What are the common side effects of Lexapro (escitalopram)?

Common Side Effects of Lexapro (Escitalopram)

The most common side effects of Lexapro include nausea (15%), insomnia (9%), ejaculation disorder (9% in males), diarrhea (8%), fatigue (5%), dizziness (5%), sweating (5%), and somnolence (6%), with most adverse effects being mild to moderate and transient. 1

Most Frequent Side Effects in Adults with Depression

The FDA-approved labeling identifies the following common adverse reactions occurring in ≥5% of patients at approximately twice the rate of placebo 1:

• Nausea (15%) - most common gastrointestinal effect, typically mild and transient 1
• Insomnia (9%) 1
• Ejaculation disorder (9% in males) - primarily ejaculatory delay 1
• Diarrhea (8%) 1
• Fatigue (5%) 1
• Dizziness (5%) 1
• Increased sweating (5%) 1
• Somnolence (6%) 1

Additional Common Side Effects (2-5% incidence)

Other adverse reactions occurring in ≥2% of patients and more frequently than placebo include 1:

• Gastrointestinal: Constipation (3%), indigestion (3%), abdominal pain (2%), dry mouth 1
• Sexual dysfunction: Impotence (3% in males), anorgasmia (2% in females), decreased libido (3%) 1
• Respiratory: Rhinitis (5%), sinusitis (3%) 1
• Psychiatric: Decreased appetite (3%), weakness 1
• Other: Influenza-like symptoms (5%), shaking/tremor, feeling anxious, yawning 1

Side Effects in Anxiety Disorders

For generalized anxiety disorder, the profile is similar but with some differences in frequency 1:

• Nausea (18%) - notably higher than in depression trials 1
• Somnolence (13%) - higher than depression trials 1
• Ejaculation disorder (14% in males) 1
• Insomnia (12%) 1
• Fatigue (8%) 1
• Decreased libido (7%) 1
• Anorgasmia (6% in females) 1

Pediatric-Specific Side Effects

Children and adolescents (ages 6-17) experience a generally similar profile to adults, but with additional reactions occurring at ≥2% 2, 1:

• Back pain 1
• Urinary tract infection 1
• Vomiting 1
• Nasal congestion 1
• Increased thirst 1
• Abnormal increase in muscle movement or agitation 1
• Nosebleed 1
• Heavy menstrual periods 1
• Possible slowed growth rate and weight changes - height and weight should be monitored during treatment 1

Dose-Dependent Effects

Higher doses (20 mg/day) produce significantly more adverse effects than lower doses (10 mg/day), with the 20 mg dose showing approximately twice the incidence of several side effects compared to 10 mg. 1

Common reactions with dose-dependent increases at 20 mg/day versus 10 mg/day 1:

• Insomnia: 14% vs 7% 1
• Diarrhea: 14% vs 6% 1
• Dry mouth: 9% vs 4% 1
• Somnolence: 9% vs 4% 1
• Increased sweating: 8% vs 3% 1
• Dizziness: 7% vs 4% 1

Serious Adverse Effects (Less Common)

Potentially serious adverse effects requiring monitoring include suicidal thinking and behavior (particularly in patients under age 24), behavioral activation/agitation, serotonin syndrome, abnormal bleeding, and seizures. 2, 1

Suicidality Risk

• Boxed warning for suicidal thinking and behavior through age 24 2
• Pooled absolute rates: 1% with antidepressants vs 0.2% with placebo 2
• Number needed to harm: 143 2
• Close monitoring recommended especially in first months and after dose adjustments 2, 1

Behavioral Activation/Agitation

• More common in younger children than adolescents 2
• Includes motor/mental restlessness, insomnia, impulsiveness, disinhibited behavior, aggression 2
• May occur early in treatment or with dose increases 2
• Supports slow up-titration strategy 2

Serotonin Syndrome

• Occurs in 14-16% of SSRI overdoses 2
• Signs include tremor, diarrhea, delirium, neuromuscular rigidity, hyperthermia 2
• Risk increased when combining with other serotonergic medications 2, 1

Neonatal Effects with Third-Trimester Exposure

Third-trimester SSRI exposure is associated with neonatal adaptation syndrome, presenting with continuous crying, irritability, jitteriness, tremors, hypertonia, tachypnea, feeding difficulty, and sleep disturbance. 2

Neonatal signs typically 2:

• Onset: Hours to days after birth 2
• Duration: Usually resolve within 1-2 weeks, though may persist up to 4 weeks 2
• Symptoms: Crying, irritability, tremors, poor suck, feeding difficulty, hypertonia, tachypnea, sleep disturbance, hypoglycemia, seizures 2

Discontinuation Rates

• Depression trials: 6% discontinued due to adverse events (vs 2% placebo) 1
• Anxiety trials: 8% discontinued due to adverse events (vs 4% placebo) 1
• Pediatric trials: 3.5% discontinued (vs 1% placebo) 1
• Most common reasons for discontinuation: nausea (2%), ejaculation disorder (2%), insomnia (1%), fatigue (1%) 1

Sexual Dysfunction Considerations

Sexual dysfunction is significantly underreported in clinical trials, and actual incidence is likely higher than labeled rates. 1

The FDA labeling acknowledges that reliable estimates are difficult to obtain because patients and physicians may be reluctant to discuss sexual side effects, and labeled incidence rates likely underestimate actual occurrence 1.

Clinical Pitfalls to Avoid

• Starting at too high a dose: Begin at 10 mg/day; the 20 mg dose has substantially higher adverse event rates 1
• Inadequate patient education about transient nausea: Nausea is common (15-18%) but typically mild and transient 1
• Failure to monitor for behavioral activation in children: Younger children are at higher risk 2
• Combining with other serotonergic agents without caution: Increases serotonin syndrome risk 2, 1
• Abrupt discontinuation: Though escitalopram has lower discontinuation syndrome risk than paroxetine or venlafaxine, tapering over 10-14 days is still recommended 3