Is it safe to use Lexapro (escitalopram) with Omeprazole (omeprazole) in a 53-year-old patient with a history of Hypertension (HTN) on Lisinopril, during cross-titration from Cymbalta (duloxetine) to Lexapro (escitalopram)?

From the FDA Drug Label

Concomitant Medications Since escitalopram is the active isomer of racemic citalopram (Celexa), the two agents should not be coadministered. Patients should be advised to inform their physician if they are taking, or plan to take, any prescription or over-the-counter drugs, as there is a potential for interactions

Patients should be cautioned about the concomitant use of Escitalopram and NSAIDs, aspirin, warfarin, or other drugs that affect coagulation since combined use of psychotropic drugs that interfere with serotonin reuptake and these agents has been associated with an increased risk of bleeding

The patient's use of Lexapro (escitalopram) with Omeprazole may increase the levels of Lexapro, potentially increasing the risk of QT prolongation. However, the provided drug label does not directly address the interaction between Lexapro and Omeprazole.

• The patient has a history of Hypertension (HTN) and is on Lisinopril.
• The patient is being cross-titrated from Cymbalta (duloxetine) to Lexapro (escitalopram). Given the potential interaction and the patient's medical history, it is recommended to exercise caution and monitor the patient closely for any adverse effects, particularly heart palpitations or other symptoms of QT prolongation 1.

From the Research

Caution is advised when using Lexapro (escitalopram) with omeprazole in a 53-year-old hypertensive patient on lisinopril during cross-titration from Cymbalta (duloxetine), as the combination may increase the risk of QT prolongation, particularly with omeprazole potentially increasing escitalopram blood levels, as noted in a study published in 2024 2. While this combination is generally considered safe, there are several important considerations.

• Omeprazole can potentially increase escitalopram blood levels by inhibiting its metabolism through the CYP2C19 enzyme pathway, which might increase the risk of side effects such as QT prolongation.
• During cross-titration, it's essential to follow a gradual approach, typically tapering duloxetine while slowly introducing escitalopram to minimize discontinuation symptoms and potential drug interactions.
• The patient should be monitored for signs of serotonin syndrome, especially during the overlap period when both antidepressants are present in the system.
• Blood pressure should be regularly checked as both antidepressants can affect blood pressure, particularly in combination with lisinopril.
• Patients should report any unusual symptoms such as irregular heartbeat, severe dizziness, confusion, or significant mood changes. The cross-titration should be supervised by a healthcare provider who can adjust the schedule based on the patient's response and tolerance, taking into account the potential risks of QT prolongation, as highlighted in studies such as 2 and 3, which compared the risk of QT prolongation among SSRIs.