Escitalopram Side Effects
Escitalopram causes common adverse effects in approximately 63% of patients, with the most frequent being nausea (15%), insomnia (9%), ejaculation disorder (9% in males), diarrhea (8%), and somnolence (6%), though most are mild to moderate and transient. 1, 2
Most Common Side Effects
The FDA-approved labeling and clinical guidelines identify the following adverse effects occurring in ≥5% of patients at rates approximately twice that of placebo: 2
- Nausea (15%) - most common reason for discontinuation 1, 2
- Insomnia (9%) - occurs early in treatment 2
- Sexual dysfunction (9% ejaculatory delay in males, 3% impotence, 2% anorgasmia in females) - persistent throughout treatment 1, 2
- Diarrhea (8%) 2
- Somnolence/fatigue (5-6%) - may improve with bedtime dosing 3, 2
- Dizziness (5%) 2
- Sweating (increased) 1, 2
- Dry mouth 1, 2
In pediatric patients (6-17 years), additional side effects include increased thirst, abnormal muscle movement/agitation, nosebleeds, difficult urination, heavy menstrual periods, and possible slowed growth requiring monitoring. 2
Serious Cardiovascular Risks
Escitalopram carries a dose-dependent risk of QT interval prolongation, particularly at 20 mg/day doses, with FDA boxed warnings limiting maximum doses to 40 mg/day in adults and 20 mg/day in adults over 60 years due to risk of Torsades de Pointes, ventricular tachycardia, and sudden death. 1, 3
- ECG monitoring is recommended in patients with cardiac risk factors, electrolyte abnormalities, or concomitant QT-prolonging medications 3
- Among SSRIs, sertraline has lower QTc prolongation risk than citalopram or escitalopram in cardiovascular disease patients 1
Serotonin Syndrome
Serotonin syndrome develops within 24-48 hours when combining escitalopram with other serotonergic medications, characterized by mental status changes, neuromuscular hyperactivity (tremor, rigidity), and autonomic hyperactivity (hyperthermia, diarrhea, delirium). 1, 3
- Escitalopram is contraindicated with MAOIs and requires caution with triptans, tramadol, other SSRIs/SNRIs, St. John's Wort, and tryptophan 3, 2
- Occurs in 14-16% of SSRI overdoses 1
Bleeding Risk
Gastrointestinal bleeding risk increases with SSRIs (OR 1.2-1.5), especially with concomitant aspirin or NSAIDs. 1, 3
- Rare bleeding events include ecchymosis, hematoma, epistaxis, petechiae, and hemorrhage 3
- Consider gastroprotection in high-risk patients on antiplatelet therapy 1
Hyponatremia
Hyponatremia occurs in 0.5-12% of older adults (OR 3.3 for SSRIs vs other antidepressants), typically within the first month of treatment. 1, 3
- Monitor sodium levels in elderly patients, particularly during the first 4 weeks 1
Suicidality Risk
Age-related suicidality risk is slightly increased in adults 18-24 years (OR 2.30), neutral in adults 25-64 years, and protective in adults ≥65 years (OR 0.06), with highest risk within 1-2 months of initiation or dose increase. 1, 3
- Close monitoring is essential during the first 8 weeks of treatment in young adults 1
Pregnancy and Breastfeeding Concerns
Third-trimester SSRI exposure causes neonatal adaptation syndrome (continuous crying, irritability, jitteriness) with onset ranging from hours to days after birth. 3
- Late pregnancy SSRI use may increase risk of persistent pulmonary hypertension of the newborn (number needed to harm 286-351), though evidence is conflicting 1
- Escitalopram transfers into breast milk in low concentrations with typically undetectable infant plasma levels 1, 3
Discontinuation Syndrome
Escitalopram should be tapered over 10-14 days to minimize withdrawal symptoms including dizziness, fatigue, lethargy, and anxiety. 3
- Abrupt discontinuation can cause flu-like symptoms and sensory disturbances 3
Other Notable Adverse Effects
- Hepatotoxicity: 0.5-3% develop asymptomatic mild transaminase elevation, typically within 6 months 1
- Weight changes: Less common than with other antidepressants 1
- Seizures: Rare, but use caution in patients with seizure history 2
Management Strategies
Start with 10 mg/day and gradually titrate to minimize gastrointestinal and CNS side effects; consider bedtime dosing if daytime dizziness is problematic. 3