Selective serotonin reuptake inhibitors (SSRIs)
ATC code: N06AB10 (Escitalopram)
S-enantiomer of citalopram. The most selective SSRI – blocks the serotonin transporter with minimal effect on norepinephrine, dopamine, and other receptors. Two binding sites: primary (inhibits reuptake) and allosteric (stabilizes binding to the primary site). This provides more complete and rapid transporter blockade compared to racemic citalopram.
First line
Escitalopram is approved for generalized anxiety disorder. and recommend SSRIs as first-line therapy for GAD. Start at 10 mg, may increase to 20 mg. In anxious patients, consider starting at 5 mg for the first week to minimize paradoxical anxiety worsening at treatment initiation. Response develops over 4-8 weeks.
First line
Escitalopram is a first-line antidepressant per 2023 guidelines. Start at 10 mg once daily, increase to 20 mg after 3-4 weeks if needed. Maximum dose 20 mg daily. The Cipriani meta-analysis (2018, Lancet) ranked escitalopram among the top antidepressants for the balance of efficacy and tolerability out of 21 agents. Assess response at 4-6 weeks.
First line
Escitalopram is effective for social anxiety disorder. SSRIs are first-choice therapy per and recommendations. Dosage is the same as for depression – 10-20 mg daily. Treatment is long-term – continue for at least 12 months after remission. Early discontinuation frequently leads to relapse.
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
Not recommended
Escitalopram is an SSRI antidepressant. It is prescribed for depression, generalized anxiety disorder, panic disorder, and social anxiety ( 2022 and NG222 guidelines). For workplace stress reduction or concentration improvement, escitalopram does not work: no clinical studies of such use exist. The drug has serious risks: sexual dysfunction (often persistent), QT-interval prolongation ( warning, 2011; limited to 20 mg in older adults), discontinuation syndrome on abrupt stopping, and increased suicide risk in young adults (FDA boxed warning). If escitalopram was prescribed for stress or concentration, consider seeking a second opinion.
26 pairs found. Sorted from critical to minor.
Mechanism
Escitalopram (SSRI) raises synaptic serotonin. Linezolid reversibly inhibits MAO. Co-administration sharply amplifies serotonergic transmission. The boxed warning applies to all SSRIs paired with linezolid.
Symptoms
Serotonin syndrome: agitation, confusion, tremor, myoclonus, hyperreflexia, dilated pupils. Autonomic features: profuse sweating, tachycardia, hypertension, fever above 38.5 °C. Severe cases progress to seizures, rhabdomyolysis, disseminated intravascular coagulation, and death. First signs appear within hours of concurrent dosing.
Management
The combination is not prescribed. Stop escitalopram at least 2 weeks before linezolid. If urgent antibiotic therapy is needed, use vancomycin, daptomycin, or ceftaroline based on susceptibility.
Opens the checker prefilled with this drug. Pick the second one from your regimen.
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FDA category C. SSRIs in the third trimester may cause neonatal respiratory distress, jitteriness, and irritability (neonatal adaptation syndrome). First-trimester use does not increase the overall risk of congenital malformations. The decision to continue therapy is individualized, weighing the risk of depression relapse for the mother against potential fetal exposure.
Escitalopram is evaluated for the following indications with varying evidence strength: Generalized anxiety disorder (evidence tier A), Social anxiety disorder (evidence tier A), Major depressive disorder (evidence tier A). See the full indication matrix with dosing and citations above on this page.
Common side effects of Escitalopram (≥ 1 in 100): Nausea (especially in the first 1-2 weeks, then resolves), Headache, Insomnia or somnolence, Sexual dysfunction (decreased libido, anorgasmia, delayed ejaculation), Dry mouth, Sweating. See the Safety section for uncommon and serious reactions.
FDA category C. FDA category C. SSRIs in the third trimester may cause neonatal respiratory distress, jitteriness, and irritability (neonatal adaptation syndrome). First-trimester use does not increase the overall risk of congenital malformations. The decision to continue therapy is individualized, weighing the risk of depression relapse for the mother against potential fetal exposure.
