What are the side effects of Lexapro (escitalopram)?

Side Effects of Lexapro (Escitalopram)

Lexapro (escitalopram) commonly causes nausea, sexual dysfunction, insomnia, drowsiness, fatigue, dizziness, dry mouth, and sweating as its most frequent side effects, with sexual effects and gastrointestinal symptoms being particularly prominent. 1

Common Side Effects

Escitalopram's FDA label identifies the following common side effects (occurring in ≥2% of patients and at rates greater than placebo):

• Gastrointestinal effects:

  • Nausea (15%)
  • Diarrhea (8%)
  • Constipation (3%)
  • Indigestion (3%)
  • Abdominal pain (2%)

• Neurological/psychiatric effects:

  • Insomnia (9%)
  • Somnolence/drowsiness (6%)
  • Dizziness (5%)
  • Decreased appetite (3%)
  • Decreased libido (3%)

• Sexual dysfunction:

  • Ejaculation disorder (primarily delayed ejaculation) (9% in males)
  • Impotence (3% in males)
  • Anorgasmia (2% in females)

• Other common effects:

  • Fatigue (5%)
  • Increased sweating (5%)
  • Rhinitis (5%)
  • Sinusitis (3%)
  • Influenza-like symptoms (5%) 1, 2

Timing and Duration of Side Effects

Most side effects appear within the first few weeks of treatment:

• Gastrointestinal side effects like nausea typically occur within the first 2 weeks of treatment, with 75-80% being mild in severity and 60-65% resolving within the first month 2
• Sexual dysfunction tends to persist longer, with 83% of patients still experiencing it at 3 months 3
• The full therapeutic effect may take 4-6 weeks to develop, though some symptom improvement may occur within 1-2 weeks 4

Serious Side Effects

While less common, serious side effects requiring immediate medical attention include:

• Serotonin syndrome: Mental status changes, neuromuscular hyperactivity, autonomic instability, and gastrointestinal symptoms 3
• QT prolongation: Particularly with doses exceeding 20mg/day in adults over 60 years 2
• Hyponatremia: Occurs in 0.5-12% of older adults, typically within the first month 2
• Suicidality: Slightly increased risk in adults 18-24 years of age, particularly within 1-2 months of initiation or dose increase 2
• Discontinuation syndrome: Characterized by dizziness, fatigue, headaches, nausea, sensory disturbances, anxiety, irritability, and agitation when doses are missed or the medication is abruptly discontinued 2

Special Populations

Pregnancy and Breastfeeding

• Third-trimester use of SSRIs including escitalopram has been linked to neonatal complications including crying, irritability, jitteriness, feeding difficulties, sleep disturbance, and rarely seizures 2
• Escitalopram transfers in low concentrations into breast milk 2

Elderly Patients

• Start with lower doses due to risk of higher concentrations and more side effects 3
• Increased risk of hyponatremia (0.5-12%) 2

Drug Interactions

Escitalopram has several important drug interactions:

• Contraindicated with MAOIs: Can cause serotonin syndrome 2
• Caution with other serotonergic drugs: Including other antidepressants, opioids, stimulants, and certain over-the-counter medications 2
• QT prolongation risk: Increased when combined with other QT-prolonging medications 2
• Cytochrome P450 interactions: Escitalopram may have fewer drug interactions than other SSRIs, with citalopram/escitalopram having the least effect on CYP450 isoenzymes 2, 5

Management of Side Effects

• Sexual dysfunction: Options include dose reduction, drug holidays, or switching to medications with fewer sexual side effects (mirtazapine, SNRIs, bupropion) 3
• Nausea/vomiting: Take medication with food, gradual dose titration, temporary use of antacids 3
• Sleep disturbances: Adjust timing of medication (morning for insomnia, bedtime for drowsiness) 3
• Weight changes: Regular monitoring of weight, dietary counseling, exercise recommendations 3

Discontinuation Considerations

When stopping escitalopram, a gradual taper is recommended to minimize discontinuation symptoms, which may include dizziness, fatigue, headaches, nausea, sensory disturbances, and anxiety 2. Escitalopram has a lower risk of discontinuation syndrome than some other SSRIs like paroxetine 2.