Cipralex


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escitalopram oxalate

Cipralex (UK), Lexapro

Pharmacologic class: Selective serotonin reuptake inhibitor

Therapeutic class: Antidepressant

Pregnancy risk category C

Action

Prevents serotonin reuptake by CNS neurons, making more serotonin available in brain and thereby relieving depression

Availability

Oral solution: 5 mg/5 ml

Tablets: 5 mg, 10 mg, 20 mg

Indications and dosages

Major depression

Adults: Initially, 10 mg P.O. daily as a single dose. After at least 1 week, may increase to 20 mg P.O. daily, as needed.

Adolescents ages 12 to 17: Initially, 10 mg P.O. daily. After at least 3 weeks, may increase to 20 mg P.O. daily as needed.

Elderly adults and patients with hepatic impairment: Maximum dosage of 10 mg P.O. daily as a single dose

Generalized anxiety disorder

Adults: Initially, 10 mg P.O. daily as a single dose. After at least 1 week, may increase to 20 mg P.O. daily as needed.

Dosage adjustment

• Hepatic impairment
• Elderly patients

Contraindications

• Hypersensitivity to drug
• Concurrent use of pimozide
• MAO inhibitor use within past 14 days

Precautions

Use cautiously in:
• renal or hepatic impairment, other conditions that cause altered metabolism or hemodynamic responses, history of mania or seizures, suicidal tendency
• concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, warfarin, or other drugs that affect coagulation
• elderly patients
• pregnant or breastfeeding patients
• children younger than age 12 with major depression and younger than age 18 with generalized anxiety disorder (safety and efficacy not established).

Administration

• Give with or without food in the morning or evening.

Don't give within 14 days of MAO inhibitor.

Adverse reactions

CNS: drowsiness, dizziness, insomnia, fatigue, neuroleptic malignant syndrome-like reactions, increased risk of suicide or suicidal ideation (especially in child or adolescent)

EENT: rhinitis, sinusitis

GI: nausea, vomiting, diarrhea, constipation, dyspepsia, abdominal pain, dry mouth

GU: ejaculatory disorders, erectile dysfunction, anorgasmia (in females), decreased libido

Metabolic: hyponatremia (in association with syndrome of inappropriate antidiuretic hormone secretion)

Other: increased appetite, flulike symptoms, serotonin syndrome

Interactions

Drug-drug.Aspirin, NSAIDs, warfarin: increased risk of bleeding

Carbamazepine, lithium: decreased effects of escitalopram

Citalopram: increased risk of serious toxic effects

MAO inhibitors: increased escitalopram blood level and risk of toxicity

Pimozide: prolonged QT interval

Triptans: weakness, hyperreflexia, incoordination

Drug-diagnostic tests.Sodium: decreased level

Drug-herbs.Ginkgo, St. John's wort: increased risk of adverse effects

Drug-behaviors.Alcohol use: increased motor impairment

Patient monitoring

Assess patient's mood closely. Watch for signs and symptoms of increased depression or suicidal ideation (especially in child or adolescent).

Monitor patient closely for serotonin syndrome or neuroleptic malignant syndrome-like reactions; immediately discontinue drug if these occur.
• Be aware that gradual dosage reduction rather than abrupt cessation is recommended. When drug is discontinued, monitor for dysphoric mood, irritability, agitation, dizziness, sensory disturbances, anxiety, confusion, headache, lethargy, emotional lability, and insomnia.

Patient teaching

• Advise patient to minimize GI upset by eating small, frequent servings of food and drinking plenty of fluids.
• Inform patient that full drug effect may take up to 4 weeks. Caution him not to overuse drug or stop drug abruptly.

Tell patient (and parent or significant other as appropriate) to contact prescriber immediately if depression worsens or suicidal thoughts develop (especially in child or adolescent).