Excreted in breast milk. Relative infant dose is low. Escitalopram and sertraline are preferred SSRIs during breastfeeding per LactMed.
Escitalopram is contraindicated in: Concurrent use with MAO inhibitors (and within 14 days of their discontinuation); QT prolongation or congenital long QT syndrome; Concurrent use with pimozide or other drugs that significantly prolong QT; Hypersensitivity to escitalopram or citalopram. Full list in the Safety section.
Mechanism
IV methylene blue is a reversible MAO-A inhibitor. Escitalopram (SSRI) raises synaptic serotonin. Combined action sharply amplifies serotonergic transmission.
Symptoms
Serotonin syndrome: agitation, confusion, tremor, myoclonus, hyperreflexia, dilated pupils. Autonomic features: profuse sweating, tachycardia, hypertension, fever above 38.5 °C. Severe cases progress to seizures, rhabdomyolysis, disseminated intravascular coagulation, and death. First signs appear within hours of concurrent dosing.
Management
Avoid the combination. IV methylene blue is reserved for emergencies. For planned use, stop escitalopram 5 days in advance. On SSRI therapy, administer only for life-threatening indications under ICU monitoring.
Mechanism
Escitalopram is an SSRI. Combined with phenelzine causes serotonin syndrome. Nardil Section 4.
Symptoms
Hyperthermia, myoclonus, tachycardia.
Management
Combination contraindicated. 2-week washout.
Mechanism
Escitalopram (SSRI) depletes the platelet serotonin pool, impairing primary haemostasis. Aspirin irreversibly blocks platelet cyclooxygenase. Combined, GI bleeding risk roughly doubles.
Symptoms
Gum bleeding, epistaxis, bruising without trauma, black tarry stools, blood in urine. Severe cases include gastrointestinal or intracranial haemorrhage.
Management
The combination is acceptable at low aspirin doses (75–100 mg as cardioprotection). Mandatory PPI cover with pantoprazole. Alternative antidepressants with minimal platelet effect: mirtazapine or agomelatine.
Sources
Mechanism
Escitalopram (SSRI) is a citalopram enantiomer with dose-dependent QT prolongation. The Lexapro label caps escitalopram at 20 mg/day specifically because of QT risk. Effects add with amiodarone.
Symptoms
QT prolongation on ECG. Clinically: dizziness, syncope, palpitations. Severe cases progress to polymorphic ventricular tachycardia (torsades de pointes) with risk of ventricular fibrillation and sudden cardiac death. Risk is higher with hypokalaemia, hypomagnesaemia, bradycardia, and ischaemic heart disease.
Management
Avoid where possible. If escitalopram is needed, cap at 10 mg/day; ECG before start and at 2 weeks, with potassium and magnesium maintained. Alternative antidepressants with minimal QT effect: mirtazapine or agomelatine.
Mechanism
Both drugs raise serotonergic transmission and prolong QT. Combined action carries serotonin syndrome and torsades de pointes risks. Escitalopram weakly blocks CYP2D6 and amitriptyline levels rise modestly.
Symptoms
Serotonin syndrome (agitation, tremor, tachycardia). QT prolongation on ECG. Amitriptyline anticholinergic effects (dry mouth, constipation, confusion in older patients).
Management
Avoid the combination. Alternative antidepressants if escitalopram fails: mirtazapine or agomelatine. If amitriptyline fails for neuropathic pain: gabapentin or pregabalin.
Mechanism
Escitalopram (SSRI) depletes the platelet serotonin pool, impairing primary haemostasis. Apixaban inhibits factor Xa. Combined, GI bleeding risk rises 1.5- to 2-fold.
Symptoms
Gum bleeding, epistaxis, bruising without trauma, black tarry stools, blood in urine. Severe cases include gastrointestinal or intracranial haemorrhage.
Management
The combination is acceptable. PPI cover with pantoprazole is mandatory. Alternative antidepressants with minimal platelet effect: mirtazapine or agomelatine.
