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

Lexapro (Escitalopram) Side Effects

Lexapro commonly causes nausea (15%), insomnia (9%), sexual dysfunction (9% ejaculatory delay in men), dizziness (5%), fatigue (5%), and sweating, with most adverse effects being mild to moderate and transient. 1

Most Common Side Effects

Gastrointestinal Effects

• Nausea is the most frequent side effect, occurring in 15% of patients (compared to 7% with placebo), and is the most common reason for treatment discontinuation 1
• Diarrhea affects 8% of patients, constipation 3%, indigestion 3%, and abdominal pain 2% 1
• Dry mouth occurs in 5% of patients 1

Sexual Dysfunction

• Ejaculatory delay occurs in 9% of male patients (compared to <1% with placebo), making it one of the most prominent side effects 1
• Impotence affects 3% of male patients and anorgasmia occurs in 2% of female patients 1
• Decreased libido is reported in 3% of patients 1

Central Nervous System Effects

• Insomnia affects 9% of patients (compared to 4% with placebo) and is a leading cause of discontinuation 1
• Somnolence/sleepiness occurs in 6% of patients 1
• Dizziness affects 5% of patients 1
• The medication can impair ability to make decisions, think clearly, or react quickly, requiring caution with driving and operating machinery 1

Other Common Effects

• Fatigue occurs in 5% of patients 1
• Increased sweating affects approximately 5% or more of patients 1
• Decreased appetite is reported in 3% of patients 1
• Weakness and feeling anxious are commonly reported 1

Serious Side Effects Requiring Immediate Attention

Cardiovascular Risks

• Escitalopram should not exceed 40 mg/day in adults or 20 mg/day in adults over 60 years due to dose-dependent QT interval prolongation that can lead to Torsade de Pointes, ventricular tachycardia, and sudden death 2
• ECG monitoring is recommended in patients with cardiac risk factors or on higher doses 2

Serotonin Syndrome

• Serotonin syndrome develops within 24-48 hours when combining escitalopram with other serotonergic medications (MAOIs, other SSRIs, SNRIs, triptans, tramadol, St. John's Wort, tryptophan) 2, 1
• Symptoms include mental status changes (confusion, agitation), neuromuscular hyperactivity (tremor, rigidity, hyperreflexia), and autonomic instability (hypertension, tachycardia, hyperthermia, diaphoresis) 2
• Advanced cases can progress to fever, seizures, arrhythmias, and unconsciousness 2

Bleeding Risk

• Gastrointestinal bleeding risk increases (OR 1.2-1.5) with SSRIs, particularly when combined with aspirin or NSAIDs 2
• Abnormal bleeding manifestations include ecchymosis, hematoma, epistaxis, petechiae, and hemorrhage 2

Suicidality

• Risk of suicidality is highest within 1-2 months of initiation or dose increase, particularly in adults aged 18-24 years (OR 2.30) 2
• Risk is neutral in adults 25-64 years and protective in adults ≥65 years (OR 0.06) 2

Hyponatremia

• Hyponatremia occurs in 0.5-12% of older adults (OR 3.3 compared to other drug classes), typically developing within the first month of treatment 2

Discontinuation and Withdrawal

Discontinuation Syndrome

• Escitalopram should be tapered over 10-14 days to minimize withdrawal symptoms including dizziness, fatigue, lethargy, and anxiety 2
• About 6% of depressed patients discontinued treatment due to adverse events (compared to 2% with placebo) 1
• At 20 mg/day dosing, discontinuation rates increase to 10% (significantly higher than 4% at 10 mg/day and 3% with placebo) 1

Special Population Considerations

Pediatric Patients

• Side effects in children and adolescents include increased thirst, abnormal increase in muscle movement or agitation, nosebleed, difficult urination, and heavy menstrual periods 1
• Possible slowed growth rate and weight changes require monitoring of height and weight during treatment 1
• Back pain, urinary tract infection, vomiting, and nasal congestion occur at higher rates than in adults 1

Pregnancy and Breastfeeding

• Third-trimester SSRI exposure causes neonatal adaptation syndrome characterized by continuous crying, irritability, and jitteriness, with onset ranging from hours to days after birth 2
• Escitalopram transfers into breast milk in low concentrations, with infant plasma levels typically undetectable 2

Management Strategies to Minimize Side Effects

Dosing Recommendations

• Start with lower doses (10 mg/day) and gradually titrate to minimize gastrointestinal and CNS side effects 2
• Take medication at bedtime if daytime dizziness is problematic 2
• Anxiety or agitation can occur initially, making it advisable to start with a subtherapeutic "test" dose 2

Drug Interactions

• Escitalopram has the least effect on CYP450 isoenzymes compared to other SSRIs, resulting in lower propensity for drug interactions 2
• Avoid combining with MAOIs and use caution with other serotonergic drugs 2, 1
• Strong CYP450 inducers may decrease efficacy 2

Common Pitfalls to Avoid

• Do not drink alcohol while taking escitalopram 1
• Do not abruptly discontinue without tapering 2
• Avoid over-the-counter serotonergic compounds like St. John's Wort or dextromethorphan 2, 1
• Monitor for worsening depression or suicidal thoughts, especially in the first 1-2 months 2