Introduction to Escitalopram

Escitalopram (Lexapro, Cipralex, Lexamil, Lexam, Losita , Seroplex, Elicea, Esitalo, Entact , Exodus, Esto, Reposil, Nexito, Animaxen Anxiset-E) is an SSRI (selective serotonin re-uptake inhibitor) anti-depressant medication, also prescribed to adults for general anxiety disorder, and sometimes for panic disorder, social anxiety disorder, or obsessive-compulsive disorder.

Using Escitalopram

Escitalopram is available in 5, 10, and 20 mg tablets and a 1mg/ml oral solution and prescribed to adults and adolescents from 12-17 yrs for major depression, and adults for generalized anxiety disorder, panic disorder, social anxiety disorder and obsessive-compulsive disorder. The recommended therapeutic dose for major depression is 10mg/day taken either morning or evening. For anxiety, panic or obsessive compulsive disorder this may be increased to a daily dose of 20mg or even 30mg in some cases. Like all SSRI drugs, escitalopam takes a period of time to have full effect on serotonin levels, and patients may thus not experience benefits for up to 4 weeks into its daily use.[1]

Caution with escitalopram is advised in elderly patients and warnings on the box insert suggest a daily dose of no more than 10mg for patients over 65 years of age. Escitalopram can have an effect on the QT interval (a feature of heart rate indicative of risk of developing abnormal electrical activity or arrythmia); most recent data suggests this risk and has further clarified that it is dose dependent. Adults under 65 years of age with hepatic (liver function) impairment are also advised to not exceed 10mg/day of escitalopram. The available data here has been subject to a Europe-wide review.

Effects of Escitalopram

Escitalopram has been shown to be more effective for patients with major depressive disorder and better tolerated than many other SSRI medications in a 8 week trial.[2]

Interactions with Escitalopram

SSRIs, including escitalopram, must not be taken with MAO (monoamine oxidase) inhibitor antidepressant drugs such as isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate), selegiline (Eldepryl) and procarbazine (Matulane) since escitalopram as an SSRI will interact with MAO inhibitors to produce possibly life-threatening symptoms, including rapid heart rate changes, muscle spasms, large fluctuations in blood pressure, high blood pressure, confusion, high fever, tremor or muscle rigidity, and unconsciousness. Anyone taking an MAO inhibitor must wait least 14 days after discontinuing it to begin taking escitalopram, and anyone taking escitalopram must stop and wait at least 14 days before starting an MAO inhibitor.[3]

Different Uses for Escitalopram

In the United States escilatopram is FDA approved for treatment of major depression and generalized anxiety disorder, and in the European Union escitalopram is also indicated for social anxiety disorder, panic disorder and obsessive-compulsive disorder. [4][5][6] Treatment of social anxiety disorder, panic disorder and obsessive-compulsive disorder with escitalopram is off label in the United States.

Pharmacology of Escitalopram

Escitalopram increases intrasynaptic levels of the neurotransmitter serotonin by blocking the reuptake of the neurotransmitter into the presynaptic neuron. Of the SSRIs currently on the market, escitalopram has the highest affinity for the human serotonin transporter (SERT). The enantiomer of escitalopram ((R)-citalopram) counteracts to a certain degree the serotonin-enhancing action of escitalopram. As a result, escitalopram has been claimed to be a more potent antidepressant than citalopram, which is a mixture of escitalopram and (R)-citalopram. In order to explain this phenomenon, researchers from Lundbeck proposed that escitalopram enhances its own binding via an additional interaction with another allosteric site on the transporter[7].
In vitro studies using human liver microsomes indicated that CYP3A4 and CYP2C19 are the primary isozymes involved in the N-demethylation of escitalopram. The resulting metabolites, desmethylescitalopram and didesmethylescitalopram, are significantly less active and their contribution to the overall action of escitalopram is negligible.[8]

Chemistry of Escitalopram

Column 1	Column 2
Systematic(IUPAC) name:	(1S)-1-[3-(dimethylamino)propyl]-1-(4-fluorophenyl)-1,3-dihydro-2-benzofuran-5-carbonitrile
Synonyms:	S-(+)-Citalopram; Cipralex, Lexapro, Gaudium, Lu-26-054-0 (oxalate)
Molecular Formula:	C20H21FN2
Molar mass:	324.40 g/mol; 414.43 g/mol (oxalate)
CAS Registry Number:	128196-01-0, 219861-08-2
Melting Point:	147-148°C (oxalate)
Boiling Point:	no data
Flash Point:	no data
Solubility:	Freely soluble in Methanol and Dimethylsulfoxide (DMSO), soluble in isotonic saline, sparingly soluble in Water and in Ethanol, Slightly soluble in Ethyl acetate, Insoluble in Heptane
Additionnal data:	none
Notes:	oxalate crystallyzed from acetone, aspect : white to slightly yellow powder

