Medications: Lexapro^® – escitalopram

Lexapro^® is a selective serotonin reuptake inhibitor (SSRI) indicated for:

• Acute and Maintenance Treatment of Major Depressive Disorder (MDD) in adults and adolescents aged 12-17 years (1.1)
• Acute Treatment of Generalized Anxiety Disorder (GAD) in adults (1.2)

DOSAGE AND ADMINISTRATION

Lexapro should generally be administered once daily, morning or evening with or without food (2.1, 2.2)

• No additional benefits seen at 20 mg/day dose (2.1).
• 10 mg/day is the recommended dose for most elderly patients and patients with hepatic impairment (2.3)
• No dosage adjustment for patients with mild or moderate renal impairment. use caution in patients with severe renal impairment (2.3).
• Discontinuing Lexapro: A gradual dose reduction is recommended (2.4).

Most commonly observed adverse reactions (incidence ≥ 5% and at least twice the incidence of placebo patients) are: insomnia, ejaculation disorder (primarily ejaculatory delay), nausea, sweating increased, fatigue and somnolence, decreased libido, and anorgasmia (6.1).

• Serotonin Syndrome and MAOIs: Do not use MAOIs intended to treat psychiatric disorders with Lexapro or within 14 days of stopping treatment with Lexapro. Do not use Lexapro within 14 days of stopping an MAOI intended to treat psychiatric disorders. In addition, do not start Lexapro in a patient who is being treated with linezolid or intravenous methylene blue (4.1).
• Pimozide: Do not use concomitantly (4.2).
• Known hypersensitivity to escitalopram or citalopram or any of the inactive ingredients (4.3).

WARNINGS AND PRECAUTIONS:

• Serotonin Syndrome: Serotonin syndrome has been reported with SSRIs and SNRIs, including Lexapro, both when taken alone, but especially when co-administered with other serotonergic agents (including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. John’s Wort). If such symptoms occur, discontinue Lexapro and initiate supportive treatment. If concomitant use of Lexapro with other serotonergic drugs is clinically warranted, patients should be made aware of a potential increased risk for serotonin syndrome, particularly during treatment initiation and dose increases (4, 5.2).
• Discontinuation of Treatment with Lexapro: A gradual reduction in dose rather than abrupt cessation is recommended whenever possible (5.3).
• Seizures: Prescribe with care in patients with a history of seizure (5.4).
• Activation of Mania/Hypomania: Screen patients for bipolar disorder. (5.5).
• Hyponatremia: Can occur in association with SIADH (5.6)
• Abnormal Bleeding: Use caution in concomitant use with NSAIDs, aspirin, warfarin or other drugs that affect coagulation (5.7).
• Interference with Cognitive and Motor Performance: Use caution when operating machinery (5.8).
• Angle Closure Glaucoma: Angle closure glaucoma has occurred in patients with untreated anatomically narrow angles treated with antidepressants. (5.9)
• Use in Patients with Concomitant Illness: Use caution in patients with diseases or conditions that produce altered metabolism or hemodynamic responses (5.10)

Concomitant use with SSRIs, SNRIs or Tryptophan is not recommended (7.2). Use caution when concomitant use with drugs that affect Hemostasis (NSAIDs, Aspirin, Warfarin) (7.6).

In clinical trials of escitalopram, there were reports of escitalopram overdose, including overdoses of up to 600 mg, with no associated fatalities. During the postmarketing evaluation of escitalopram, Lexapro overdoses involving overdoses of over 1000 mg have been reported. As with other SSRIs, a fatal outcome in a patient who has taken an overdose of escitalopram has been rarely reported. Symptoms most often accompanying escitalopram overdose, alone or in combination with other drugs and/or alcohol, included convulsions, coma, dizziness, hypotension, insomnia, nausea, vomiting, sinus tachycardia, somnolence, and ECG changes (including QT prolongation and very rare cases of torsade de pointes). Acute renal failure has been very rarely reported accompanying overdose.

Management of Overdose: Establish and maintain an airway to ensure adequate ventilation and oxygenation. Gastric evacuation by lavage and use of activated charcoal should be considered. Careful observation and cardiac and vital sign monitoring are recommended, along with general symptomatic and supportive care. Due to the large volume of distribution of escitalopram, forced diuresis, dialysis, hemoperfusion, and exchange transfusion are unlikely to be of benefit. There are no specific antidotes for Lexapro. In managing overdosage, consider the possibility of multiple-drug involvement. The physician should consider contacting a poison control center for additional information on the treatment of any overdose.