Escitalopram

How it works

It selectively inhibits the serotonin transporter, increasing synaptic serotonin availability and thereby improving mood and anxiety over several weeks.

Prescribing in practice

• Older patients should receive a reduced maximum dose because of dose-dependent QT-interval prolongation, and concurrent QT-prolonging or interacting drugs should be reviewed.
• SSRIs increase the risk of hyponatraemia (often from SIADH) and of gastrointestinal bleeding, particularly with concurrent NSAIDs, antiplatelets or anticoagulants; consider gastroprotection.
• Withdraw gradually to avoid discontinuation symptoms and monitor for increased agitation or suicidal thoughts early in treatment.

Monitoring

Monitor mood and suicidality early in treatment, check sodium in those at risk of hyponatraemia, and consider ECG where there are additional QT risk factors.

Counselling the patient

• Benefit builds over a few weeks; continue as prescribed even if you feel no immediate change.
• Report dizziness, drowsiness, confusion or falls, which may indicate low sodium.
• Do not stop suddenly, and ask before taking anti-inflammatory painkillers.

Evidence & guidelines

MHRA guidance highlights dose-dependent QT prolongation with (es)citalopram and recommends lower maximum doses in older adults, while SSRI efficacy in late-life depression is supported by trial evidence.