Sources
Mechanism
Escitalopram is a citalopram enantiomer with the same effects. Additive seizure threshold reduction (bupropion + escitalopram). High-dose escitalopram prolongs QT.
Symptoms
Seizures (especially with prior epilepsy or eating disorders), QT prolongation on ECG, dizziness.
Management
The combination is used for antidepressant augmentation. Cap escitalopram at 10 mg and bupropion at 300 mg/day. Avoid in prior epilepsy or eating disorders.
Mechanism
Additive QT prolongation. Escitalopram prolongs QT dose-dependently ( Lexapro caps at 20 mg/day); ciprofloxacin contributes more weakly but additively.
Symptoms
QT prolongation on ECG. Clinically: dizziness, syncope, palpitations. Severe cases progress to polymorphic ventricular tachycardia (torsades de pointes) with risk of ventricular fibrillation and sudden cardiac death. Risk is higher with hypokalaemia, hypomagnesaemia, bradycardia, and ischaemic heart disease.
Management
During ciprofloxacin therapy, cap escitalopram at 10 mg/day. Alternative antibiotics: a cephalosporin or nitrofurantoin (no QT effect).
Mechanism
Escitalopram is the S-enantiomer of citalopram. Combined use is a doubling of the same drug without therapeutic purpose. Additive QT prolongation and serotonin syndrome risk.
Symptoms
QT prolongation on ECG. Clinically: dizziness, syncope, palpitations. Severe cases progress to polymorphic ventricular tachycardia (torsades de pointes). Risk is higher with hypokalaemia, hypomagnesaemia, bradycardia, and ischaemic heart disease.
Management
The combination is not prescribed. Choose one: escitalopram (more selective and active) is preferable. When switching, allow a 1-week washout.
Mechanism
Both prolong QT, and clarithromycin blocks CYP3A4 (a minor escitalopram metabolic route). Escitalopram levels rise moderately. In patients with hypokalaemia or other arrhythmia risk factors, torsades de pointes risk increases.
Symptoms
QT prolongation on ECG. Clinically: dizziness, syncope, palpitations. Severe cases progress to polymorphic ventricular tachycardia (torsades de pointes) with risk of ventricular fibrillation and sudden cardiac death. Risk is higher with hypokalaemia, hypomagnesaemia, bradycardia, and ischaemic heart disease.
Management
Avoid where possible. Alternative antibiotics: azithromycin (with caution given its own QT risk) or doxycycline. During clarithromycin therapy, cap escitalopram at 10 mg/day.
Mechanism
Both drugs prolong QT. Escitalopram does so dose-dependently ( Lexapro caps at 20 mg/day), dronedarone does too. Effects add up.
Symptoms
QT prolongation on ECG. Clinically: dizziness, syncope, palpitations. Severe cases progress to polymorphic ventricular tachycardia (torsades de pointes). Risk is higher with hypokalaemia, hypomagnesaemia, bradycardia, and ischaemic heart disease.
Management
Avoid the combination. If escitalopram is needed, cap at 10 mg/day; ECG before start and at 2 weeks; maintain potassium and magnesium. Alternative antidepressants: mirtazapine or agomelatine.
Mechanism
SSRI + SNRI – serotonergic load rises, serotonin syndrome risk. The combination has no therapeutic rationale.
Symptoms
Serotonin syndrome: agitation, confusion, tremor, myoclonus, hyperreflexia. Autonomic features: sweating, tachycardia, hypertension, fever. First signs appear within hours of co-administration.
Management
The combination is not prescribed. When switching antidepressants, allow a 1-week washout. For augmentation, use mirtazapine or agomelatine.
Mechanism
Two SSRIs simultaneously raise synaptic serotonin activity. Fluoxetine's active metabolite (norfluoxetine) persists in plasma for up to 5 weeks, so serotonin syndrome risk outlasts fluoxetine discontinuation.
