What causes epigastric pain associated with escitalopram (citalopram's active enantiomer) use?

From the Guidelines

Escitalopram-induced epigastric pain is primarily caused by the medication's effect on the gastrointestinal system, particularly its impact on serotonin receptors in the gut, which affects gut motility and sensitivity. This SSRI antidepressant can irritate the stomach lining and increase acid production, leading to discomfort in the upper abdomen 1. The evidence suggests that selective serotonin reuptake inhibitors, such as escitalopram, may not directly improve visceral pain because they do not block the reuptake of the key neurotransmitters involved in the perception of visceral pain, serotonin and norepinephrine 1.

Possible Mechanisms and Solutions

• The pain may result from escitalopram's impact on serotonin receptors in the gut, which affects gut motility and sensitivity 1.
• Taking escitalopram with food can help reduce this side effect, as can starting with a lower dose (typically 5mg daily) before gradually increasing to the therapeutic dose (usually 10-20mg daily).
• If the pain persists, the doctor might recommend taking the medication at a different time of day, using a stomach-protecting medication like omeprazole, or switching to another antidepressant.
• Most gastrointestinal side effects of escitalopram tend to improve within 2-4 weeks as the body adjusts to the medication, but persistent or severe pain should be reported to the healthcare provider immediately.

Comparison with Other Medications

• Tricyclic antidepressants (TCAs) and serotonin norepinephrine reuptake inhibitors (SNRIs) can reduce perception of pain at different levels of the brain-gut axis via multiple mechanisms, and may be considered as alternative treatments for epigastric pain 1.
• The evidence suggests that TCAs, such as amitriptyline, may be more effective than SSRIs, such as escitalopram, in improving epigastric pain, especially when gastric emptying is normal 1.

From the FDA Drug Label

Gastrointestinal Disorders Nausea 15% 7% Diarrhea 8% 5% Constipation 3% 1% Indigestion 3% 1% Abdominal Pain 2% 1%

The cause of epigastric pain associated with escitalopram use is not directly stated in the drug label. However, abdominal pain is listed as a treatment-emergent adverse event, occurring in 2% of patients treated with escitalopram and 1% of patients receiving placebo 2.

• Gastrointestinal disorders such as nausea, diarrhea, constipation, and indigestion are also reported. It can be inferred that escitalopram may contribute to epigastric pain due to its association with abdominal pain and other gastrointestinal disorders, but the exact cause is not specified.

From the Research

Epigastric Pain Associated with Escitalopram Use

• Epigastric pain is a type of abdominal pain that can be associated with various factors, including the use of certain medications like escitalopram 3, 4, 5, 6, 7.
• The exact cause of epigastric pain associated with escitalopram use is not clearly understood, but it may be related to the medication's effects on the gastrointestinal system 3, 4.
• Studies have shown that escitalopram can cause gastrointestinal symptoms, including nausea, vomiting, and abdominal pain, in some patients 3, 4, 5, 6, 7.
• The frequency and severity of these symptoms can vary depending on the individual and the dose of the medication 3, 4, 5, 6, 7.

Gastrointestinal Symptoms and Escitalopram

• Gastrointestinal symptoms, including epigastric pain, are common adverse effects of selective serotonin reuptake inhibitors (SSRIs) like escitalopram 3, 4, 5, 6, 7.
• Escitalopram has been shown to produce transient changes in nausea and vomiting, as well as total upper gastrointestinal symptoms, during the first two weeks of treatment 3.
• However, the frequency and severity of gastrointestinal symptoms did not differ significantly between patients receiving placebo and those receiving escitalopram in some studies 3, 6.
• Other studies have found that escitalopram can be effective in reducing symptoms of functional gastrointestinal disorders, such as irritable bowel syndrome, in some patients 4, 6, 7.

Factors Influencing Epigastric Pain and Escitalopram Use

• The relationship between epigastric pain and escitalopram use may be influenced by various factors, including the dose and duration of treatment, individual patient characteristics, and the presence of underlying gastrointestinal conditions 3, 4, 5, 6, 7.
• Further research is needed to fully understand the causes and mechanisms of epigastric pain associated with escitalopram use and to identify effective strategies for managing these symptoms in patients taking this medication 3, 4, 5, 6, 7.