What are the side effects of Lexapro (escitalopram) 20 mg?

Lexapro (Escitalopram) 20 mg Side Effects

Lexapro 20 mg causes common side effects including nausea (15%), insomnia (9-14%), sexual dysfunction (9-14% in males, 2-6% in females), diarrhea (8-14%), and fatigue (5-8%), with serious but rare risks including suicidal thoughts in young adults, serotonin syndrome, and abnormal bleeding. 1

Common Side Effects (Occurring in ≥2% of Patients)

Gastrointestinal Effects

• Nausea is the most common side effect, occurring in 15% of patients taking escitalopram compared to 7% with placebo 1
• Diarrhea occurs in 8-14% of patients (dose-dependent, with higher rates at 20 mg) 1
• Constipation affects 3-6% of patients 1
• Dry mouth, indigestion, abdominal pain, and vomiting each occur in 2-3% of patients 1

Sexual Dysfunction

• Ejaculatory delay or disorder occurs in 9-14% of males (significantly higher at 20 mg dose) 1
• Decreased libido affects 3-7% of patients 1
• Anorgasmia occurs in 2-6% of females 1
• Impotence affects 3% of males 1
• Sexual dysfunction may persist after discontinuation in rare cases, though this is not well-quantified 2

Neuropsychiatric Effects

• Insomnia occurs in 9-14% of patients (dose-dependent, with 14% at 20 mg versus 7% at 10 mg) 1
• Somnolence affects 6-9% of patients 1
• Dizziness occurs in 5-7% of patients 1
• Fatigue affects 5-8% of patients 1

Other Common Effects

• Increased sweating occurs in up to 8% of patients at 20 mg 1
• Decreased appetite affects 3% of patients 1
• Influenza-like symptoms occur in 5% of patients 1
• Rhinitis and sinusitis each affect 3-5% of patients 1

Serious Side Effects Requiring Immediate Medical Attention

Suicidal Thoughts and Behavior

• Increased risk of suicidal thoughts or actions in children, teenagers, and young adults under 25 years, particularly within the first few months of treatment or with dose changes 1
• Monitor for new or worsening depression, anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, or suicidal ideation 1

Serotonin Syndrome

• Life-threatening condition that can occur, especially when combined with other serotonergic medications 1
• Symptoms include agitation, hallucinations, confusion, racing heartbeat, high or low blood pressure, sweating, fever, muscle rigidity, coordination problems, nausea, vomiting, and diarrhea 1

Bleeding Risk

• Escitalopram increases risk of abnormal bleeding or bruising, particularly when combined with warfarin, NSAIDs, or aspirin 1
• Gastrointestinal bleeding risk has an odds ratio of 1.2-1.5, with higher risk when combined with antiplatelet or NSAID therapy 3

Cardiovascular Effects

• QT prolongation is dose-dependent; FDA issued a 2012 boxed warning not to exceed 40 mg daily (or 20 mg daily in adults over 60 years) 3
• Escitalopram, along with citalopram and amitriptyline, carries risk for QT prolongation 3

Hyponatremia

• Occurs in 0.5-12% of older adults 3
• Odds ratio of 3.3 for SSRIs compared with other antidepressant classes 3
• Typically occurs within the first month of treatment 3
• Symptoms include headache, weakness, confusion, problems concentrating, and memory problems 1
• Elderly patients are at greater risk 1

Other Serious Effects

• Seizures or convulsions can occur 1
• Manic episodes (greatly increased energy, severe insomnia, racing thoughts, reckless behavior, excessive happiness or irritability) 1
• Severe allergic reactions including trouble breathing, facial swelling, rash, or hives 1
• Visual problems including eye pain, vision changes, or eye swelling (angle-closure glaucoma risk) 1
• Hepatotoxicity: 0.5-3% will have asymptomatic mild transaminase elevation, typically within 6 months 3

Dose-Dependent Side Effects

The 20 mg dose shows approximately twice the incidence of several side effects compared to 10 mg: 1

• Insomnia: 14% at 20 mg versus 7% at 10 mg
• Diarrhea: 14% at 20 mg versus 6% at 10 mg
• Dry mouth: 9% at 20 mg versus 4% at 10 mg
• Somnolence: 9% at 20 mg versus 4% at 10 mg
• Dizziness: 7% at 20 mg versus 4% at 10 mg
• Increased sweating: 8% at 20 mg versus 3% at 10 mg

Discontinuation Symptoms

Stopping escitalopram abruptly can cause withdrawal symptoms including: 1

• Anxiety, irritability, mood changes, restlessness
• Headache, sweating, nausea, dizziness
• Electric shock-like sensations, shaking, confusion
• Sleep disturbances

Special Populations

Pregnancy

• Late pregnancy use may increase risk of neonatal complications 1
• Patients should discuss risks versus benefits with their healthcare provider 1

Breastfeeding

• Escitalopram passes into breast milk 1
• Discussion with healthcare provider recommended regarding infant feeding 1

Clinical Considerations

Escitalopram demonstrates linear pharmacokinetics with steady-state achieved within 7-10 days, has low protein binding (56%), and minimal cytochrome P450 interactions 4

The drug is generally well-tolerated with a low discontinuation rate due to adverse events, showing no statistically significant difference from placebo in discontinuation rates at 10 mg daily 5

Weight changes are not clinically significant with escitalopram treatment in controlled trials 1