side effects of lexapro_ad

[Guest guest]

Escitalopram oxalate

HEALTH LIBRARY

ADD/ADHD Allergy Alternative Medicine Arthritis Asthma Beyond Dieting Body Aches & Pains Breast Cancer Cancer Awareness Cardio Health Children's Health Contraception COPD/Emphysema Dental Health Diabetes Elder Care Emergency Room Epilepsy Erectile Dysfunction Eye Care Fertility Fitness Gastrointestinal Health Hair Loss Headache Healthcare Today Healthy Aging HIV and AIDS Infectious Diseases Kidney Health Leukemia Liver Health Lung Cancer Lymphoma Multiple Sclerosis Men's Health Mental Health Nutrition Osteoporosis Pregnancy & Childbirth Sexual Health Skin Health Sleep Disorders Special Events Stroke Surgeries & Procedures Teen Health Thyroid Health Urologic Health Vascular Disease Women's Health Workplace Health

Health Updates

Get the latest health information from leading experts, delivered direct to your email box!

HEALTH HEADLINES

SIDE EFFECTS

Adverse event information for LEXAPRO was collected from 715 patients with major depressive disorder who were exposed to escitalopram and from 592 patients who were exposed to placebo in double-blind, placebo-controlled trials. An additional 284 patients with major depressive disorder were newly exposed to escitalopram in open-label trials. The adverse event information for LEXAPRO in patients with GAD was collected from 429 patients exposed to escitalopram and from 427 patients exposed to placebo in double-blind, placebo-controlled trials.

Adverse events during exposure were obtained primarily by general inquiry and recorded by clinical investigators using terminology of their own choosing. Consequently, it is not possible to provide a meaningful estimate of the proportion of individuals experiencing adverse events without first grouping similar types of events into a smaller number of standardized event categories. In the tables and tabulations that follow, standard World Health Organization (WHO) terminology has been used to classify reported adverse events.

The stated frequencies of adverse events represent the proportion of individuals who experienced, at least once, a treatment-emergent adverse event of the type listed. An event was considered treatment-emergent if it occurred for the first time or worsened while receiving therapy following baseline evaluation.

From Our Sponsors

Adverse Events Associated with Discontinuation of Treatment

Major Depressive Disorder

Among the 715 depressed patients who received LEXAPRO in placebo-controlled trials, 6% discontinued treatment due to an adverse event, as compared to 2 % of 592 patients receiving placebo. In two fixed-dose studies, the rate of discontinuation for adverse events in patients receiving 10 mg/day LEXAPRO was not significantly different from the rate of discontinuation for adverse events in patients receiving placebo. The rate of discontinuation for adverse events in patients assigned to a fixed dose of 20 mg/day LEXAPRO was 10% which was significantly different from the rate of discontinuation for adverse events in patients receiving 10 mg/day LEXAPRO (4%) and placebo (3%). Adverse events that were associated with the discontinuation of at least 1% of patients treated with LEXAPRO, and for which the rate was at least twice the placebo rate, were nausea (2%) and ejaculation disorder (2% of male patients).

Generalized Anxiety Disorder

Among the 429 GAD patients who received LEXAPRO 10-20 mg/day in placebo-controlled trials, 8% discontinued treatment due to an adverse event, as compared to 4 % of 427 patients receiving placebo. Adverse events that were associated with the discontinuation of at least 1% of patients treated with LEXAPRO, and for which the rate was at least twice the placebo rate, were nausea (2%), insomnia (1%), and fatigue (1%).

Incidence of Adverse Events in Placebo-Controlled Clinical Trials

Major Depressive Disorder

Table 1 enumerates the incidence, rounded to the nearest percent, of treatment emergent adverse events that occurred among 715 depressed patients who received LEXAPRO at doses ranging from 10 to 20 mg/day in placebo-controlled trials. Events included are those occurring in 2% or more of patients treated with LEXAPRO and for which the incidence in patients treated with LEXAPRO was greater than the incidence in placebo-treated patients.

The prescriber should be aware that these figures can not be used to predict the incidence of adverse events in the course of usual medical practice where patient characteristics and other factors differ from those which prevailed in the clinical trials. Similarly, the cited frequencies cannot be compared with figures obtained from other clinical investigations involving different treatments, uses, and investigators. The cited figures, however, do provide the prescribing physician with some basis for estimating the relative contribution of drug and non-drug factors to the adverse event incidence rate in the population studied.

