Escitalopram
Cipralex · Escitalopram Teva · Escitalopram Accord
The most selective of the SSRIs and one of the best tolerated for depression and generalised anxiety disorder. What governs dosing is not efficacy but the heart: a dose-dependent QT prolongation was identified, and the maximum dose has since been capped at 20 mg for adults and 10 mg for patients over 65 years. In the elderly, hyponatraemia is the adverse effect most often causing discontinuation.
Dose-dependent QT prolongation with risk of torsades de pointes, particularly in hypokalaemia, bradycardia, or concurrent treatment with other QT-prolonging drugs. Do not exceed 20 mg daily, and not 10 mg in patients over 65 years or with known slow CYP2C19 metabolism.
Dosing in adults
| Indication | Regimen | Comment |
|---|---|---|
| Depression | 10 mg daily, increase to 20 mg with insufficient effect | 20 mg is the absolute maximum dose in adults |
| Generalised anxiety disorder, social phobia, OCD | 10 mg daily, individual increase to a maximum of 20 mg | evaluate after 4–6 weeks |
| Panic disorder | 5 mg daily the first week, then 10 mg | low starting dose dampens the initial anxiety amplification |
| Patients over 65 years | 5 mg daily as start, maximum 10 mg daily | reduced maximum dose |
| Slow CYP2C19 metaboliser | 5 mg daily as start, maximum 10 mg daily | exposure is twice as high as in normal metabolisers |
No dose adjustment in mild to moderate renal impairment. At eGFR below 30 ml/min, documentation is absent — caution and slow uptitration.
5 mg daily for the first two weeks in mild to moderate hepatic failure, then maximum 10 mg. In severe hepatic failure, particular caution and the lowest possible dose are required.
No approved indication in children and adolescents under 18 years; efficacy data are insufficient and suicidal behaviour was observed more often than with placebo in studies. Treatment under 18 years belongs within child and adolescent psychiatry.
Avoid in patients with known prolonged QT interval, with other QT-prolonging medication, or with untreated hypokalaemia — choose sertraline instead. Do not discontinue abruptly: escitalopram causes marked discontinuation symptoms and must be tapered over at least 2–4 weeks.
Pharmacokinetics
- BIOAVAIL.
- approximately 80 %
- t½
- approximately 30 hours
- PROTEIN BINDING
- approximately 56 %
- METABOLISM
- CYP2C19 mainly, also 3A4 and 2D6
- INHIBITS
- CYP2D6 weakly
- EXCRETION
- Renal, as metabolites
- STEADY STATE
- approximately 1 week
- ONSET
- 2–4 weeks for antidepressant effect