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SSRI Antidepressant Pregnancy: Avoid in late pregnancy; neonatal adaptation syndrome

Escitalopram

Brand names: Cipralex

Adult dose

Dose: 10 mg once daily
Route: Oral
Frequency: Once daily
Max: 10 mg/day in over 65s (MHRA restriction); 20 mg/day in standard adults
MHRA 2011: Maximum dose in over 65s is 10 mg/day due to QT prolongation risk

Paediatric dose

Dose: Seek specialist opinion N/A/kg
Route: Oral
Frequency: Seek specialist opinion
Max: Seek specialist opinion
Seek specialist opinion

Dose adjustments

Renal

No adjustment if eGFR above 30; use with caution if eGFR under 30

Hepatic

Halve dose in moderate-severe hepatic impairment

Paediatric weight-based calculator

Seek specialist opinion

Clinical pearls

  • S-enantiomer of citalopram — slightly more potent (10 mg escitalopram approximately equivalent to 20 mg citalopram) but same QT concern applies
  • MHRA 2011: Maximum 10 mg/day in over 65s — same rationale as citalopram dose restriction
  • Excellent tolerability profile — fewer drug interactions than fluoxetine or paroxetine due to minimal CYP inhibition
  • Evidence base for efficacy in late-life depression is strong — well-tolerated at restricted elderly dose
  • Hyponatraemia monitoring essential in first month — risk shared with all SSRIs in elderly

Contraindications

  • Concurrent MAOI use
  • Congenital long QT syndrome
  • Concurrent QT-prolonging drugs

Side effects

  • Nausea
  • QT prolongation (dose-dependent)
  • Hyponatraemia
  • Sexual dysfunction
  • Insomnia or somnolence
  • Increased bleeding risk

Interactions

  • MAOIs (serotonin syndrome)
  • QT-prolonging drugs (additive risk)
  • NSAIDs / warfarin (bleeding)
  • Cimetidine / omeprazole (increase levels via CYP2C19)

Monitoring

  • ECG (QTc) before starting
  • Sodium
  • Mood and suicide risk

Reference: BNFc; BNF 90; MHRA Drug Safety Update 2011 (escitalopram QT); NICE CG90 (Depression); AGS Beers Criteria 2023. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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