Escitalopram (Cipralex, Lexapro, Conjupram, Zytapram) is used to manage acute Generalized Anxiety Disorder and for acute and maintenance therapy in patients with Unipolar Major Depressive Disorder.

It may also be used in the treatment of the following disorders:

• Binge eating disorder
• Bulimia nervosa
• Obsessive-compulsive disorder
• Body dysmorphic disorder
• Panic disorder
• Posttraumatic stress disorder
• Premature ejaculation
• Premenstrual dysphoric disorder
• Vasomotor symptoms linked to menopause

Escitalopram Dose in Children

• Dosage guidelines for Escitalopram (Conjupram) in generalized anxiety disorder:

Initiate treatment with a lower dose, such as 5 or 10 mg, and, based on the patient's response and tolerance after a week, consider increasing it to a maximum of 20 mg once daily.

• Dosage recommendations for Lexapro (Escitalopram) in Major depressive disorder (unipolar):

Commence with an initial oral dose of 10 mg once a day, and gradually escalate by 1 mg every 7 days, up to a maximum of 20 mg daily. In some cases, a daily dosage of 30 mg may be required.

• Use of Escitalopram in Binge eating disorder (off-label):

While Escitalopram is employed to address binge eating disorders, limited information is available. If the medication is well-tolerated, the initial dose of 10 mg can be raised to a maximum of 30 mg daily.

• Body dysmorphic disorder (off-label use):

The effectiveness of Escitalopram in treating body dysmorphic disorder is not fully explored. The medication can be initiated at a dose of 10.

In some cases, experts have administered up to 60 mg of escitalopram for body dysmorphic disorder.

However, raising the dose beyond the recommended amount necessitates cardiac monitoring.

Before any dose escalation, it is essential for all patients to undergo electrocardiography (ECG).

Bulimia nervosa as an alternative agent (off-label use):

Depending on the reaction and tolerance, 10 mg once daily to a maximum of 30 mg once daily.

Obsessive-compulsive disorder (OCD) (off-label use):

10 mg orally once per day up to 40 mg once per day. Every week, the dosage should be raised by 10 mg. In refractory cases, higher dosages of up to 60 mg have been administered.

Escitalopram dose in Panic disorder (off-label use):

Start your therapy with a low dose, such as 5 mg once per day, and work your way up to 20 mg once per day, at most, at weekly intervals.

Posttraumatic stress disorder (off-label use):

Start escitalopram in a dose of 10 mg once daily and increase the dose by 5-10 mg at weekly intervals to a maximum of 40 mg once daily.

Premature ejaculation (off-label use):

Escitalopram's role in premature ejaculation is only partially understood. Start with a dose of 10 mg once per day and work your way up to 20 mg once per day.

Premenstrual dysphoric disorder (off-label use):

Continuous daily dosing regimen:

• Start with a daily dose of 5–10 mg. After a month, raise the dosage to a maximum of 20 mg once per day.

Intermittent regimens:

• Luteal phase dosing regimen: Start two weeks before the anticipated start of the menstrual cycle at a dose of 5 to 10 mg. The dosage may be raised to 20 mg once daily.
• Symptom-onset dosing regimen: Start at a dose of 5 - 10 mg once daily on the day of symptoms onset and continue until a few days of the menstrual cycle. The dose may be increased to 20 mg once daily.

Vasomotor symptoms associated with menopause as an alternative agent (off-label use):

• Escitalopram may be used as an alternative to hormonal therapy in patients with perimenopausal symptoms.
• The dose is 10 mg once daily. Based on the response and tolerability, it may be increased to 20 mg once daily.

How to discontinue Escitalopram?

• Escitalopram should be gradually tapered off in patients who have been using it for more than three weeks.
• The dose should be gradually reduced by 5 - 10 mg over a period of 2 - 4 weeks.
• If the patient's symptoms reappear, restart the previous dose on which the patient was stable and then start tapering more slowly.
• Patients using escitalopram for more than six months may benefit from tapering it over a period of three months.

How to switch to other antidepressant drugs?