The most commonly observed adverse events in LEXAPRO patients (incidence of approximately 5% or greater and approximately twice the incidence in placebo patients) were insomnia, ejaculation disorder (primarily ejaculatory delay), nausea, sweating increased, fatigue, and somnolence (see TABLE 1).

TABLE 1 Treatment-Emergent Adverse Events: Incidence in Placebo-Controlled Clinical Trials for Major Depressive Disorder *

(Percentage of Patients Reporting Event)

Body System / Adverse Event

LEXAPRO

Placebo

(N=715)

(N=592)

Autonomic Nervous System Disorders

Dry Mouth

6%

5%

Sweating Increased

5%

2%

Central & Peripheral Nervous System Disorders

Dizziness

5%

3%

Gastrointestinal Disorders

Nausea

15%

7%

Diarrhea

8%

5%

Constipation

3%

1%

Indigestion

3%

1%

Abdominal Pain

2%

1%

General

Influenza-like Symptoms

5%

4%

Fatigue

5%

2%

Psychiatric Disorders

Insomnia

9%

4%

Somnolence

6%

2%

Appetite Decreased

3%

1%

Libido Decreased

3%

1%

Respiratory System Disorders

Rhinitis

5%

4%

Sinusitis

3%

2%

Urogenital

Ejaculation Disorder1,2

9%

<1%

Impotence2

3%

<1%

Anorgasmia3

2%

<1%

*Events reported by at least 2% of patients treated with LEXAPRO are reported, except for the following events which had an incidence on placebo > LEXAPRO: headache, upper respiratory tract infection, back pain, pharyngitis, inflicted injury, anxiety.

1Primarily ejaculatory delay.

2Denominator used was for males only (N=225 LEXAPRO ; N=188 placebo).

3Denominator used was for females only (N=490 LEXAPRO ; N=404 placebo).

Generalized Anxiety Disorder

Table 2 enumerates the incidence, rounded to the nearest percent, of treatment emergent adverse events that occurred among 429 GAD patients who received LEXAPRO 10 to 20 mg/day in placebo-controlled trials. Events included are those occurring in 2% or more of patients treated with LEXAPRO and for which the incidence in patients treated with LEXAPRO was greater than the incidence in placebo-treated patients.

The most commonly observed adverse events in LEXAPRO patients (incidence of approximately 5% or greater and approximately twice the incidence in placebo patients) were nausea, ejaculation disorder (primarily ejaculatory delay), insomnia, fatigue, decreased libido, and anorgasmia (see TABLE 2).

TABLE 2 Treatment-Emergent Adverse Events: Incidence in Placebo-Controlled Clinical Trials for Generalized Anxiety Disorder*

(Percentage of Patients Reporting Event)

Body System / Adverse Event

LEXAPRO

Placebo

(N=429)

(N=427)

Autonomic Nervous System Disorders

Dry Mouth

9%

5%

Sweating Increased

4%

1%

Central & Peripheral Nervous System Disorders

Headache

24%

17%

Paresthesia

2%

1%

Gastrointestinal Disorders

Nausea

18%

8%

Diarrhea

8%

6%

Constipation

5%

4%

Indigestion

3%

2%

Vomiting

3%

1%

Abdominal Pain

2%

1%

Flatulence

2%

1%

Toothache

2%

0%

General

Fatigue

8%

2%

Influenza-like Symptoms

5%

4%

Musculoskeletal

Neck/Shoulder Pain

3%

1%

Psychiatric Disorders

Somnolence

13%

7%

Insomnia

12%

6%

Libido Decreased

7%

2%

Dreaming Abnormal

3%

2%

Appetite Decreased

3%

1%

Lethargy

3%

1%

Yawning

2%

1%

Urogenital

Ejaculation Disorder1,2

14%

2%

Anorgasmia3

6%

<1%

Menstrual Disorder

2%

1%

*Events reported by at least 2% of patients treated with LEXAPRO are reported, except for the following events which had an incidence on placebo > LEXAPRO: inflicted injury, ,dizziness, back pain, upper respiratory tract infection, rhinitis, pharyngitis.

1Primarily ejaculatory delay.

2Denominator used was for males only (N=182 LEXAPRO; N=195 placebo).

3Denominator used was for females only (N=247 LEXAPRO; N=232 placebo).

