What are the recommendations for taking escitalopram (selective serotonin reuptake inhibitor) before surgery?

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Escitalopram Before Surgery: Perioperative Management

Continue escitalopram throughout the perioperative period, including the day of surgery, to prevent withdrawal syndrome while monitoring for serotonin syndrome risk when combined with other serotonergic agents. 1

Primary Recommendation

  • Antidepressants including SSRIs like escitalopram should be continued perioperatively to avoid withdrawal symptoms. 1
  • The risk of withdrawal outweighs theoretical concerns about drug interactions in the surgical setting, making continuation the safer approach for patient outcomes including quality of life and morbidity prevention.

Rationale for Continuation

Withdrawal Syndrome Risk

  • Escitalopram discontinuation syndrome occurs frequently and can manifest within days of stopping the medication. 2, 3
  • Common withdrawal symptoms include dizziness (44%), muscle tension (44%), chills (44%), confusion (40%), and amnesia (28%). 2
  • Withdrawal symptoms can be easily misidentified as signs of impending relapse or postoperative complications. 3
  • Higher doses and plasma concentrations of escitalopram increase the risk of discontinuation syndrome. 2

Cardiovascular Considerations

  • A case report documented postoperative hypotension requiring vasopressor support following abrupt antidepressant withdrawal before cardiac surgery, which resolved upon medication reinitiation. 4
  • This demonstrates that withdrawal can cause clinically significant cardiovascular instability in the perioperative period.

Quality of Life Benefits

  • In patients undergoing CABG surgery, escitalopram treatment started 2-3 weeks preoperatively resulted in better quality of life and less pain after surgery, though it did not affect morbidity and mortality. 5
  • This supports both continuation in patients already taking escitalopram and potential initiation in depressed surgical candidates.

Critical Monitoring Requirements

Serotonin Syndrome Risk

  • Monitor for serotonin syndrome when escitalopram is combined with other serotonergic agents commonly used perioperatively. 5, 1

  • High-risk combinations include:

    • Opioids with serotonergic activity (fentanyl, meperidine, methadone, tramadol, tapentadol) 5
    • Antiemetics (ondansetron, granisetron, metoclopramide) 5
    • Other antidepressants (SNRIs, tricyclics, trazodone) 5
    • Triptans (though these should be held on day of surgery per separate guidelines) 5

  • Serotonin syndrome presents with neuroexcitatory symptoms, autonomic dysfunction, and neuromuscular abnormalities. 5

  • While the risk exists, it is generally low when SSRIs are combined with other serotonergic agents in clinical practice, as these medications are frequently co-prescribed. 5

Special Surgical Considerations

Bariatric Surgery

  • RYGB surgery significantly decreases escitalopram serum concentrations by 33% within 2 weeks postoperatively, with further decreases at 6 weeks. 6
  • This occurs even with minimal changes in body mass index (<5%), indicating altered gastrointestinal absorption rather than weight-related changes. 6
  • For patients undergoing bariatric surgery, plan for potential dose adjustments postoperatively and monitor for loss of therapeutic effect.

Practical Implementation

Preoperative Instructions

  • Instruct patients to take their usual morning dose of escitalopram on the day of surgery with a small sip of water. 1
  • Document the medication on the perioperative medication reconciliation.
  • Alert the anesthesia team to monitor for serotonin syndrome if multiple serotonergic agents will be used.

Postoperative Management

  • Resume escitalopram as soon as oral intake is tolerated postoperatively. 1
  • If prolonged NPO status is anticipated, consider alternative routes or temporary substitution, though this is rarely necessary given escitalopram's long half-life.
  • Very slow tapering is recommended if discontinuation is ever necessary, particularly in patients on higher doses. 2

Common Pitfalls to Avoid

  • Do not abruptly discontinue escitalopram before surgery based on outdated concerns about SSRI perioperative risks. 1, 3
  • Do not confuse withdrawal symptoms (dizziness, confusion, muscle tension) with postoperative complications or emerging delirium. 2, 3
  • Do not assume that short-term use (even 10 weeks) eliminates withdrawal risk—tapering is advisable regardless of treatment duration. 7
  • Do not overlook the need for dose adjustment after bariatric procedures. 6

References

1
Guideline

Perioperative Medication Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

4
Research

Hypotension following cardiac surgery associated with paroxetine and mirtazapine withdrawal.

The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG, 2008

5
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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