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Escitalopram (Lexapro)

SSRI • Last reviewed 2025-09-26

Guideline1clinicaldepression

General information

Escitalopram is the S-enantiomer of citalopram and a first-line selective serotonin reuptake inhibitor (SSRI) for major depressive disorder and generalized anxiety disorder in adults. It is favored for its clean adverse-effect profile and low propensity for cytochrome-mediated drug interactions.

Tablets (5, 10, 20 mg) and a 1 mg/mL oral solution allow flexible titration. Most patients start at 10 mg once daily with an option to increase to 20 mg after a minimum of one week, balancing response with adverse effects such as insomnia, nausea, or sexual dysfunction.

Meta-analyses show escitalopram achieves high remission rates versus other SSRIs with comparable discontinuation due to adverse events. Benefits in anxiety disorders extend across comorbid GAD and social anxiety, though longer titration may be needed for panic symptoms.

Clinicians monitor for SSRI-emergent activation or akathisia, hyponatremia in older adults, and rare QT prolongation at supratherapeutic exposures or when combined with other QT-prolonging agents.

Dosing & administration

Start 10 mg once daily; increase to 20 mg/day after ≥1 week if needed.

Consider 5 mg start for anxious, elderly, or CYP2C19 poor metabolizer patients.

Avoid doses >20 mg/day; QTc liability rises at high exposures.

Mechanism of action

Escitalopram selectively inhibits serotonin transporter (SERT) reuptake, increasing synaptic 5-HT. Allosteric modulation of SERT by escitalopram may accelerate transporter occupancy compared with racemic citalopram.

Metabolism & pharmacokinetics

Bioavailability approaches 80% with minimal food effect. Peak concentrations occur ~5 hours post-dose; steady state is achieved within 7–10 days. Metabolism occurs through CYP2C19 (primary) with minor CYP2D6 and CYP3A4 contribution, producing inactive metabolites eliminated renally. Half-life averages 27–32 hours, supporting once-daily dosing.

Drug interactions

Avoid concomitant monoamine oxidase inhibitors (MAOIs), linezolid, or methylene blue.

CYP2C19 strong inhibitors (e.g., omeprazole) may raise exposure; consider 10 mg max in poor metabolizers or with inhibitors.

Use caution with other QT-prolonging agents (antiarrhythmics, antipsychotics); baseline ECG in high-risk patients.

Monitoring & safety checks

Discontinuation guidance

Taper over at least 1–2 weeks when clinically feasible; withdrawal symptoms are uncommon but may include irritability, insomnia, or flu-like complaints. Longer tapers benefit patients treated >6 months.

References

  1. Escitalopram Prescribing Information — DailyMed
  2. Comparative efficacy and acceptability of 21 antidepressants — Lancet (2018) DOI: 10.1016/S0140-6736(17)32802-7
  3. APA Clinical Practice Guideline for the Treatment of Depression — American Psychiatric Association (2023)Guidelinedepressionclinical

Educational use only — verify details in current prescribing information and authoritative clinical guidelines before making prescribing decisions.