Instruct patient to immediately discontinue drug and notify prescriber if the following symptoms occur: overheating, muscle rigidity, altered mental status, irregular pulse or blood pressure, rapid or irregular heart beat, excessive sweating, involuntary muscle movements, fever, or seizures.
• Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.

escitalopram

(ess-sit-al-o-pram) ,

Cipralex

(trade name),

Lexapro

(trade name)

Classification

Therapeutic: antidepressants
Pharmacologic: selective serotonin reuptake inhibitors ssris
Pregnancy Category: C

Indications

Major depressive disorder.Generalized anxiety disorder (GAD).Panic disorder.Obsessive-compulsive disorder (OCD).Post-traumatic stress disorder (PTSD).Social anxiety disorder (social phobia).Premenstrual dysphoric disorder (PMDD).

Action

Selectively inhibits the reuptake of serotonin in the CNS.

Therapeutic effects

Antidepressant action.

Pharmacokinetics

Absorption: 80% absorbed following oral administration.
Distribution: Enters breast milk.
Metabolism and Excretion: Mostly metabolized by the liver (primarily CYP3A4 and CYP2C19 isoenzymes); 7% excreted unchanged by kidneys.
Half-life: ↑ in elderly and patients with hepatic impairment.

Time/action profile (antidepressant effect)

ROUTEONSETPEAKDURATION
POwithin 1–4 wkunknownunknown

Contraindications/Precautions

Contraindicated in: Hypersensitivity;Concurrent pimozide;Concurrent use of MAO inhibitors or MAO-like drugs (linezolid or methylene blue);Concurrent use of citalopram.
Use Cautiously in: History of mania (may activate mania/hypomania);History of seizures;Patients at risk for suicide;Hepatic impairment (dose ↓ recommended);Severe renal impairment; Obstetric: Neonates exposed to SSRIs in the 3rd trimester may develop drug discontinuation syndrome manifested by respiratory distress, feeding difficulty, and irritability; Lactation: May cause adverse effects in infant; consider risk/benefit; Pediatric: May ↑ risk of suicide attempt/ideation especially during early treatment or dose adjustment; safety not established in children <12 yr; Geriatric: ↓ doses recommended due to ↓ drug clearance in older patients.

Adverse Reactions/Side Effects

Central nervous system

  • neuroleptic malignant syndrome (life-threatening)
  • suicidal thoughts (life-threatening)
  • insomnia (most frequent)
  • dizziness
  • drowsiness
  • fatigue

Gastrointestinal

  • diarrhea (most frequent)
  • nausea (most frequent)
  • abdominal pain
  • constipation
  • dry mouth
  • indigestion

Genitourinary

  • anorgasmia
  • ↓ libido
  • ejaculatory delay
  • erectile dysfunction

Dermatologic

  • sweating

Endocrinologic

  • syndrome on inappropriate secretion of antidiuretic hormone (SIADH)

Fluid and Electrolyte

  • hyponatremia

Metabolic

  • serotonin syndrome (life-threatening)
  • ↑ appetite

Interactions

Drug-Drug interaction

May cause serious, potentially fatal reactions when used with MAO inhibitors ; allow at least 14 days between escitalopram and MAO inhibitors.Concurrent use with MAO-inhibitor-like drugs, such as linezolid or methylene blue may ↑ risk of serotonin syndrome; concurrent use contraindicated; do not start therapy in patients receiving linezolid or methylene blue ; if linezolid or methylene blue need to be started in a patient receiving escitalopram, immediately discontinue escitalopram and monitor for signs/symptoms of serotonin syndrome for 2 wk or until 24 hr after last dose of linezolid or methylene blue, whichever comes first (may resume escitalopram therapy 24 hr after last dose of linezolid or methylene blue)Concurrent use with pimozide may result in prolongation of the QTc interval and is contraindicated.Use cautiously with other centrally acting drugs (including alcohol, antihistamines, opioid analgesics, and sedative/hypnotics ; concurrent use with alcohol is not recommended).Drugs that affect serotonergic neurotransmitter systems, including tricyclic antidepressants, SNRIs, fentanyl, buspirone, tramadol, and triptans ↑ risk of serotonin syndromeCimetidine may ↑ levels.Serotonergic effects may be ↑ by lithium (concurrent use should be carefully monitored).Carbamazepine may ↓ levels.May ↑ levels of metoprolol.Use cautiously with tricyclic antidepressants due to unpredictable effects on serotonin and norepinephrine reuptake.↑ risk of bleeding with aspirin, NSAIDs, clopidogrel, or warfarin.↑ risk of serotonin syndrome with St. John's wort and SAMe.