Dose Dependency of Adverse Events

The potential dose dependency of common adverse events (defined as an incidence rate of $ 5% in either the 10 mg or 20 mg LEXAPRO groups) was examined on the basis of the combined incidence of adverse events in two fixed-dose trials. The overall incidence rates of adverse events in 10 mg LEXAPRO-treated patients (66%) was similar to that of the placebo-treated patients (61%), while the incidence rate in 20 mg/day LEXAPRO-treated patients was greater (86%). Table 2 shows common adverse events that occurred in the 20 mg/day LEXAPRO group with an incidence that was approximately twice that of the 10 mg/day LEXAPRO group and approximately twice that of the placebo group.

TABLE 3 Incidence of Common Adverse Events* in Patients with Major Depressive Disorder Receiving Placebo, 10 mg/day LEXAPRO, or 20 mg/day LEXAPRO

Placebo

10 mg/day

20 mg/day

Adverse Event

(N=311)

(N=310)

(N=125)

Insomnia

4%

7%

14%

Diarrhea

5%

6%

14%

Dry Mouth

3%

4%

9%

Somnolence

1%

4%

9%

Dizziness

2%

4%

7%

Sweating Increased

<1%

3%

8%

Constipation

1%

3%

6%

Fatigue

2%

2%

6%

Indigestion

1%

2%

6%

*Adverse events with an incidence rate of at least 5% in either of the LEXAPRO groups and with an incidence rate in the 20 mg/day LEXAPRO group that was approximately twice that of the 10 mg/day LEXAPRO group and the placebo group.

Male and Female Sexual Dysfunction with SSRIs

Although changes in sexual desire, sexual performance and sexual satisfaction often occur as manifestations of a psychiatric disorder, they may also be a consequence of pharmacologic treatment. In particular, some evidence suggests that selective serotonin reuptake inhibitors (SSRIs) can cause such untoward sexual experiences.

Reliable estimates of the incidence and severity of untoward experiences involving sexual desire, performance and satisfaction are difficult to obtain, however, in part because patients and physicians may be reluctant to discuss them. Accordingly, estimates of the incidence of untoward sexual experience and performance cited in product labeling are likely to underestimate their actual incidence.

Table 4 shows the incidence rates of sexual side effects in patients with major depressive disorder and GAD in placebo controlled trials.

TABLE 4 Incidence of Sexual Side Effects in Placebo-Controlled Clinical Trials

Adverse Event

LEXAPRO™

Placebo

In Males Only

(N= 407)

(N= 383)

Ejaculation Disorder

12%

1%

(primarily ejaculatory delay)

Decreased Libido

6%

2%

Impotence

2%

<1%

In Females Only

(N= 737)

(N= 636)

Decreased Libido

3%

1%

Anorgasmia

3%

<1%

There are no adequately designed studies examining sexual dysfunction with escitalopram treatment.

Priapism has been reported with all SSRIs.

While it is difficult to know the precise risk of sexual dysfunction associated with the use of SSRIs, physicians should routinely inquire about such possible side effects.

Vital Sign Changes

LEXAPRO and placebo groups were compared with respect to (1) mean change from baseline in vital signs (pulse, systolic blood pressure, and diastolic blood pressure) and (2) the incidence of patients meeting criteria for potentially clinically significant changes from baseline in these variables. These analyses did not reveal any clinically important changes in vital signs associated with LEXAPRO treatment. In addition, a comparison of supine and standing vital sign measures in subjects receiving LEXAPRO indicated that LEXAPRO treatment is not associated with orthostatic changes.

Weight Changes

Patients treated with LEXAPRO in controlled trials did not differ from placebo-treated patients with regard to clinically important change in body weight.

Laboratory Changes

LEXAPRO and placebo groups were compared with respect to (1) mean change from baseline in various serum chemistry, hematology, and urinalysis variables and (2) the incidence of patients meeting criteria for potentially clinically significant changes from baseline in these variables. These analyses revealed no clinically important changes in laboratory test parameters associated with LEXAPRO treatment.

ECG Changes

Electrocardiograms from LEXAPRO (N=625), racemic citalopram (N=351), and placebo (N=527) groups were compared with respect to (1) mean change from baseline in various ECG parameters and (2) the incidence of patients meeting criteria for potentially clinically significant changes from baseline in these variables. These analyses revealed (1) a decrease in heart rate of 2.2 bpm for LEXAPRO and 2.7 bpm for racemic citalopram, compared to an increase of 0.3 bpm for placebo and (2) an increase in QTc interval of 3.9 msec for LEXAPRO and 3.7 msec for racemic citalopram, compared to 0.5 msec for placebo. Neither LEXAPRO nor racemic citalopram were associated with the development of clinically significant ECG abnormalities.

