Does escitalopram (Lexapro) increase the risk of bruising?

Escitalopram and Risk of Bruising

Yes, escitalopram (Lexapro) can increase the risk of bruising due to its effects on platelet function and blood coagulation. The FDA drug label explicitly warns that escitalopram and other SSRIs may increase the risk of bleeding or bruising, particularly when combined with other medications affecting coagulation 1.

Mechanism of Action

Escitalopram affects bleeding risk through several mechanisms:

1. Platelet dysfunction: SSRIs like escitalopram inhibit serotonin reuptake in platelets, which impairs platelet aggregation and function
2. Antiplatelet effects: This impairment of platelet function can lead to prolonged bleeding time
3. Potentiation of other medications: The risk is significantly higher when combined with other medications affecting coagulation

Risk Factors for Increased Bruising

The risk of bruising with escitalopram is particularly elevated in patients who are:

• Taking blood thinners such as warfarin (Coumadin, Jantoven)
• Using nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen
• Taking aspirin, even at low doses
• Elderly patients (who may have more fragile blood vessels)
• Patients with liver disease (which can affect drug metabolism)
• Those with seasonal allergies (as noted in case reports) 2

Clinical Evidence

The FDA drug label for escitalopram clearly states: "Escitalopram tablets and other antidepressant medicines may increase your risk of bleeding or bruising, especially if you take the blood thinner warfarin (Coumadin®, Jantoven®), a nonsteroidal anti-inflammatory drug (NSAIDs, like ibuprofen or naproxen), or aspirin" 1.

Case reports have documented:

• Epistaxis (nosebleeds) associated with escitalopram use 2
• Various bleeding manifestations ranging from ecchymoses and hematomas to more serious hemorrhages 1

Management Recommendations

For patients on escitalopram who experience increased bruising:

1. Assess bleeding risk: Evaluate for concomitant use of medications that affect coagulation
2. Monitor closely: Watch for signs of abnormal bleeding including ecchymoses, epistaxis, hematomas, petechiae, or gastrointestinal bleeding
3. Consider alternatives: In patients with high bleeding risk, consider alternative antidepressants with potentially lower bleeding risk
4. Medication adjustments:
   • Avoid combining escitalopram with NSAIDs when possible
   • Use caution with anticoagulants and antiplatelet agents
   • Consider the lowest effective dose of escitalopram

Important Caveats

• The bleeding risk appears to be a class effect of SSRIs, not specific to escitalopram alone
• The absolute risk of clinically significant bleeding is generally low in patients without other risk factors
• The risk-benefit ratio still favors using escitalopram for most patients with depression or anxiety
• Patients should be cautioned not to discontinue escitalopram abruptly as this can lead to withdrawal symptoms

While rare case reports have associated escitalopram with more severe hematological effects such as thrombocytopenia 3, these are extremely uncommon and should not deter appropriate use of the medication when indicated.

Patient Education

Patients taking escitalopram should be advised to:

• Report any unusual bleeding or bruising to their healthcare provider
• Inform all healthcare providers about escitalopram use before procedures
• Be aware of the increased risk when combined with OTC pain relievers like aspirin or NSAIDs
• Not stop taking escitalopram without consulting their healthcare provider

In conclusion, while escitalopram can increase the risk of bruising, particularly when combined with other medications affecting coagulation, the overall risk-benefit profile remains favorable for most patients requiring SSRI therapy.