Route/Dosage

Oral (Adults) Depression and GAD–10 mg once daily, may be ↑ to 20 mg once daily after 1 wk.

Hepatic Impairment

Oral (Adults) 10 mg once daily.
Oral (Geriatric Patients) 10 mg once daily.
Oral (Children ≥12 yr) Depression—10 mg once daily, may be ↑ to 20 mg once daily after 3 wk.

Availability (generic available)

Tablets: 5 mg, 10 mg, 20 mg Cost: Generic — 5 mg $13.16 / 100, 10 mg $13.87 / 100, 20 mg $18.01 / 100
Oral solutionpeppermint flavor: 1 mg/mL Cost: Generic — $190.20 / 240 mL

Nursing implications

Nursing assessment

  • Monitor mood changes and level of anxiety during therapy.
  • Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults ≤24 yr. After starting therapy, children, adolescents, and young adults should be seen by health care professional at least weekly for 4 wk, every 3 wk for next 4 wk, and on advice of health care professional thereafter.
  • Assess for sexual dysfunction (erectile dysfunction; decreased libido).
  • Assess for serotonin syndrome (mental changes [agitation, hallucinations, coma], autonomic instability [tachycardia, labile BP, hyperthermia], neuromuscular aberrations [hyperreflexia, incoordination], and/or GI symptoms [nausea, vomiting, diarrhea]), especially in patients taking other serotonergic drugs (SSRIs, SNRIs, triptans).

Potential Nursing Diagnoses

Ineffective coping (Indications)
Risk for injury (Side Effects)
Sexual dysfunction (Side Effects)

Implementation

  • Do not confuse Lexapro with Loxitane (loxapine).
  • Do not administer escitalopram and citalopram concomitantly. Taper to avoid potential withdrawal reactions. Reduce dose by 50% for 3 days, then again by 50% for 3 days, then discontinue.
  • Oral: Administer as a single dose in the morning or evening without regard to meals.

Patient/Family Teaching

  • Instruct patient to take escitalopram as directed. Take missed doses on the same day as soon as remembered and consult health care professional. Resume regular dosing schedule next day. Do not double doses. Do not stop abruptly; should be discontinued gradually. Instruct patient to read Medication Guide before starting and with each Rx refill in case of changes.
  • May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
  • Advise patient, family, and caregivers to look for suicidality, especially during early therapy or dose changes. Notify health care professional immediately if thoughts about suicide or dying, attempts to commit suicide, new or worse depression or anxiety, agitation or restlessness, panic attacks, insomnia, new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior or if rash or symptoms of serotonin syndrome occur.
  • Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any other Rx, OTC, or herbal products, especially alcohol or other CNS depressants.
  • Instruct female patients to notify health care professional if pregnancy is planned or suspected or if they plan to breast feed. If used during pregnancy, should be tapered during 3rd trimester to avoid neonatal serotonin syndrome.
  • Emphasize importance of follow-up exams to monitor progress.

Evaluation/Desired Outcomes

  • Increased sense of well-being.
    • Renewed interest in surroundings. May require 1–4 wk of therapy to obtain antidepressant effects. Full antidepressant effects occur in 4–6 wk.
  • Decrease in anxiety.

Cipralex

A brand name for ESCITALOPRAM.
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