What are the side effects of Lexapro (escitalopram)?

Lexapro (Escitalopram) Side Effects

Most Common Side Effects

The most frequently reported side effects of Lexapro include nausea (15%), insomnia (9%), ejaculation disorder/delayed ejaculation (9% in males), diarrhea (8%), somnolence (6%), dizziness (5%), sweating (5%), fatigue (5%), and decreased libido (3%). 1

Gastrointestinal Effects

• Nausea is the single most common side effect, occurring in 15% of patients versus 7% on placebo, and represents one of the primary reasons patients discontinue SSRI therapy. 1
• Diarrhea affects 8% of patients compared to 5% on placebo 1
• Constipation (3%), indigestion (3%), and abdominal pain (2%) occur less frequently 1
• Escitalopram may be better tolerated than sertraline regarding gastrointestinal side effects, making it a preferred choice when GI tolerability is a concern. 2
• Taking medication with food may help reduce nausea 2

Sexual Dysfunction

• Ejaculatory delay is the predominant sexual side effect, occurring in 9% of male patients versus <1% on placebo, and is severe enough to cause treatment discontinuation in 2% of patients. 1
• Impotence affects 3% of male patients 1
• Anorgasmia occurs in 2% of female patients 1
• Decreased libido affects 3% of all patients 1
• When sexual dysfunction becomes intolerable on escitalopram, augmentation with bupropion is recommended as it has significantly lower rates of sexual adverse events and can mitigate SSRI-induced sexual dysfunction. 3

Central Nervous System Effects

• Insomnia occurs in 9% versus 4% on placebo and is the most common reason for discontinuation in pediatric patients 1
• Somnolence/drowsiness affects 6% of patients 1
• Dizziness occurs in 5% versus 3% on placebo 1
• Memory impairment (51%), decreased concentration (50%), and fatigue (45%) are commonly reported in naturalistic settings but may be underreported in clinical trials. 4

Neuropsychiatric Effects

• Headache is significantly more common with escitalopram compared to other SSRIs in head-to-head comparisons. 4
• Decreased appetite affects 3% of patients 1
• Yawning (47%) and light-headedness (43%) are frequently reported in real-world practice 4

Serious but Less Common Side Effects

Cardiac Effects

• QT prolongation and potential for ventricular arrhythmias can occur, particularly in patients >65 years, where 20% may reach potentially pro-arrhythmic concentrations even at the standard 10 mg dose due to age-dependent reduction in drug clearance. 5
• Serum concentrations should be kept below 100 nM to reduce arrhythmia risk, requiring therapeutic drug monitoring in high-risk patients including those >65 years, those on additional pro-arrhythmic drugs, or those with genetic predisposition for acquired long-QT syndrome. 5
• Bradycardia (heart rate <60 bpm) occurred in 14% of overdose cases 6

Serotonin Syndrome

• Serotonin syndrome occurred in 15% of escitalopram-alone overdoses, characterized by inducible clonus and hyperreflexia, and can develop within 24-48 hours after combining serotonergic medications or dose increases. 6, 2
• Monitor for mental status changes, autonomic instability (tachycardia, labile blood pressure, hyperthermia), and neuromuscular symptoms (tremor, rigidity, myoclonus) 2

Electrolyte Disturbances

• Syndrome of inappropriate antidiuretic hormone (SIADH) and hyponatremia can occur, requiring monitoring in high-risk patients. 7

Ophthalmologic Effects

• Vision blurred is significantly associated with escitalopram use, with most eye disorders occurring within the first 30 days of treatment. 8
• Visual impairment, mydriasis, and other eye disorders have been reported 8

Dermatologic Effects

• Skin rash and dermatitis medicamentosa can occur, though cutaneous reactions to escitalopram are rare 9
• Sweating affects 38% of patients in naturalistic settings 4
• Pruritus is significantly more common with escitalopram compared to other SSRIs 4

Discontinuation Syndrome

Abrupt cessation can cause discontinuation syndrome including dizziness, fatigue, headaches, nausea, vomiting, diarrhea, insomnia, anxiety, and irritability, necessitating a gradual taper rather than abrupt cessation. 2

Age-Specific Considerations

Pediatric Patients (6-17 years)

• The overall adverse reaction profile is similar to adults 1
• Additional reactions include back pain, urinary tract infection, vomiting, and nasal congestion (≥2% and greater than placebo) 1
• Insomnia is the most common reason for discontinuation (1% versus 0% on placebo) 1

Older Adults (>65 years)

• Due to age-dependent reduction in drug clearance, 20% of patients >65 years are predicted to reach potentially pro-arrhythmic concentrations following intake of just 10 mg escitalopram, requiring dose adjustment and therapeutic drug monitoring. 5

Discontinuation Rates

• 6% of adult patients discontinued escitalopram due to adverse events versus 2% on placebo 1
• At 20 mg/day, discontinuation rate increases to 10% 1
• 3.5% of pediatric patients discontinued treatment versus 1% on placebo 1

Critical Clinical Pitfalls to Avoid

• Never prescribe standard doses to patients >65 years without considering therapeutic drug monitoring, as age-related pharmacokinetic changes dramatically increase risk of cardiotoxicity. 5
• Always assess for polypharmacy with other serotonergic agents before initiating or increasing doses to prevent serotonin syndrome. 2
• Do not abruptly discontinue escitalopram; always use a gradual taper to minimize withdrawal symptoms. 2
• Monitor for eye disorders, particularly vision changes, within the first 30 days of treatment. 8