What are the risks of starting escitalopram (Selective Serotonin Reuptake Inhibitor) 5 mg?

Risks of Starting Escitalopram 5 mg

Starting escitalopram 5 mg carries several potential risks, with the most serious being increased suicidal thoughts or behaviors, particularly in children, adolescents, and young adults within the first few months of treatment. 1

Common Side Effects

Escitalopram can cause several common side effects that typically emerge within the first few weeks of treatment:

• Gastrointestinal effects:

  • Dry mouth
  • Nausea
  • Diarrhea
  • Heartburn

• Neurological effects:

  • Headache
  • Somnolence or insomnia
  • Dizziness
  • Vivid dreams
  • Tremor

• Other common effects:

  • Changes in appetite
  • Weight changes
  • Fatigue
  • Nervousness
  • Diaphoresis (excessive sweating)
  • Bruxism (teeth grinding) 2

Serious Risks and Warnings

Suicidality Risk

The FDA has issued a boxed warning for all SSRIs including escitalopram regarding increased risk of suicidal thinking and behavior in children, adolescents, and young adults up to age 24. The absolute risk difference is approximately 0.7% compared to placebo, with a number needed to harm of 143 2, 1.

Behavioral Activation/Agitation

This can manifest as:

• Motor or mental restlessness
• Insomnia
• Impulsiveness
• Talkativeness
• Disinhibited behavior
• Aggression

This is more common in younger patients and those with anxiety disorders compared to depressive disorders. It typically occurs early in treatment or with dose increases 2.

Serotonin Syndrome

This potentially life-threatening condition can include:

• Agitation, hallucinations, or changes in mental status
• Coordination problems or muscle twitching
• Racing heartbeat, blood pressure changes
• Sweating or fever
• Nausea, vomiting, diarrhea
• Muscle rigidity 1

Other Serious Risks

• Severe allergic reactions
• Abnormal bleeding (especially with NSAIDs, aspirin, or blood thinners)
• Seizures
• Hypomania/mania
• Hyponatremia (low sodium levels, especially in elderly)
• Visual problems
• Sexual dysfunction 1, 2

Special Population Considerations

Children and Adolescents

While the starting dose of escitalopram for adolescents is typically 10 mg daily, the 5 mg dose represents a more cautious approach. Close monitoring is essential, especially during the first few months of treatment 2, 3.

Elderly Patients

Lower starting doses are recommended due to increased risk of side effects, particularly hyponatremia and falls 3.

Patients with Hepatic Impairment

Escitalopram is metabolized by CYP2C19, CYP2D6, and CYP3A4 enzymes. Patients with liver impairment may require dose adjustments 4.

Discontinuation Effects

If escitalopram is stopped abruptly, withdrawal symptoms may occur, including:

• Anxiety, irritability, mood changes
• Headache, sweating, nausea, dizziness
• Electric shock-like sensations
• Shaking, confusion 1

Monitoring Recommendations

1. Monitor closely for suicidal thoughts and behaviors, especially during the first few months of treatment or with dose changes
2. Watch for signs of behavioral activation/agitation
3. Be alert for symptoms of serotonin syndrome, especially if combined with other serotonergic medications
4. Monitor for changes in mood that could indicate switch to mania/hypomania
5. Assess for sexual dysfunction, which can affect treatment adherence 2, 1

Drug Interactions

Escitalopram should not be used with:

• MAOIs (including linezolid)
• Pimozide
• Other serotonergic drugs without careful monitoring

Caution is needed when combining with:

• NSAIDs, aspirin, or blood thinners (increased bleeding risk)
• Medications metabolized by CYP2C19, CYP2D6, or CYP3A4 1, 4

Despite these risks, escitalopram has a favorable pharmacokinetic profile with low protein binding (56%) and is less likely to cause drug interactions compared to some other antidepressants 4.