Can Lexapro (escitalopram) cause hypotension?

Can Lexapro Cause Hypotension?

Yes, Lexapro (escitalopram) can cause hypotension, though it occurs rarely. The FDA drug label specifically lists hypotension as a potential adverse effect of escitalopram overdose, and case reports document instances of hypotension even at therapeutic doses. 1

Mechanism and Frequency

Selective Serotonin Reuptake Inhibitors (SSRIs) like escitalopram generally have limited effects on the autonomic nervous system compared to other antidepressant classes, making them relatively safer from a cardiovascular perspective 2. However, hypotension can still occur through several mechanisms:

• Direct cardiovascular effects at therapeutic doses (rare)
• More commonly as part of overdose toxicity
• Orthostatic (postural) hypotension, particularly in elderly patients

Risk Factors for Lexapro-Induced Hypotension

Certain patients are at higher risk for experiencing hypotension with Lexapro:

• Elderly patients
• Patients with pre-existing cardiovascular disease
• Patients taking other medications that can lower blood pressure
• Patients with volume depletion
• Those with hepatic impairment (leading to higher drug concentrations)

Clinical Presentation

Hypotension associated with Lexapro may present as:

• Asymptomatic blood pressure reduction
• Symptomatic orthostatic hypotension with dizziness and lightheadedness
• Presyncope or syncope in severe cases
• Bradycardia may accompany hypotension 3

Evidence from Case Reports

A detailed case report describes a 60-year-old woman who developed symptomatic bradycardia (heart rate 39 beats/min) and mild hypotension (systolic BP 105 mm Hg) after taking citalopram (the racemic mixture containing escitalopram) at just 20 mg daily for two weeks. The patient experienced presyncopal symptoms, requiring hospital admission and medication discontinuation 3.

Management of Lexapro-Induced Hypotension

For patients experiencing hypotension while on Lexapro:

1. Mild asymptomatic hypotension: Monitor closely

2. Symptomatic hypotension:

   • Consider dose reduction
   • Evaluate for discontinuation if symptoms are significant
   • Ensure adequate hydration
   • Review concomitant medications that might contribute to hypotension

3. Severe hypotension or overdose situations:

   • Discontinue the medication
   • Provide supportive care
   • Consider activated charcoal for recent ingestions
   • Monitor cardiac function (ECG) due to risk of QT prolongation and arrhythmias
   • In severe cases, vasopressors may be required 4, 1

Prevention and Monitoring

For patients starting Lexapro:

• Monitor blood pressure and heart rate during the first week of therapy and when doses are modified, especially in elderly patients and those with cardiovascular disease 3
• Consider orthostatic vital sign measurements in high-risk patients
• Start with lower doses in elderly patients or those with cardiovascular risk factors
• Educate patients about potential symptoms of hypotension (dizziness, lightheadedness) and when to seek medical attention

Comparison with Other Antidepressants

SSRIs like Lexapro generally have a more favorable cardiovascular profile compared to other antidepressant classes:

• Tricyclic antidepressants: Higher risk of orthostatic hypotension
• SNRIs (particularly venlafaxine): More likely to cause hypertension than hypotension
• MAOIs: Significant risk of orthostatic hypotension and potential for hypertensive crisis
• SSRIs (including Lexapro): Generally lower risk of cardiovascular effects, but hypotension can still occur 2

While hypotension with Lexapro is uncommon at therapeutic doses, clinicians should remain vigilant, particularly when treating elderly patients or those with cardiovascular comorbidities.