Symptoms
Serotonin syndrome: agitation, confusion, tremor, myoclonus, hyperreflexia, dilated pupils. Autonomic features: sweating, tachycardia, hypertension, fever. First signs appear within hours of co-administration.
Management
The combination is not prescribed. When switching from fluoxetine to escitalopram, allow at least a 5-week washout. From escitalopram to fluoxetine, 2 weeks suffice.
Mechanism
Additive QT prolongation. Escitalopram prolongs QT dose-dependently ( Lexapro caps at 20 mg/day) and haloperidol prolongs QT too. In patients with hypokalaemia, hypomagnesaemia, ischaemic heart disease, or bradycardia, torsades de pointes risk is especially high.
Symptoms
QT prolongation on ECG. Clinically: dizziness, syncope, palpitations. Severe cases progress to polymorphic ventricular tachycardia (torsades de pointes) with risk of ventricular fibrillation and sudden cardiac death. Risk is higher with hypokalaemia, hypomagnesaemia, bradycardia, and ischaemic heart disease.
Management
Avoid the combination. Alternative antipsychotics with minimal QT effect: olanzapine or aripiprazole. Alternative antidepressants: mirtazapine or agomelatine.
Mechanism
Additive serotonergic effect. Mirtazapine blocks 5-HT2A/2C/3 but activates 5-HT1A. Combined with escitalopram (SSRI), serotonin syndrome has been reported, especially at high doses.
Symptoms
Serotonin syndrome: agitation, confusion, tremor, myoclonus, hyperreflexia. Autonomic features: sweating, tachycardia, hypertension, fever. First signs appear within hours of co-administration.
Management
The combination may be used for augmentation ('California rocket fuel') but requires caution. Escitalopram up to 10 mg, mirtazapine 15–30 mg. Monitor blood pressure, pulse, and mental status in the early weeks.
Mechanism
Additive QT prolongation at high quetiapine doses. Escitalopram prolongs QT dose-dependently ( caps at 20 mg/day).
Symptoms
QT prolongation on ECG. Dizziness, syncope, palpitations. Severe cases: polymorphic ventricular tachycardia (torsades de pointes). Risk is higher with hypokalaemia and hypomagnesaemia.
Management
The combination is acceptable at low doses: escitalopram ≤10 mg, quetiapine ≤300 mg/day. ECG before start and at 2 weeks; maintain potassium and magnesium. Alternative antipsychotics: olanzapine or aripiprazole.
Mechanism
Two SSRIs simultaneously raise synaptic serotonin activity. Without added clinical benefit, additive effect raises serotonin syndrome, hyponatraemia, and GI bleeding risks.
Symptoms
Serotonin syndrome: agitation, confusion, tremor, myoclonus, hyperreflexia, dilated pupils. Autonomic features: sweating, tachycardia, hypertension, fever. First signs appear within hours of co-administration.
Management
The combination is not prescribed. If one SSRI is ineffective, switch to another after a 2-week washout (or 5 weeks after fluoxetine). In severe depression, monotherapy plus mirtazapine or psychotherapy.
Mechanism
Tacrolimus prolongs the QT interval, especially with hypomagnesaemia (typical on calcineurin inhibitors). Escitalopram also prolongs QT dose-dependently ( caps at 20 mg/day). Effects add up.
Symptoms
QT prolongation on ECG, dizziness, syncope, palpitations. Severe cases: polymorphic ventricular tachycardia (torsades de pointes). Risk is higher with hypokalaemia and hypomagnesaemia.
Management
Limit the combination: cap escitalopram at 10 mg/day. ECG before start and at 2 weeks; maintain potassium and magnesium. Alternative antidepressant with minimal QT effect: mirtazapine or agomelatine.
Mechanism
Escitalopram (SSRI) raises synaptic serotonin; tramadol blocks serotonin and norepinephrine reuptake. Combined action sharply amplifies serotonergic transmission – serotonin syndrome risk.
Symptoms
Serotonin syndrome: agitation, confusion, tremor, myoclonus, hyperreflexia, dilated pupils. Autonomic features: sweating, tachycardia, hypertension, fever. First signs appear within hours of co-administration.
