What can be added to Lexapro (escitalopram) 20 mg to help a 54-year-old female patient with increased anxiety, irritability, and low libido?

Management of Increased Anxiety, Irritability, and Low Libido in a Patient on Escitalopram

Bupropion is the most appropriate medication to add to escitalopram for this 54-year-old female patient experiencing increased anxiety, irritability, and low libido. 1

Understanding the Current Situation

• The patient is currently on escitalopram 20 mg, which is the maximum recommended dose for anxiety disorders 2
• She is experiencing three main issues: increased anxiety, irritability, and low libido
• Sexual dysfunction is a common side effect of SSRIs like escitalopram, affecting up to 59.1% of patients on antidepressants 3
• Escitalopram specifically causes decreased libido in 3% of female patients and anorgasmia in 3% of female patients according to FDA data 2

First-Line Augmentation Option

• Bupropion (starting at 37.5 mg every morning, gradually increasing to 150 mg twice daily) is the optimal choice for augmentation based on:
  • Demonstrated efficacy in resolving SSRI-induced sexual dysfunction (94% of patients had complete or partial resolution of orgasm dysfunction) 1
  • Activating properties that can help with energy levels and potentially address anxiety when combined with an SSRI 4
  • Low risk of drug interactions with escitalopram, which has minimal effects on CYP450 isoenzymes 4

Dosing and Administration

• Start bupropion at 37.5 mg every morning, then increase by 37.5 mg every 3 days 4
• Target dose is 150 mg twice daily, with the second dose given before 3 pm to minimize insomnia 4
• Monitor for increased anxiety initially, as bupropion can be activating 4
• Assess response after 4-6 weeks of combined therapy 5

Alternative Options if Bupropion is Ineffective or Contraindicated

1. Mirtazapine (starting at 7.5 mg at bedtime, up to 30 mg):

   • Associated with much lower rates of sexual dysfunction (24.4%) compared to SSRIs (58-73%) 3
   • Can be particularly helpful if the patient also has insomnia, as it promotes sleep 4
   • Well-tolerated and can help with anxiety symptoms 4

2. Consider switching from escitalopram to another agent:

   • If augmentation fails, switching to mirtazapine monotherapy may be beneficial as it has a sexual dysfunction rate of only 24.4% 3, 6
   • Alternatively, consider nefazodone which has very low rates of sexual dysfunction (8%) 3

Monitoring and Follow-up

• Assess response to combined therapy after 2-4 weeks 5
• Use standardized assessment tools to monitor anxiety symptoms and sexual function 5
• Monitor for potential drug interactions, though escitalopram has a favorable drug interaction profile compared to other SSRIs 4
• Be aware that bupropion is contraindicated in patients with seizure disorders 4

Important Caveats and Considerations

• Bupropion should not be used in patients with seizure disorders or eating disorders due to increased seizure risk 4
• The second dose of bupropion should be given before 3 pm to minimize insomnia 4
• Sexual dysfunction from SSRIs can sometimes persist even after discontinuation of the medication, so early intervention is important 7
• If anxiety worsens with bupropion, consider lowering the dose or switching to mirtazapine 4, 6
• Avoid combining escitalopram with other serotonergic medications due to risk of serotonin syndrome 4