General

Pronunciation
ess-sit-AL-o-pram

Trade Name(s)

• Lexapro

Pregnancy Category
Category C

Ther. class.
antidepressants

Pharm. class.
selective serotonin reuptake inhibitors ssris

Indications

• Major depressive disorder

• Generalized anxiety disorder (GAD)

Unlabelled Use(s):

• Panic disorder

• Obsessive-compulsive disorder (OCD)

• Post traumatic stress disorder (PTSD

• Social anxiety discorder (social phobia)

• Premenstrual dysphoric disorder (PMDD)

Action

Selectively inhibits the reuptake of serotonin in the CNS

Therapeutic Effect(s):
Antidepressant action

Pharmacokinetics

Absorption: 80% absorbed following oral administration

Distribution: Enters breast milk

Metabolism and Excretion: Mostly metabolized by the liver (primarily CYP3A4 and CYP2C19 isoenzymes); 7% excreted unchanged by kidneys

Half-life: Increased in geriatric patients and patients with hepatic impairment

TIME/ACTION PROFILE (antidepressant effect)

ROUTE	ONSET	PEAK	DURATION
PO	within 1–4 wk	Unknown	Unknown

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity

• Concurrent MAO inhibitors

• Concurrent use of citalopram

Use Cautiously in:

• History of mania (may activate mania/hypomania)

• History of seizures

• Patients at risk for suicide

• Hepatic impairment (dose reduction recommended)

• Geri: Hepatic impairment or geriatric patients ( doses recommended)

• Severe renal impairment

• OB: Neonates exposed to SSRI in 3rd trimester may develop drug discontinuation syndrome including respiratory distress, feeding difficulty, and irritability. Weigh risks and benefits

• Lactation: May cause adverse effects in infant; risk/benefit should be considered

• Pedi: May risk of suicide attempt/ideation especially during early treatment or dose adjustment in children/adolescents (unlabeled for pediatric use)

Adverse Reactions/Side Effects

CNS: insomnia, dizziness, drowsiness, fatigue.

GI: diarrhea, nausea, abdominal pain, constipation, dry mouth, indigestion.

GU: anorgasmia, decreased libido, ejaculatory delay, erectile dysfunction.

Derm: increased sweating.

Endo: syndrome on inappropriate secretion of antidiuretic hormone (SIADH).

F and E: hyponatremia.

Metabolic: increased appetite.

*CAPITALS indicates life-threatening.
*italic indicates most frequent.

Interactions

Drug-Drug

• May cause serious, potentially fatal reactions when used with MAO inhibitors; allow at least 14 days between escitalopram and MAO inhibitors

• Use cautiously with other centrally acting drugs (including alcohol, antihistamines, opioid analgesics, and sedative/hypnotics; concurrent use with alcohol is not recommended)

• Concurrent use with sumatriptan or other 5-HT3 agonist vascular headache suppressants may result in weakness, hyperreflexia, and incoordination

• Cimetidine blood levels of escitalopram

• Serotonergic effects may be by lithium (concurrent use should be carefully monitored)

• Carbamazepine may blood levels

• May blood levels of metoprolol

• Concurrent use with tricyclic antidepressants should be undertaken with caution because of altered pharmacokinetics

Drug-Natural Products
risk of serotonin syndrome with St. John's wort and SAMe

Route/Dosage

• PO (Adults): 10 mg once daily, may be increased to 20 mg once daily after one week.

Hepatic Impairment

• PO (Adults): 10 mg once daily.

• PO (Geriatric Patients): 10 mg once daily.

Availability

• Tablets: 5 mg, 10 mg, 20 mg

» Cost: 5 mg $214.97/90, 10 mg $228.97/90, 20 mg $239.97/90.

• Oral solution (peppermint): 1 mg/ml in 240-ml bottles

» Cost: $131.64/240 ml.

Assessment

• Monitor mood changes and level of anxiety during therapy

• Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be increased for children or adolescents. After starting therapy, children and adolescents should be seen by health care professional at least weekly for 4 wks, every 2 wks for next 4 wks, and on advice of health care professional thereafter

• Assess for sexual dysfunction (erectile dysfunction; decreased libido)

Potential Nursing Diagnoses

• Ineffective coping (Indications)

• Risk for injury (Side Effects)

• Sexual dysfunction (Side Effects)

• Post-trauma syndrome (Indications)

Implementation

• Do not administer escitalopram and citalopram concomitantly. Taper to avoid potential withdrawal reactions. Reduce dose by 50% for 3 days, then again by 50% for 3 days, then discontinue

• PO: Administer as a single dose in the morning or evening without regard to meals

Patient/Family Teaching

• Instruct patient to take escitalopram as directed. Take missed doses on the same day as soon as remembered and consult health care professional. Resume regular dosing schedule next day. Do not double doses. Do not stop abruptly, should be discontinued gradually

• May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known

• Advise patient to avoid alcohol and other CNS-depressant drugs during therapy and to consult a health care professional before taking other Rx or OTC medications or herbal products

• Instruct female patients to notify health care professional if pregnancy is planned or suspected or if they plan to breastfeed an infant

• Caution patients that escitalopram should not be used for at least 14 days after discontinuing MAO inhibitors, and at least 14 days should be allowed after stopping escitalopram before starting an MAO inhibitor

• Emphasize importance of follow-up exams to monitor progress

• Encourage patient participation in psychotherapy to improve coping skills

• Refer patient/family to local support groups

Evaluation/Desired Outcomes

• Increased sense of well-being

» Renewed interest in surroundings. May require 1–4 wk of therapy to obtain antidepressant effects. Full antidepressant effects occur in 4–6 wks

• Decrease in anxiety

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