Escitalopram

How it works

As the active enantiomer of citalopram, it selectively inhibits serotonin reuptake at the presynaptic transporter, increasing synaptic serotonin availability.

Prescribing in practice

• Escitalopram causes dose-dependent QT-interval prolongation, so it should be avoided in known QT prolongation and used cautiously with other QT-prolonging drugs or electrolyte disturbance.
• There is an increased risk of suicidal thoughts and behaviour early in treatment, particularly in younger adults, warranting close monitoring.
• Risk of hyponatraemia, gastrointestinal bleeding and serotonin syndrome increases with concomitant drugs such as NSAIDs, anticoagulants and other serotonergic agents.

Monitoring

Monitor mood and suicidal ideation early in treatment and consider ECG and electrolytes where cardiac risk or QT-prolonging therapy is present.

Counselling the patient

• Antidepressant effect may take a few weeks; continue treatment as prescribed.
• Report worsening mood or thoughts of self-harm, especially in the first weeks.
• Do not stop suddenly, as discontinuation symptoms can occur; taper under guidance.

Evidence & guidelines

Escitalopram is a recommended first-line SSRI in NICE depression guidance, and the MHRA has highlighted its dose-dependent QT-prolongation risk.