Escitalopram Drug Interactions in Caesarean Section
Escitalopram can be safely continued during caesarean section with minimal drug interaction concerns, as it has the lowest propensity for CYP450-mediated interactions among SSRIs and does not significantly interact with standard perioperative medications used in CS. 1
Key Drug Interaction Considerations
Serotonin Syndrome Risk
The primary concern with escitalopram during CS is serotonin syndrome when combined with other serotonergic agents. 1
Contraindicated combinations:
- MAOIs (including linezolid and isoniazid) - absolute contraindication due to severe serotonin syndrome risk 1
- Tramadol, meperidine, methadone, and fentanyl - exercise extreme caution as these opioids have serotonergic properties 1
Monitor closely when combining with:
Standard CS Anesthetic and Analgesic Agents
Escitalopram does NOT significantly interact with recommended CS medications:
Neuraxial opioids (safe to use):
Non-opioid analgesics (safe to use):
- Paracetamol (acetaminophen) - no interaction 1
- NSAIDs (ibuprofen, diclofenac, naproxen, ketorolac) - monitor for increased bleeding risk as SSRIs can potentiate NSAID-induced bleeding 1
- Intravenous dexamethasone - no interaction 1
Anesthetic agents (safe to use):
- Volatile agents (sevoflurane, isoflurane, desflurane) - no interaction 1
- Local anesthetics (bupivacaine for spinal/epidural) - no interaction 1
- Midazolam - safe when used as single dose for sedation 1
CYP450 Enzyme Considerations
Escitalopram has minimal CYP450 inhibitory effects compared to other SSRIs, making it one of the safest choices for avoiding drug interactions. 1, 2
- Does not significantly inhibit CYP2D6, CYP3A4, CYP1A2, CYP2C19, or CYP2C9 1
- Ritonavir (potent CYP3A4 inhibitor) does not affect escitalopram pharmacokinetics 2
- Cimetidine and omeprazole increase escitalopram exposure by 72% and 51% respectively, but these changes are not clinically significant 2
QT Prolongation
Monitor for QT prolongation when escitalopram is combined with other QT-prolonging drugs used perioperatively. 1
- Escitalopram (and citalopram) can prolong QT interval 1
- Avoid combining with other QT-prolonging agents when possible 1
- Consider preoperative ECG if multiple QT-prolonging drugs are necessary 1
Bleeding Risk Management
SSRIs including escitalopram increase bleeding risk, particularly when combined with NSAIDs or aspirin. 1
Practical approach:
- Continue escitalopram perioperatively (abrupt discontinuation risks withdrawal syndrome) 1
- Use NSAIDs as recommended for CS analgesia but monitor surgical site for bleeding 1
- Avoid aspirin in analgesic doses; low-dose aspirin for antiplatelet therapy can continue if strongly indicated 1
- Observe for ecchymosis, hematoma, epistaxis, petechiae, or hemorrhage 1
Breastfeeding Considerations
Escitalopram is compatible with breastfeeding and does not interact with postoperative analgesics. 3, 4
- Escitalopram transfers to breast milk in small amounts 3, 4
- No short-term adverse effects reported in breastfed infants 3, 4
- All recommended CS analgesics (morphine, paracetamol, NSAIDs) are compatible with breastfeeding 1
Clinical Pitfalls to Avoid
Do not discontinue escitalopram perioperatively - this increases risk of withdrawal syndrome (dizziness, fatigue, myalgias, nausea, anxiety, irritability) without reducing drug interaction risk. 1
Do not use tramadol for rescue analgesia - tramadol has serotonergic properties and significantly increases serotonin syndrome risk when combined with escitalopram. 1
Do not assume all opioids are contraindicated - morphine (the recommended opioid for CS) does not have significant serotonergic activity and is safe to use. 1
Monitor respiratory rate if midazolam is used - while generally safe as a single dose, midazolam can cause respiratory depression (rate <10 bpm) requiring verbal stimulation, though this is unrelated to escitalopram interaction. 1, 5