What are the potential side effects of escitalopram (Lexapro) 5mg in a 73kg female patient with intermittent anxiety and vertigo?

Side Effects of Escitalopram 5mg in a 73-year-old Female with Anxiety and Vertigo

Escitalopram 5mg is an appropriate starting dose for an elderly female with anxiety and vertigo symptoms, but patients should be monitored for common side effects including nausea, dizziness, headache, insomnia, and fatigue, which may initially worsen vertigo symptoms.

Common Side Effects

Escitalopram may cause several common side effects, particularly during the initial weeks of treatment:

• Gastrointestinal effects: Nausea (15-18%), diarrhea (8%), constipation (3-5%), vomiting (3%) 1
• Neurological effects: Dizziness (5%), headache, somnolence (6-13%) 1
• Sleep disturbances: Insomnia (9-12%), abnormal dreams (3%) 1
• Other common effects:
  • Fatigue (5-8%)
  • Increased sweating
  • Dry mouth
  • Decreased appetite (3%) 1

Special Considerations for Elderly Patients with Vertigo

For a 73-year-old female with vertigo symptoms, certain side effects require particular attention:

• Dizziness: May exacerbate existing vertigo symptoms, especially during the first 1-2 weeks of treatment 2
• Initial anxiety/agitation: SSRIs can temporarily worsen anxiety symptoms before improvement occurs, potentially intensifying vertigo 2
• Orthostatic hypotension: Can worsen balance issues and increase fall risk 1

Sexual Side Effects

Though less commonly discussed, sexual side effects are important to note:

• Decreased libido (3-7%)
• Anorgasmia (2-6% in females)
• Ejaculatory disorders (primarily in males) 1

Serious but Rare Side Effects

Monitor for these less common but serious adverse effects:

• Serotonin syndrome: Characterized by agitation, hallucinations, rapid heartbeat, fever, muscle rigidity, coordination problems 1
• Hyponatremia: Elderly patients are at increased risk for low sodium levels, which can manifest as headache, weakness, confusion, and difficulty concentrating 1
• Bleeding risk: Especially if combined with NSAIDs, aspirin, or warfarin 1
• QT interval prolongation: Use with caution in patients taking other medications that may prolong QT interval 2

Dosing Recommendations for Elderly Patients

• Starting dose: 5mg daily is appropriate (lower than the standard 10mg adult starting dose) 2
• Titration: Any dose increases should be gradual and based on response and tolerability 2
• Maximum dose: Generally not to exceed 10mg daily in elderly patients 2

Management of Side Effects

• Nausea: Take medication with food
• Sleep disturbances: Adjust timing of medication (morning for insomnia, evening for daytime drowsiness)
• Dizziness/vertigo exacerbation: Consider temporary dose reduction if symptoms are severe; reassure patient that these effects often diminish after 1-2 weeks 2

Monitoring Recommendations

• First few weeks: More frequent monitoring for side effects, especially worsening anxiety or vertigo
• Sodium levels: Consider checking in elderly patients, especially if confusion or worsening dizziness occurs
• QT interval: Consider baseline ECG if patient has cardiac risk factors or is on other QT-prolonging medications

Drug Interactions

Escitalopram has minimal effects on CYP450 enzymes compared to other SSRIs, resulting in fewer drug interactions 3. However, caution is still advised with:

• MAOIs (contraindicated)
• Other serotonergic medications
• Medications that prolong QT interval
• NSAIDs, aspirin, or warfarin (increased bleeding risk) 1

Remember that side effects are often most pronounced in the first 1-2 weeks and tend to diminish with continued treatment. The low starting dose of 5mg is appropriate for minimizing side effects in this elderly patient with vertigo.