maximum recommended dose 10 mg/day
  • Hepatic impairment (moderate): Maximum recommended dose 10 mg/day; monitor closely
  • Hepatic impairment (severe): Use with caution; consider lower dose, maximum 10 mg/day
Monitoring, pregnancy & toxicity
  • Suicidal ideation and behaviour · At start of treatment, during dose changes, and in young adults
  • Clinical response and mood · Within 2-4 weeks after starting or adjusting dose
  • Serotonin syndrome symptoms · During treatment, especially when adding other serotonergic drugs
  • QT interval · Consider in patients with risk factors for QT prolongation or at high doses
  • Hyponatraemia · In elderly or patients on diuretics, if symptoms occur
  • Pregnancy: Use during pregnancy only if potential benefit justifies risk. Untreated depression may also affect pregnancy outcomes. Third-trimester exposure may cause neonatal adaptation syndrome. Consider tapering before delivery if possible, but do not stop abruptly. Specialist advice recommended.
  • Toxicity: Gastrointestinal symptoms (nausea, vomiting, diarrhoea) · Supportive care; monitor hydration
  • Toxicity: CNS symptoms (drowsiness, dizziness, tremor, agitation, seizures) · Supportive care; manage seizures with benzodiazepines if needed
  • Toxicity: Serotonin syndrome · Stop the drug; supportive measures; consider cyproheptadine in severe cases
  • Toxicity: QT prolongation and cardiac arrhythmias · Monitor ECG; treat arrhythmias as per protocols; consider activated charcoal if recent ingestion
Clinical notes
Escitalopram is indicated for major depressive disorder (MDD), generalised anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder, and social anxiety disorder. Common adverse effects include nausea, headache, somnolence or insomnia, increased sweating, and sexual dysfunction. Abrupt discontinuation can cause withdrawal symptoms, so the dose should be tapered. Use with caution in patients with epilepsy, bipolar disorder, and cardiac conduction abnormalities. There is a risk of serotonin syndrome when combined with other serotonergic drugs, such as triptans, tramadol, or MAO inhibitors. CYP2C19 inhibitors (e.g., omeprazole) may raise escitalopram levels; caution is needed with co-prescribing.

Log in to read the full escitalopram monograph

A free account unlocks the complete drug reference, the interaction checker, prescription practice and every other learning tool.

Log inCreate a free account

BNF; local formulary