Side Effects of Nexito (Escitalopram)
Nexito (escitalopram) commonly causes nausea, insomnia, sexual dysfunction, fatigue, dizziness, and sweating, with approximately 63% of patients experiencing some side effects, though most are mild to moderate and transient. 1, 2
Common Side Effects
The most frequently reported adverse effects occurring in ≥5% of patients and at least twice the rate of placebo include: 2
- Nausea (15-18% vs 7-8% placebo) - most common reason for discontinuation 2
- Insomnia (9-12% vs 4-6% placebo) 2
- Ejaculation disorder in males (9-14% vs <1-2% placebo), primarily ejaculatory delay 2
- Fatigue (5-8% vs 2% placebo) 2
- Somnolence/sleepiness (6-13% vs 2-7% placebo) 2
- Dizziness (5% vs 3% placebo) 2
- Increased sweating 1, 2
Additional common effects (2-5% incidence) include: 2
- Diarrhea (8% vs 5-6% placebo)
- Decreased libido (3-7% vs 1-2% placebo)
- Dry mouth
- Constipation (3-5% vs 1-4% placebo)
- Decreased appetite
- Tremors 1
- Weakness 1, 2
- Anxiety 1, 2
Dose-Dependent Effects
Higher doses (20 mg/day) produce significantly more side effects than lower doses (10 mg/day), with discontinuation rates of 10% at 20 mg versus 4% at 10 mg. 2 The following adverse effects approximately double when escalating from 10 mg to 20 mg daily: 2
- Insomnia (7% → 14%)
- Diarrhea (6% → 14%)
- Dry mouth (4% → 9%)
- Somnolence (4% → 9%)
- Increased sweating (3% → 8%)
Serious Adverse Effects
Serotonin Syndrome
Serotonin syndrome is a potentially fatal complication characterized by mental status changes, autonomic instability, and neuromuscular symptoms. 1 Clinical features include: 3, 1
- Mental status changes (agitation, confusion, anxiety)
- Autonomic hyperactivity (fever, tachycardia, tachypnea, diaphoresis, mydriasis)
- Neuromuscular abnormalities (tremor, clonus, hyperreflexia, hypertonia, rigidity)
- Advanced symptoms may include seizures, arrhythmias, and unconsciousness 1
Risk is highest when combining escitalopram with other serotonergic agents including MAOIs (contraindicated), triptans, tramadol, opioids, stimulants, amphetamines, or St. John's Wort. 1, 2
Discontinuation Syndrome
Abrupt cessation of escitalopram can cause withdrawal symptoms, though escitalopram has a lower risk than paroxetine, fluvoxamine, or sertraline. 1 Symptoms include: 1
- Dizziness, fatigue, lethargy
- Headaches, general malaise
- Nausea, sensory disturbances
- Anxiety, irritability, agitation
Other Serious Effects
- QT prolongation - escitalopram has a lower risk than citalopram but caution is needed with other QT-prolonging drugs 3, 1
- Abnormal bleeding - especially when combined with aspirin or NSAIDs 1
- Hyponatremia 2
- Seizures (rare) 2
- Increased risk of nonfatal suicide attempts - SSRIs as a class show increased risk (odds ratio 1.57-2.25) though no increase in completed suicides 3
Special Population Considerations
Pregnancy and Neonatal Effects
Third-trimester SSRI exposure causes neonatal adaptation syndrome in newborns, though treatment should be continued at the lowest effective dose as maternal withdrawal may be more harmful. 3, 1 Neonatal signs include: 3
- Continuous crying, irritability, jitteriness, restlessness
- Tremors, hypertonia, rigidity
- Tachypnea, respiratory distress
- Feeding difficulty, poor suck
- Sleep disturbance
- Hypoglycemia
- Seizures (rare)
Symptoms typically onset within hours to days after birth and resolve within 1-4 weeks. 3
Pediatric Patients
In children and adolescents, additional side effects beyond those in adults include: 2
- Back pain
- Urinary tract infection
- Vomiting
- Nasal congestion
- Possible slowed growth rate and weight changes requiring monitoring 2
Elderly Patients
Escitalopram is considered a preferred SSRI for older adults compared to paroxetine and fluoxetine, which should generally be avoided in this population. 1 No clinically significant dose adjustment is required based on age alone. 4
Sexual Dysfunction
Sexual side effects are significantly underreported but occur frequently with escitalopram. 2 Rates include: 2
- Male ejaculation disorder: 9-14% (primarily ejaculatory delay)
- Impotence: 3%
- Anorgasmia (females): 2-6%
- Decreased libido: 3-7%
Paroxetine has higher rates of sexual dysfunction than escitalopram, while bupropion has significantly lower rates. 3
Management Strategies
Start with lower doses (5-10 mg) and titrate slowly, particularly in patients with anxiety disorders who may experience initial agitation. 1 Consider a subtherapeutic "test" dose initially. 1
For nausea (the most common reason for discontinuation), taking medication with food may help, though absorption is not affected. 2, 4
Avoid alcohol during treatment as escitalopram can impair decision-making, thinking, and reaction time. 2 Do not drive or operate heavy machinery until effects are known. 2
Drug Interaction Profile
Escitalopram has minimal effects on cytochrome P450 enzymes, resulting in a lower propensity for drug interactions compared to other SSRIs. 1, 4 However, cimetidine and omeprazole increase escitalopram exposure by 72% and 51% respectively, though these changes are not considered clinically significant. 4
Contraindicated combinations include MAOIs due to serotonin syndrome risk. 1, 2
Cardiovascular Considerations
Among SSRIs used in cardiovascular disease, sertraline has been studied most extensively and has lower QTc prolongation risk than citalopram or escitalopram. 3 Escitalopram should be used with caution in patients with heart problems, hypertension, or history of stroke. 2