[9]

Pharmacokinetic Data

Column 1	Column 2
Bioavailability:	80%
Protein Binding:	approximately 56%
Metabolism:	liver, specifically the enzymes CYP3A4 and CYP2C19
Half-life:	27-32 hours

The Dangers of Escitalopram

Physical Health Risks

Serotonin Syndrom

Escitalopram can in rare cases cause serotonin syndrome, a life-threatening condition with symptoms that can include lack of coordination, muscle twitches, sweating and/or fever, nausea, vomiting, diarrhea, racing heartbeat, low or high blood pressure, and muscle rigidity. This type of episode may occur if the medication is taken at too high a dose. For example; you purposefully start increasing your dose without your doc's approval; if you only however take 2x - 3x your daily dose a serious reaction is unlikely, and it would take a serious attempt to overdose. Further, if increasing your dosage too quickly or too high, there remains some chance.

The main problem is the use of any psychoactive drugs which operate on the receptors the antidepressant blocks, thus many medications - OTC, prescription, diet, and Herbal - should be taken into consideration while on cipralex. Hopefully, your doctor and pharmacist communicate and are intelligent. And avoid any recreational drug that actd at 5HT2a, etc. receptors. If you do use drugs, much lower dosages would be safer. Personally pure MDMA had all the fucked-up effects of Serotonin Syndrome.

Withdrawal

Patients can experience withdrawal symptoms when stopping escitalopram, including dizziness, tingling, tiredness, vivid dreams, irritability, or poor mood. The risk of experiencing withdrawal symptoms is higher when escilatopram is suddenly or abruptly discontinued rather than tapered slowly. [10].

Overdose

Excessive doses of escitalopram usually cause relatively minor effects such as agitation and tachycardia. However, dyskinesia, hypertonia and clonus may occur in some cases. Plasma escitalopram concentrations are usually in a range of 20-80 μg/L in therapeutic situations and may reach 80-200 μg/L in the elderly, patients with hepatic dysfunction, those who are poor CYP2C19 metabolizers or following acute overdose. Monitoring of the drug in plasma or serum is generally accomplished using chromatographic methods. Chiral techniques are available to distinguish escitalopram from its racemate, citalopram[11].

Reported Deaths

Mental Health Risks

Suicidal Ideation and Behavior

Antidepressants such as escitalopram have been shown to increase the risk of suicidal thinking and suicidal behavior children and young people up to the age of 24 with major depressive disorder and other psychiatric disorders. This risk has not been established in adults, thought there has been Doctors and patients must weigh the potential therapeutic value of escilatopram against this risk when considering its use by these patients. https://drugs.com/monograph/escit...m-oxalate.html[/FOOTNOTE].

Mental Health Risk 1

Mental Health Risk 2

Side Effects

The most common side effects associated with escitalopram are agitation or restlessness, blurred vision, diarrhea, difficulty sleeping, drowsiness, dry mouth, fever, frequent urination, headache, indigestion, nausea, increased or decreased appetite, increased sweating, sexual difficulties (decreased sexual ability or desire, ejaculatory delay), taste alterations, tremor (shaking), weight changes. Although changes in sexual desire, sexual performance, and sexual satisfaction often occur as a result of depression itself, they also may be a consequence of the drugs used to treat depression.

Roughly one in 11 men are reported to have difficulties ejaculating while taking escitalopram. As well, some patients experience withdrawal upon stopping escitalopram as part of SSRI therapy. Such withdrawal symptoms include dizziness, tingling, tiredness, vivid dreams, irritability, or poor mood. The dose of the SSRI can be reduced slowly as opposed to being abruptly stopped to avoid these symptoms[12].

