What is the prescribed dosage and potential side effects of Lexapro (escitalopram) for a 16-year-old patient?

Lexapro (Escitalopram) for a 16-Year-Old: Dosing and Side Effects

Why Lexapro is Prescribed for Adolescents

Lexapro is FDA-approved for adolescents aged 12-17 years specifically for the treatment of major depressive disorder (MDD). 1 The medication has demonstrated efficacy in treating depression and associated anxiety symptoms in this age group through multiple controlled clinical trials. 2, 3

• Escitalopram is a selective serotonin reuptake inhibitor (SSRI) that works by increasing serotonin availability in the brain, which helps regulate mood and anxiety. 4
• Clinical studies show that extended use of escitalopram in adolescents results in significant improvement in depressive symptoms compared to placebo. 2
• The medication is also used off-label for anxiety disorders including generalized anxiety disorder, panic disorder, and social anxiety disorder in adolescents. 3

Prescribed Dosage for a 16-Year-Old

The typical starting dose is 10 mg once daily, which is also the recommended maintenance dose for adolescents. 1

• The maximum FDA-approved dose is 20 mg daily, though doses above 20 mg are not recommended due to increased risk of side effects, particularly QT prolongation. 5, 1
• Escitalopram can be taken with or without food at any time of day. 1
• Steady-state blood levels are achieved within 7-10 days of starting treatment. 4
• The medication has a half-life of 27-33 hours, making once-daily dosing appropriate. 4, 3
• If dose adjustment is needed, increases should occur after at least 3 weeks at the current dose. 1

Common Side Effects in Adolescents

The most frequently reported side effects in adolescent patients (occurring in ≥5% and more than placebo) include headache, nausea, and insomnia. 1, 2

Gastrointestinal Effects:

• Nausea (15% vs 7% placebo) 1
• Diarrhea (8% vs 5% placebo) 1
• Vomiting 1, 2
• Constipation (3% vs 1% placebo) 1
• Abdominal pain (2% vs 1% placebo) 1

Neurological/Psychiatric Effects:

• Insomnia (9% vs 4% placebo) 1
• Somnolence/sleepiness (6% vs 2% placebo) 1
• Dizziness (5% vs 3% placebo) 1
• Fatigue (5% vs 2% placebo) 1
• Increased thirst 1
• Abnormal increase in muscle movement or agitation 1

Other Effects:

• Influenza-like symptoms (5% vs 4% placebo) 1
• Decreased appetite (3% vs 1% placebo) 1
• Increased sweating 1
• Urinary tract infection 2
• Nosebleed 1
• Heavy menstrual periods in females 1

Serious Side Effects Requiring Immediate Attention

All adolescents taking escitalopram must be monitored closely for worsening depression, suicidal thoughts, or unusual behavioral changes, especially during the first few months of treatment or after dose changes. 1

Black Box Warning - Suicidality:

• Antidepressants increase the risk of suicidal thinking and behavior in children and adolescents with major depressive disorder. 1
• Close monitoring is essential, particularly during initial treatment and dose adjustments. 1
• Families should watch for agitation, irritability, unusual behavior changes, or emergence of suicidal thoughts. 1

Other Serious Risks:

• Serotonin syndrome: Can occur when combined with other serotonergic drugs (triptans, other antidepressants, St. John's Wort, tramadol). Symptoms include agitation, confusion, rapid heart rate, high blood pressure, dilated pupils, muscle rigidity, and high fever. 1
• Activation of mania/hypomania: Escitalopram can trigger manic episodes, particularly at higher doses (20 mg), even in patients without prior bipolar disorder history. 6
• Seizures: May lower seizure threshold. 1
• Abnormal bleeding: Increased risk when combined with NSAIDs, aspirin, or anticoagulants. 1
• Hyponatremia: Low sodium levels, particularly in elderly patients. 1
• QT prolongation: Dose-dependent risk of cardiac rhythm abnormalities. 5

Growth and Development Considerations

Height and weight should be monitored during treatment with escitalopram in adolescents due to potential effects on growth rate. 1

• Decreased appetite is a common side effect that may impact nutritional intake. 1
• Regular monitoring of growth parameters is recommended throughout treatment. 1

What Families Should Know

Taking the Medication:

• Take exactly as prescribed; do not stop abruptly without medical guidance. 1
• If a dose is missed, take it as soon as remembered unless it's almost time for the next dose—never double up. 1
• Avoid alcohol while taking escitalopram. 1
• The medication may cause drowsiness or affect decision-making; caution with driving or operating machinery until effects are known. 1

When to Contact the Healthcare Provider:

• Any thoughts of self-harm or suicide 1
• Unusual agitation, irritability, or behavioral changes 1
• New or worsening anxiety or panic attacks 1
• Difficulty sleeping or changes in sleep patterns 1
• Impulsive or aggressive behavior 1
• Extreme increase in activity or talking (mania) 1

Drug Interactions to Avoid:

• MAO inhibitors (must allow ≥14 days between discontinuation of MAOI and starting escitalopram) 1
• Other medications containing escitalopram or citalopram 1
• Triptans for migraine 1
• Other antidepressants (SSRIs, SNRIs, tricyclics) 1
• Tramadol 1
• St. John's Wort or tryptophan supplements 1

Timeline for Effectiveness

Initial response to escitalopram may be observed within 2 weeks, but full therapeutic benefit typically requires 6-8 weeks of treatment. 2, 7

• Anxiety symptoms may improve before depressive symptoms. 7
• If no improvement is seen after 6-8 weeks at an adequate dose, reassessment of the treatment plan is warranted. 2
• Extended treatment (24 weeks) shows continued improvement in adolescents with MDD. 2

Discontinuation

Escitalopram should never be stopped abruptly; gradual tapering is necessary to minimize withdrawal symptoms. 1

• Discontinuation symptoms can include dizziness, sensory disturbances, agitation, anxiety, confusion, and headache. 1
• Tapering should be done under medical supervision, typically reducing by 5 mg every 1-2 weeks. 5