From the FDA Drug Label
- 2 Serotonin Syndrome The development of a potentially life-threatening serotonin syndrome has been reported with SNRIs and SSRIs, including Escitalopram, alone but particularly with concomitant use of other serotonergic drugs (including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St John’s Wort) and with drugs that impair metabolism of serotonin (in particular, MAOIs, both those intended to treat psychiatric disorders and also others, such as linezolid and intravenous methylene blue).
The best approach to manage a patient's mood disorder with lithium, Seroquel (Quetiapine), and Lexapro (Escitalopram) is to:
- Monitor the patient for the emergence of serotonin syndrome, particularly during treatment initiation and dose increases, due to the concomitant use of lithium and Escitalopram.
- Counsel the patient on the potential increased risk for serotonin syndrome and the importance of reporting any symptoms.
- Adjust the treatment regimen as needed to minimize the risk of serotonin syndrome.
- Educate the patient on the importance of hydration to avoid lithium toxicity.
- Monitor the patient's lithium levels regularly, as ordered by the healthcare provider [ 1 ].
From the Research
The best approach to managing a patient's mood disorder with lithium, quetiapine (Seroquel), and escitalopram (Lexapro) is to prioritize lithium as the primary mood stabilizer, given its superiority in maintaining therapeutic effects and reducing symptoms of mania and depression, as demonstrated in a randomized controlled trial 2.
Key Considerations
- Lithium should be started at a low dose (300mg daily) and gradually increased to therapeutic levels while monitoring serum concentrations (target 0.6-1.2 mEq/L) 3.
- Quetiapine can be added as an adjunctive treatment, starting at 50mg at bedtime, potentially increasing to 300-600mg daily for bipolar disorder or 150-300mg for adjunctive treatment in depression 3.
- Escitalopram should begin at 10mg daily, potentially increasing to 20mg if needed, while monitoring for potential interactions with lithium and quetiapine 3.
Monitoring and Maintenance
- Regular blood work is essential, including lithium levels every 3-6 months, complete blood count, renal and thyroid function tests, and metabolic panels 4.
- Monitor for side effects like tremor, sedation, weight gain, and QT prolongation, and adjust medications as needed 5.
- Patients should maintain adequate hydration, consistent salt intake, and avoid NSAIDs which can increase lithium levels 6.