Addiction

Physical Addiction

Escitalopram discontinuation, particularly abruptly, may cause certain withdrawal symptoms such as "electric shock" sensations (also known as "brain shivers" or "brain zaps"), dizziness, acute depression and irritability, bladder control issues, as well as heightened senses of akathisia.[13]

Mental Addiction

History of Escitalopram

Escitalopram was developed in close cooperation between Lundbeck and Forest Laboratories. Its development was initiated in the summer of 1997, and the resulting new drug application was submitted to the U.S. FDA in March 2001. The short time (3.5 years) it took to develop escitalopram can be attributed to the previous extensive experience of Lundbeck and Forest with citalopram, which has similar pharmacology.[14]

The FDA issued the approval of escitalopram for major depression in August 2002 and for generalized anxiety disorder in December 2003. Escitalopram can be considered an example of "evergreening"(also called "lifecycle management")– the long-term strategy pharmaceutical companies use in order to extend the lifetime of a drug, in this case of the citalopram franchise. Escitalopram is an enantiopure compound of the racemic mixture citalopram, used for the same indication, and for that reason it required less investment and less time to develop.

On May 23, 2006, the FDA approved a generic version of escitalopram by Teva[15]. On July 14 of that year, however, the U.S. District Court of Delaware decided in favor of Lundbeck regarding the patent infringement dispute and ruled the patent on escitalopram valid.

In 2006 Forest Laboratories was granted an 828 day (2 years and 3 months) extension on its US patent for escitalopram[16]. This pushed the patent expiration date from December 7, 2009 to September 14, 2011. Together with the 6-month pediatric exclusivity, the final expiration date was March 14, 2012.

Escitalopram

References

1. ^Baldwin, David S, Reines, Elin Heldbo, Guiton, Christina, Weiller, Emmanuelle. (2007) "Escitalopram therapy for major depression and anxiety disorders." The Annals of Pharmacotherapy 41(10), pp.1583-92
2. ^Cipriani, A; Furukawa TA; Salanti G; Geddes JR; Higgins JP; Churchill R; Watanabe N; Nakagawa A; Omori IM; McGuire H; Tansella M; Barbui C (2009 February 28). "Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis". Lancet 373 (9665): 746–58.
3. ^REFERENCE?
4. ^Kasper, S., Stein, D. J., Loft, H., & Nil, R. (2005). Escitalopram in the treatment of social anxiety disorder: randomised, placebo-controlled, flexible-dosage study. British Journal of Psychiatry, 186:222-226. DOI: 2005, 186:222-226.
5. ^Stahl, S. M., & Gergel, L. (2003). Escitalopram in the treatment of panic disorder: a randomized, double-blind, placebo-controlled trial (1322-7). Retrieved from Neuroscience Education Institute website: http://www.ncbi.nlm.nih.gov/pubmed/14658946
6. ^Naomi A. Fineberg, Angus Brown, Samar Reghunandananand Ilenia Pampaloni. Evidence-based pharmacotherapy of obsessive-compulsive disorder. International Journal of Neuropsychopharmacology (2012), 15, 1173–1191.
7. ^Cipriani, A; Furukawa TA; Salanti G; Geddes JR; Higgins JP; Churchill R; Watanabe N; Nakagawa A; Omori IM; McGuire H; Tansella M; Barbui C (2009 February 28). "Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis". Lancet 373 (9665): 746–58.
8. ^REFERENCE?
9. ^Merck Index, fifteenth edition (2013)
10. ^PLEASE DONT USE OFFSITE REFERENCES AS THEY MAY CHANGE Marks, J. W. & Omudhome, O. (2008, December 18). escitalopram, lexapro. MedicineNet.com, Retrieved from http://www.medicinenet.com/escitalopram/article.htm
11. ^R. Baselt, Disposition of Toxic Drugs and Chemicals in Man, 8th edition, Biomedical Publications, Foster City, CA, 2008, pp. 552-553
12. ^PLEASE DONT USE OFFSITE REFERENCES AS THEY MAY CHANGE Marks, J. W. & Omudhome, O. (2008, December 18). escitalopram, lexapro. MedicineNet.com, Retrieved from http://www.medicinenet.com/escitalopram/article.htm
13. ^This claim needs a reference to subtantiate, possibly the medication insert? surely there have been studies showing this?
14. ^THIS REFERENCE IS OFFSITE AND LINKS TO A MANY-PAGED LIST OF RELEASES Press release. PRNewswire-FirstCall. 2006-03-02. Retrieved 2009-01-19. Retrieved from http://news.frx.com/news_center/press_releases/all
15. ^THIS REFERENCE IS INACCURATEFull text of the federal complaint filed in the US District Court for the district of Massachusetts. Retrieved from http://amlawdaily.typepad.com/forestfca.pdf
16. ^THIS REFERENCE IS INACCURATE Full text of the federal complaint filed in the US District Court for the district of Massachusetts. Retrieved from http://amlawdaily.typepad.com/forestfca.pdf