Is it safe to start a new prescription for escitalopram (selective serotonin reuptake inhibitor) within 30 days of surgery for a patient with anxiety and depression?

Starting Escitalopram Within 30 Days of Surgery

Yes, it is safe to start escitalopram within 30 days of surgery for anxiety and depression management, and doing so may actually improve postoperative quality of life and pain outcomes without increasing morbidity or mortality. 1

Evidence Supporting Perioperative Escitalopram Initiation

In a randomized controlled trial of 361 patients undergoing elective CABG surgery, escitalopram 10 mg daily started 2-3 weeks preoperatively resulted in better quality of life and less postoperative pain compared to placebo, with no effect on morbidity and mortality. 1 This represents the highest-quality evidence directly addressing perioperative SSRI initiation.

The American Heart Association guidelines explicitly state that treating depression before CABG leads to improved psychological outcomes after surgery, supporting preoperative initiation when clinically indicated. 1

Key Safety Considerations

Serotonin Syndrome Monitoring

• Monitor for serotonin syndrome when combining escitalopram with other serotonergic agents commonly used perioperatively, including opioids (particularly tramadol, meperidine, fentanyl), antiemetics (ondansetron, metoclopramide), and other antidepressants. 2

• The clinical triad of serotonin syndrome includes neuromuscular abnormalities (tremor, hyperreflexia, myoclonus), autonomic dysfunction (hyperthermia, tachycardia, diaphoresis), and altered mental status. 2

• While theoretically concerning, the actual risk is low in clinical practice as these medications are frequently co-prescribed without incident. 2

Continuation Through Surgery

• Continue escitalopram through the perioperative period without interruption, as the risk of withdrawal outweighs theoretical concerns about drug interactions. 2

• Escitalopram has a long half-life, making brief NPO periods clinically insignificant and not requiring dose adjustment or alternative routes. 2

Medications to Strictly Avoid in This Population

When managing anxiety and depression perioperatively, certain medications must be avoided as they worsen cognitive function and increase delirium risk:

• Avoid benzodiazepines entirely, as they precipitate delirium and worsen postoperative cognitive dysfunction. 1, 3

• Avoid antihistamines (diphenhydramine, hydroxyzine, cyclizine) due to anticholinergic effects that increase delirium risk. 1, 3

• Minimize opioids using multimodal analgesia with acetaminophen as first-line, as opioids contribute to both delirium and cognitive impairment. 3

• Avoid sedative-hypnotics and anticholinergic medications (tricyclic antidepressants, paroxetine, promethazine, prochlorperazine). 1

Optimal Treatment Algorithm

For Patients Starting Treatment Within 30 Days of Surgery:

1. Initiate escitalopram 10 mg daily 2-3 weeks before elective surgery when possible, based on the randomized trial evidence showing improved quality of life and pain outcomes. 1

2. Continue escitalopram through surgery without interruption, as discontinuation risks withdrawal symptoms that outweigh theoretical perioperative concerns. 2

3. Add cognitive behavioral therapy or telephone-delivered collaborative care as first-line adjunctive treatment, which demonstrates superior efficacy when combined with SSRI therapy compared to medication alone. 3

4. Implement multimodal analgesia starting with acetaminophen, avoiding benzodiazepines and minimizing opioids to prevent delirium and cognitive dysfunction. 3

For Urgent Surgery (Cannot Wait 2-3 Weeks):

• Start escitalopram 10 mg daily immediately postoperatively once the patient can take oral medications, as the benefits for depression and anxiety management outweigh any theoretical perioperative risks. 1, 2

• The same monitoring and avoidance strategies apply as above.

Clinical Pitfalls to Avoid

• Do not delay necessary psychiatric treatment due to upcoming surgery, as untreated depression increases risk of postoperative mortality, heart failure hospitalization, MI, cardiac arrest, and need for repeat revascularization. 1, 3

• Do not substitute benzodiazepines for escitalopram in the perioperative period, even if anxiety is prominent, as benzodiazepines significantly worsen cognitive outcomes and increase delirium risk. 1, 3

• Do not discontinue escitalopram perioperatively based on outdated concerns about bleeding risk or drug interactions—the evidence shows continuation is safe and beneficial. 2

• Do not use escitalopram as monotherapy—always combine with cognitive behavioral therapy or collaborative care for optimal outcomes. 3

Special Population Considerations

Elderly Patients (>65 years):

• Escitalopram demonstrates efficacy and good tolerability in elderly patients with anxiety disorders, with improvement occurring more rapidly than with citalopram. 4

• Exercise heightened vigilance for serotonin syndrome in elderly patients, particularly those in poor physical condition, as they are at increased risk. 5

• Apply Beers Criteria to avoid other inappropriate medications that compound cognitive risk. 1