Management
Avoid the combination. For analgesia on escitalopram, use paracetamol, an NSAID, or morphine/oxycodone. For neuropathic pain, gabapentin or pregabalin.
Mechanism
SSRI + SNRI – serotonin syndrome without therapeutic rationale.
Symptoms
Serotonin syndrome: agitation, confusion, tremor, myoclonus, hyperreflexia. Autonomic features: sweating, tachycardia, hypertension, fever. First signs appear within hours of co-administration.
Management
The combination is not prescribed. When switching antidepressants, allow a 1-week washout. For augmentation, use mirtazapine or agomelatine.
Mechanism
Additive sedation. No direct pharmacokinetic interaction – escitalopram does not significantly block CYP3A4.
Symptoms
Additional drowsiness, ataxia in the first 1–2 weeks. Older patients: fall risk.
Management
Widely used in anxious-depressive disorders. Alprazolam is given for a short course (4–6 weeks) with gradual taper after escitalopram's effect stabilises. In older patients: minimum alprazolam dose; monitor cognition.
Mechanism
Both prolong QT. Escitalopram dose-dependently ( Lexapro caps at 20 mg/day), azithromycin dose-dependently (FDA warning 2013).
Symptoms
QT prolongation on ECG. Dizziness, syncope, palpitations. Rarely: polymorphic ventricular tachycardia (torsades de pointes). Risk is higher with hypokalaemia, hypomagnesaemia, bradycardia, and ischaemic heart disease.
Management
For short azithromycin courses (3–5 days) with normal potassium and magnesium, the combination is acceptable. In atrial fibrillation, hypokalaemia, or prior QT prolongation: alternative antibiotics (doxycycline, a cephalosporin).
Mechanism
Fluconazole weakly inhibits CYP3A4 and CYP2C19. Escitalopram levels may rise slightly. Additive QT risk is moderate — both prolong QT.
Symptoms
QT prolongation on ECG. Dizziness, syncope, palpitations. Rarely: polymorphic ventricular tachycardia (torsades de pointes). Risk is higher with hypokalaemia, hypomagnesaemia, bradycardia, and ischaemic heart disease.
Management
For short fluconazole courses (single 150 mg dose or 5–7 days) in patients without cardiac disease, no adjustment needed. For longer systemic therapy (over 14 days) in older patients, cap escitalopram at 10 mg/day and check ECG at 2 weeks. For superficial mycosis, alternative: topical clotrimazole or nystatin.
Mechanism
Escitalopram is metabolised mainly by CYP2C19 and partly by CYP3A4. Ketoconazole is a strong CYP3A4 inhibitor; escitalopram AUC rises modestly (20–40%) without major clinical effect. Additive QT risk is moderate.
Symptoms
QT prolongation on ECG. Dizziness, syncope, palpitations. Rarely: polymorphic ventricular tachycardia (torsades de pointes). Risk is higher with hypokalaemia, hypomagnesaemia, bradycardia, and ischaemic heart disease. Typical escitalopram side effects may appear: nausea, insomnia, decreased libido.
Management
For short systemic ketoconazole courses (7–14 days), cap escitalopram at 10 mg/day. Topical ketoconazole (shampoo, cream) does not interact. For long-term systemic therapy (e.g. invasive mycosis), antidepressant alternative: sertraline (minimal CYP3A4 interaction).
Mechanism
Prednisolone is ulcerogenic; escitalopram reduces platelet aggregation via serotonin uptake. Additive GI bleeding risk.
Symptoms
Epigastric pain, heartburn, black or tarry stools, blood in vomit, bruising. Higher risk in older patients and prior peptic ulcer.
Management
On long-term prednisolone (over 2 weeks) or in patients over 65, add pantoprazole 20 mg/day. Escitalopram also prolongs QT, so cap older patients at 10 mg/day.
Excreted in breast milk. Relative infant dose is low. Escitalopram and sertraline are preferred SSRIs during breastfeeding per LactMed.
Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.