Although data regarding switching strategies from one antidepressant to another antidepressant is limited, some of the important points are listed here:

• Cross-titration:

  • This method is usually followed especially when escitalopram or the other antidepressant has been used for more than 2 - 4 weeks.
  • One drug is gradually tapered while the dose of the other drug is increased gradually at the same time.

• Direct switch:

  • The direct switch is the abrupt discontinuation of one drug and initiating the other drug at an equivalent dose.
  • This method may be appropriate in cases where the drug has been used for less than 1 - 2 weeks or when the drug is discontinued because of the adverse effects.

Switching to or from an MAOI:

• At least a 14 days drug-free interval should be allowed when switching from an MAOI to escitalopram and vice versa.
• Cross titration is contraindicated when switching from an MAOI to an SSRI and vice versa.

Escitalopram Dose in Children

Escitalopram is not recommended for use in children less than 12 years of age. 

Escitalopram in Children and Adolescents older than 12 years:

• Depression and anxiety:

  • 10 mg once daily.
  • The dose may be increased after three weeks to 20 mg/day

• Autism and Pervasive Developmental Disorders (PDD):

  • Children and Adolescents 6 to 17 years:
    • Initiate therapy with 2.5 mg once daily.
    • Increase the dose to 5 mg/day at a weekly interval to a maximum dose of 20 mg/day.

• Social anxiety disorder:

  • Children and Adolescents 10-17 years:
    • Start escitalopram at a dose of 5 mg/day and increase the dose weekly by 5 mg/day to a maximum dose of 20 mg/day.

Pregnancy Risk Factor: C

• Escitalopram crosses over the placenta, and is distributed in amniotic fluid.
• However, there are contradicting results for the teratogenic effects.

These effects are not teratogenic:

• Cyanosis
• Apnea
• Seizures
• Neonatal Respiratory distress
• Hypoglycemia and feeding difficulties
• Hypotonia or hypertonia
• Persistent crying, irritability and jitteriness
• Tremors
• Discontinuation syndrome
• The newborn may have persistent pulmonary hypertension

Breastfeeding:

• Breast milk contains Escitalopram.
• The child should be closely monitored for changes in sleep patterns or behavior.
• It is preferable that the patient be switched to an SSRI during breastfeeding. 
• Pregnant women who are taking escitalopram during pregnancy can still take the medication.

Escitalopram dose in Kidney disease:

• CrCl of more than 20ml/min:

  • No dose adjustment required.

• CrCl of less than 20 ml/min:

  • Use with caution

Conjupram dose in Liver disease:

Use with caution. The maximum daily dose should not exceed 10 mg per day.

Common side effects of escitalopram (Lexapro, Conjupram):

Headache, insomnia, drowsiness, nausea, diarrhea, and sexual/ ejaculatory dysfunction.

Less common side effects:

• CNS:

  • Fatigue, lethargy, yawning, paraesthesias, abnormal dreams, and anorgasmia.

• Endocrine:

  • decreased libido and menstrual irregularities

• Gastrointestinal:

  • Constipation, dyspepsia, anorexia, flatulance, vomiting, and abdominal pain.

• Neuromuscular:

  • Neck, shoulder, and back pain

• Respiratory:

  • FLu-like symptoms, sinusitis, and nasal congestion.

Contraindications to Escitalopram (Lexapro):

• The following patients are not recommended to take Escitalopram:
  • Patients who are allergic to escitalopram
  • Patients who use an MAOI.
  • Patients who receive linezolid or methyleneblue or Pimozide
  • Patients with a prolong QT interval have been known to suffer from congenital Long QT syndrome.

Precautions and Warnings

• Suicidal Behaviors (US Boxed Warnings).

  • There has been a higher risk of suicide in adolescents and children who take Escitalopram (18-24 years old) for major depression.
  • Patients should be closely monitored for any changes in behavior or clinical worsening. It is not recommended for children under 12 years old.

• Escitalopram prevents platelet aggregation.

  • Patients with bleeding disorders, serious patients and those on anticoagulants like aspirin and other NSAIDs such as ibuprofen should not use it.

• QT interval effect:

  • Dose-dependent QT prolongation has been reported with Escitalopram.
  • The drug should not be prescribed to patients with heart disease or those suffering from deranged electrolytes such as hypokalemia or hypomagnesemia.

