What are the potential side effects of escitalopram (Selective Serotonin Reuptake Inhibitor - SSRI)?

Escitalopram Side Effects

Escitalopram commonly causes side effects including nausea, sleepiness, weakness, dizziness, anxiety, sexual dysfunction, sweating, tremors, decreased appetite, dry mouth, constipation, and insomnia in approximately 63% of patients. 1, 2

Common Side Effects

• Gastrointestinal effects: Nausea (15% vs 7% placebo), diarrhea (8% vs 5% placebo), constipation (3% vs 1% placebo), indigestion (3% vs 1% placebo), and abdominal pain (2% vs 1% placebo) 2
• Neurological effects: Dizziness (5% vs 3% placebo), fatigue (5% vs 2% placebo), and somnolence/sleepiness (6% vs 2% placebo) 2
• Psychiatric effects: Insomnia (9% vs 4% placebo), decreased appetite (3% vs 1% placebo), and decreased libido (3% vs 1% placebo) 2
• Sexual dysfunction: Ejaculatory delay in males (9% vs <1% placebo), impotence (3% vs <1% placebo), and anorgasmia in females (2% vs <1% placebo) 2, 3
• Other common effects: Increased sweating (5% vs 2% placebo), rhinitis (5% vs 4% placebo), and sinusitis (3% vs 2% placebo) 2

Serious Side Effects

Serotonin Syndrome

• Can occur with escitalopram alone but particularly when combined with other serotonergic medications 2
• Symptoms include mental status changes (agitation, hallucinations, delirium), autonomic instability (tachycardia, labile blood pressure, hyperthermia), neuromuscular symptoms (tremor, rigidity, hyperreflexia), and gastrointestinal symptoms (nausea, vomiting, diarrhea) 1, 4
• Advanced symptoms may include fever, seizures, arrhythmias, and unconsciousness which can be fatal 1
• Risk increases when combined with MAOIs, triptans, tricyclic antidepressants, fentanyl, tramadol, St. John's Wort, and other serotonergic medications 2

Discontinuation Syndrome

• Characterized by dizziness, fatigue, lethargy, general malaise, headaches, nausea, sensory disturbances, anxiety, irritability, and agitation 1
• Can occur following missed doses or abrupt discontinuation 1
• Escitalopram has a lower risk of discontinuation syndrome compared to paroxetine, fluvoxamine, and sertraline 1
• Gradual tapering is recommended when discontinuing treatment 2

Other Serious Side Effects

• Suicidal thoughts and behaviors, especially in children, adolescents, and young adults during the first few months of treatment 2
• Abnormal bleeding, especially when combined with aspirin or NSAIDs 1
• Hyponatremia (low sodium levels), particularly in elderly patients or those taking diuretics 2
• Activation of mania/hypomania in patients with bipolar disorder 2
• Seizures, particularly in patients with a history of seizure disorders 2
• QT prolongation (though escitalopram has less effect on CYP450 enzymes compared to other SSRIs) 1

Special Populations

Pregnant Women

• Third-trimester use of SSRIs including escitalopram has been linked to neonatal signs such as crying, irritability, tremors, poor feeding, respiratory distress, sleep disturbance, and hypoglycemia 1
• Signs typically appear within hours to days after birth and usually resolve within 1-2 weeks 1
• SSRI treatment during pregnancy should be maintained at the lowest effective dose as withdrawal may have harmful effects on the mother-infant dyad 1

Elderly Patients

• Escitalopram is considered a preferred agent for older patients with depression compared to paroxetine and fluoxetine, which should generally be avoided in this population 1
• Elderly patients may be at greater risk of developing hyponatremia with SSRIs 2

Children and Adolescents

• In pediatric patients (6-17 years), common side effects include insomnia, back pain, urinary tract infection, vomiting, and nasal congestion 2
• Monitoring for clinical worsening and emergence of suicidal thoughts is particularly important in this population 2

Drug Interactions

• Concomitant use with MAOIs is contraindicated due to risk of serotonin syndrome 1
• Caution when combining with other serotonergic drugs, including triptans, opioids, stimulants, and certain over-the-counter medications 1
• Escitalopram may interact with drugs that prolong the QT interval 1
• Escitalopram has less effect on CYP450 isoenzymes compared to other SSRIs, resulting in a lower propensity for drug interactions 1, 5

Management of Side Effects

• Start with lower doses and titrate slowly, especially in patients with anxiety disorders 1
• Consider starting with a subtherapeutic "test" dose as initial anxiety or agitation can occur 1
• Monitor for side effects, particularly during the first few weeks of treatment and after dose changes 2
• For discontinuation, gradually reduce the dose rather than abrupt cessation 2
• If intolerable symptoms occur during dose reduction, consider resuming the previous dose and tapering more gradually 2

Escitalopram has a generally favorable side effect profile compared to other antidepressants, with a lower propensity for drug interactions due to minimal effects on CYP450 enzymes 1, 5. However, careful monitoring remains essential, particularly during initiation, dose changes, and discontinuation of treatment.