ESCITALOPRAM OXALATE
Clinical safety rating: caution
MAOIs can cause serotonin syndrome and other SSRIs may have additive effects May increase risk of bleeding especially with NSAIDs or warfarin.
Selective serotonin reuptake inhibitor (SSRI); potentiates serotonergic activity by inhibiting presynaptic serotonin reuptake.
| Metabolism | Primarily hepatic via CYP2C19, CYP3A4, and CYP2D6; active metabolite S-desmethylcitalopram also undergoes glucuronidation. |
| Excretion | Renal: approximately 8% as unchanged drug; remainder as metabolites, primarily S-DCT (glucuronide and sulfate conjugates). Biliary/fecal: minimal; less than 10% of dose recovered in feces as parent drug and metabolites. |
| Half-life | Terminal elimination half-life: approximately 27–32 hours. Steady-state reached in about 1 week. The long half-life allows once-daily dosing. |
| Protein binding | Approximately 56% bound to plasma proteins (primarily albumin and alpha-1-acid glycoprotein). |
| Volume of Distribution | Vd: approximately 12–26 L/kg (mean ~20 L/kg). Indicates extensive extravascular distribution into tissues (e.g., brain). |
| Bioavailability | Oral: approximately 80% (absolute); unaffected by food. |
| Onset of Action | Oral: 2–4 weeks for full therapeutic effect; some improvement may be seen within 1–2 weeks. No parenteral formulations available. |
| Duration of Action | Duration: 24 hours with once-daily dosing due to long half-life; clinical effect persists for days to weeks after discontinuation due to gradual elimination. |
10-20 mg orally once daily; starting dose 10 mg/day, may increase to 20 mg/day after at least 1 week.
| Dosage form | TABLET |
| Renal impairment | GFR <30 mL/min: reduce dose to 10 mg/day, not to exceed 10 mg/day. GFR ≥30 mL/min: no adjustment. |
| Liver impairment | Child-Pugh A: 10 mg/day. Child-Pugh B or C: 5 mg/day for first 2 weeks, then increase to 10 mg/day if tolerated. |
| Pediatric use | Adolescents 12-17 years: 10 mg orally once daily; may increase to 20 mg/day after 3 weeks. Not approved under 12 years. |
| Geriatric use | Initial dose 5 mg orally once daily, may increase to 10 mg/day after 1-2 weeks; maximum 10 mg/day. |
| 1st trimester | Consult provider |
| 2nd trimester | Consult provider |
| 3rd trimester | Consult provider |
Clinical note
MAOIs can cause serotonin syndrome and other SSRIs may have additive effects May increase risk of bleeding especially with NSAIDs or warfarin.
| FDA category | Animal |
| Breastfeeding | Escitalopram is excreted into breast milk with a milk-to-plasma (M/P) ratio of approximately 0.5-1.0. Relative infant dose is estimated at 3-6% of maternal weight-adjusted dose. Adverse effects in breastfed infants are rare but include irritability, poor feeding, and sleep disturbance. Benefits of breastfeeding generally outweigh risks at therapeutic doses. |
| Teratogenic Risk |
■ FDA Black Box Warning
Increased risk of suicidal thinking and behavior in children, adolescents, and young adults with major depressive disorder and other psychiatric disorders.
| Common Effects | anxiety disorders |
| Serious Effects |
["Concomitant use with MAOIs (including linezolid and IV methylene blue)","Concomitant pimozide","Known hypersensitivity to escitalopram or citalopram","CYP2C19 poor metabolizers (contraindicated for doses >20 mg) [relative due to QT prolongation risk]"]
| Precautions | ["Suicidality in pediatric/young adult populations","Serotonin syndrome","QT prolongation (dose-dependent) and Torsade de Pointes","Discontinuation syndrome","Seizure threshold","Bleeding risk (especially with NSAIDs/aspirin)","Hypomania/mania activation","Angle-closure glaucoma","Hyponatremia (SIADH)"] |
| Food/Dietary |
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| First trimester: Epidemiologic studies suggest a small increased risk of congenital cardiac malformations (primarily ventricular septal defects) with maternal SSRI use. Second and third trimesters: Late exposure may increase risk of persistent pulmonary hypertension of the newborn (PPHN) and neonatal adaptation syndrome (irritability, feeding difficulties, respiratory distress). |
| Fetal Monitoring | Maternal: Assess for mood stability, suicidal ideation, and side effects (nausea, insomnia, sexual dysfunction). Fetal/neonatal: Third trimester exposure warrants monitoring for PPHN (echocardiogram if symptoms) and neonatal adaptation syndrome (observation for 48 hours after delivery). |
| Fertility Effects | Escitalopram may cause reversible sexual dysfunction (decreased libido, ejaculatory delay) in both men and women, potentially affecting fertility. Animal studies show no significant impact on fertility at clinically relevant doses. Human data on direct fertility effects are limited. |
| No significant food interactions. May be taken without regard to meals. Grapefruit juice does not affect metabolism. Avoid excessive alcohol consumption as it may exacerbate CNS depression and reduce drug efficacy. |
| Clinical Pearls | Escitalopram is the S-enantiomer of citalopram, with higher selectivity for the serotonin transporter and fewer off-target effects. It exhibits linear pharmacokinetics, unlike citalopram's nonlinear kinetics. Use with caution in patients with prolonged QTc interval; maximum dose is 20 mg/day due to dose-dependent QTc prolongation. Onset of therapeutic effect typically takes 2-4 weeks. Avoid concurrent use with MAOIs, linezolid, or methylene blue due to serotonin syndrome risk. Taper gradually to avoid discontinuation syndrome. Effective for both depression and generalized anxiety disorder. Dose adjustment in hepatic impairment: maximum 10 mg/day. No significant CYP2D6 inhibition compared to citalopram, but still potential for interactions with tamoxifen. |
| Patient Advice | Take escitalopram exactly as prescribed, usually once daily, with or without food. · It may take 2-4 weeks to feel the full benefit; do not stop abruptly without consulting your provider. · Common side effects include nausea, insomnia, drowsiness, dry mouth, and sexual dysfunction. These often improve over time. · Avoid alcohol and recreational drugs, as they can worsen side effects and reduce effectiveness. · Monitor for worsening depression, suicidal thoughts, or unusual changes in behavior, especially during initial treatment or dose changes. · Use caution when driving or operating machinery until you know how the medication affects you, as it may cause drowsiness or dizziness. · Do not take this medication within 14 days of MAO inhibitors (e.g., isocarboxazid, phenelzine) or other serotonergic drugs to prevent serotonin syndrome. · Inform all healthcare providers that you are taking escitalopram, especially before surgery or any new prescription. · If you miss a dose, take it as soon as you remember unless it is close to the next dose; do not double dose. · Store at room temperature away from moisture and heat. |