• Higher mental functions are affected:

  • It can cause impairment of higher mental functions.
  • Avoid escitalopram use by drivers and operators of heavy machinery.

• Bone fractures

  • This increases the risk of getting broken bones.

• Eye Effects

  • As a result, Escitalopram can cause narrow-angle glaucoma.

• Serotonin syndrome

  • Serotonin syndrome, which is a potentially fatal condition that can be caused by SSRIs, is a serious condition. 
  • Patients who show the following symptoms should be concerned:
    • Mental status changes (hallucinations and agitations, delirium, or coma)
    • autonomic instability: sweating, resting bradycardia/ tachycardia and changes in blood pressure
    • Neurological features (rigidity and tremor, seizures and myoclonus).
    • Gastrointestinal symptoms such as nausea, diarrhea, and vomiting can include:

• Sexual dysfunction

  • It can lead to or exacerbate sexual dysfunction.

• Hyponatremia

  • Hyponatremia may lead to reversible SIADH. Seizures may result from sodium levels below 120 mEq/l

• Bipolar disorder

  • Bipolar disorder patients should not be treated with Escitalopram. Patients with hypomania and mania should avoid Escitalopram.

• Discontinuation syndrome

  • After abruptly stopping escitalopram, patients who have been taking the drug for a long time may experience a discontinuation syndrome.
  • The symptoms of discontinuation syndrome include nausea, vomiting and diarrhea, headaches, nausea, dizziness, headaches, anorexia and tremors.
  • Other symptoms include: imbalance, electric shock-like sensations; myalgias; arrhythmias; myalgias; irritability and aggressive behavior; mood instability and confusion; difficulty concentrating.

How to Administer Escitalopram?

Administer escitalopram in the morning or evening with or without food.

Monitoring Parameters:

Patients should have the following investigations performed at baseline and then as clinically indicated:

• ECG ( for patients at-risk of QT prolongation and cardiac arrhythmias)
• Electrolytes (Sodium, Potassium, and magnesium)
• Liver and renal function tests
• Complete Blood Picture, and
• Suicidal ideation

Mechanism of action of escitalopram (Conjupram):

Escitalopram works by specifically preventing the reabsorption of serotonin, without influencing Norepinephrine or dopamine receptors.

Additionally, it has minimal impact on various receptors such as alpha and beta-adrenergic, D 1-5, H 1-3, M 1-5, and 5 HT 1-7. Escitalopram does not interact with sodium, potassium, chloride, or calcium ion channels.

The onset of its therapeutic effects usually takes approximately a week, with the maximum response observed between 4 to 8 weeks.

The medication is 80% bioavailable, and about 50% of it is bound to proteins. Escitalopram undergoes liver metabolism and has an elimination half-life ranging from 19 to 32 hours.

Escitalopram international brands:

• Antidex
• Celtium
• Cilentra
• Cipralex
• Citalo
• Citao
• Citaplex
• Clomentin
• Conjupram
• Depram
• Depresan
• Depsit
• E-Zentius
• Ecinil
• Edpa
• Elapram
• Elxion
• Epram
• Esciprex
• Escital
• Escitalpro
• Escitam
• Escivex
• Esidep
• Esipram
• Esitalo
• Eslopran
• Esopam
• Esoplex
• Esopram
• Esram
• Estimex
• Esto
• Estoram
• Etalopro
• Feliz S
• Feliz S 10
• Feliz S 20
• Feliz-20
• Ipran
• Isolift
• Jovia
• LXapam
• Leeyo
• Lepax
• Lexacure
• Lexam
• Lexapam
• Lexapro
• Lexapro Meltz
• Lexatin
• Lexcitam
• Lexdin
• Loxalate
• Neolexa
• Neopra
• Newpram
• Nexito
• Nodep
• Oxapro
• Pramokline
• Recita
• Reformex
• S-Celepra
• S-Oropram
• Saropram
• Seropam
• Seroplex
• Sipralexa
• Spador
• Sycopanaxin
• Talopram
• Taloscito
• Zelax
• Zytapram

Escitalopram Brands in Pakistan: