Is escitalopram (selective serotonin reuptake inhibitor) safe during pregnancy?

From the Guidelines

Escitalopram can be used during pregnancy when the benefits outweigh the risks, but it should be prescribed with caution, as it is considered one of the safer antidepressant options for pregnant women when treatment is necessary. The typical dosage ranges from 10-20 mg once daily 1. If you're currently taking escitalopram and become pregnant, don't stop taking it suddenly as this could lead to withdrawal symptoms and worsening depression, instead, consult your healthcare provider immediately to discuss your specific situation. Some studies suggest a small increased risk of certain birth defects, particularly when used in the first trimester, and there may be a risk of neonatal adaptation syndrome (temporary symptoms like irritability, feeding difficulties, and respiratory distress) in newborns when the medication is used late in pregnancy 1. There's also some evidence of a slight increase in the risk of persistent pulmonary hypertension in newborns. The decision to use escitalopram during pregnancy should involve weighing the mother's mental health needs against potential risks to the developing baby, as untreated depression itself carries risks during pregnancy.

Key considerations for the use of escitalopram during pregnancy include:

• The severity of current symptoms
• Previous mental health history
• Patient treatment preferences
• The potential risks and benefits of treatment, including the risk of neonatal adaptation syndrome and persistent pulmonary hypertension 1. It is essential to work with a healthcare provider to determine the best course of treatment and to monitor the health of both the mother and the developing baby throughout the pregnancy.

In terms of treatment approach, experts have recommended a stepped approach to treatment of depression during pregnancy, which includes monitoring and encouraging exercise and social support for women with mild depression, and offering evidence-based treatment, such as cognitive therapy or antidepressants, for women with moderate to severe depression 1. The American Psychiatric Association and the American College of Obstetricians and Gynecologists have published recommendations about decision-making regarding antidepressant treatment during pregnancy, which emphasize the importance of considering the severity of current symptoms, previous mental health history, and patient treatment preferences when making decisions about antidepressant use during pregnancy 1.

From the FDA Drug Label

Available data from published epidemiologic studies and postmarketing reports have not established an increased risk of major birth defects or miscarriage There are risks of persistent pulmonary hypertension of the newborn (PPHN) and poor neonatal adaptation with exposure to selective serotonin reuptake inhibitors (SSRIs), including Escitalopram, during pregnancy. In animal reproduction studies, both escitalopram and racemic citalopram have been shown to have adverse effects on embryo/fetal and postnatal development, including fetal structural abnormalities, when administered at doses greater than human therapeutic doses

Escitalopram use during pregnancy is associated with risks, including persistent pulmonary hypertension of the newborn (PPHN) and poor neonatal adaptation. Although available data do not indicate an increased risk of major birth defects or miscarriage, animal studies have shown adverse effects on embryo/fetal and postnatal development. Therefore, caution is advised when using escitalopram during pregnancy. Women should notify their healthcare providers if they become pregnant or intend to become pregnant during treatment with escitalopram 2.

From the Research

Safety of Escitalopram in Pregnancy

• The safety of escitalopram during pregnancy has been evaluated in several studies, with some indicating that it may be considered safe, particularly in terms of major malformations 3, 4, 5.
• However, exposure to escitalopram has been associated with an increased risk of perinatal complications, such as lower rates of live births and higher rates of newborns with low birth weight 3, 4.
• A literature review found that paroxetine and fluoxetine have the strongest association with negative outcomes, while the associations between sertraline and citalopram with negative outcomes remain mixed 6.
• There are limited studies on the safety of escitalopram during breastfeeding, but available data suggest that it may be safe, with no short-term adverse effects reported in newborns 3, 4, 5.
• A study on the pharmacokinetics of citalopram/escitalopram in pregnancy found that plasma (S)-citalopram concentration to dose ratios were not significantly different throughout pregnancy, but were elevated postpartum 7.
• The same study found that individuals with intermediate or poor CYP2C19 activity may be at risk for subtherapeutic S-citalopram concentrations during pregnancy, highlighting the need for dose adjustment 7.

Key Findings

• Escitalopram may be considered safe during pregnancy, particularly in terms of major malformations.
• Exposure to escitalopram may be associated with an increased risk of perinatal complications.
• Limited data suggest that escitalopram may be safe during breastfeeding.
• Pharmacokinetic studies suggest that dose adjustment may be necessary for individuals with intermediate or poor CYP2C19 activity during pregnancy.