Other Events Observed During the Premarketing Evaluation of LEXAPRO

Following is a list of WHO terms that reflect treatment-emergent adverse events, as defined in the introduction to the ADVERSE REACTIONS section, reported by the 1428 patients treated with LEXAPRO for periods of up to one year in double-blind or open-label clinical trials during its premarketing evaluation. All reported events are included except those already listed in Tables 1 & 2, those occurring in only one patient, event terms that are so general as to be uninformative, and those that are unlikely to be drug related. It is important to emphasize that, although the events reported occurred during treatment with LEXAPRO, they were not necessarily caused by it.

Events are further categorized by body system and listed in order of decreasing frequency according to the following definitions: frequent adverse events are those occurring on one or more occasions in at least 1/100 patients; infrequent adverse events are those occurring in less than 1/100 patients but at least 1/1000 patients.

Cardiovascular – Frequent: palpitation, hypertension. Infrequent: bradycardia, tachycardia, ECG abnormal, flushing, varicose vein.

Central and Peripheral Nervous System Disorders - Frequent: light-headed feeling, migraine. Infrequent: tremor, vertigo, restless legs, shaking, twitching, dysequilibrium, tics, carpal tunnel syndrome, muscle contractions involuntary, sluggishness, coordination abnormal, faintness, hyperreflexia, muscular tone increased.

Gastrointestinal Disorders - Frequent: heartburn, abdominal cramp, gastroenteritis. Infrequent: gastroesophageal reflux, bloating, abdominal discomfort, dyspepsia, increased stool frequency, belching, gastritis, hemorrhoids, gagging, polyposis gastric, swallowing difficult.

General – Frequent: allergy, pain in limb, fever, hot flushes, chest pain. Infrequent: edema of extremities, chills, tightness of chest, leg pain, asthenia, syncope, malaise, anaphylaxis, fall.

Hemic and Lymphatic Disorders - Infrequent: bruise, anemia, nosebleed, hematoma, lymphadenopathy cervical.

Metabolic and Nutritional Disorders - Frequent: increased weight. Infrequent: decreased weight, hyperglycemia, thirst, bilirubin increased, hepatic enzymes increased, gout, hypercholesterolemia.

Musculoskeletal System Disorders – Frequent: arthralgia, myalgia. Infrequent: jaw stiffness, muscle cramp, muscle stiffness, arthritis, muscle weakness, back discomfort, arthropathy, jaw pain, joint stiffness.

Psychiatric Disorders – Frequent: appetite increased, lethargy, irritability, concentration impaired. Infrequent: jitteriness, panic reaction, agitation, apathy, forgetfulness, depression aggravated, nervousness, restlessness aggravated, suicide attempt, amnesia, anxiety attack, bruxism, carbohydrate craving, confusion, depersonalization, disorientation, emotional lability, feeling unreal, tremulousness nervous, crying abnormal, depression, excitability, auditory hallucination, suicidal tendency.

Reproductive Disorders/Female* - Frequent: menstrual cramps, menstrual disorder. Infrequent: menorrhagia, breast neoplasm, pelvic inflammation, premenstrual syndrome, spotting between menses.

*% based on female subjects only: N= 905

Respiratory System Disorders - Frequent: bronchitis, sinus congestion, coughing, nasal congestion, sinus headache. Infrequent: asthma, breath shortness, laryngitis, pneumonia, tracheitis.

Skin and Appendages Disorders - Frequent: rash. Infrequent: pruritus, acne, alopecia, eczema, dermatitis, dry skin, folliculitis, lipoma, furunculosis, dry lips, skin nodule.

Special Senses - Frequent: vision blurred, tinnitus. Infrequent: taste alteration, ear ache, conjunctivitis, vision abnormal, dry eyes, eye irritation, visual disturbance, eye infection, pupils dilated, metallic taste.

Urinary System Disorders - Frequent: urinary frequency, urinary tract infection. Infrequent: urinary urgency, kidney stone, dysuria, blood in urine.

Events Reported Subsequent to the Marketing of Racemic Citalopram

Although no causal relationship to racemic citalopram treatment has been found, the following adverse events have been reported to be temporally associated with racemic citalopram treatment and were not observed during the premarketing evaluation of escitalopram or citalopram: acute renal failure, akathisia, allergic reaction, anaphylaxis, angioedema, choreoathetosis, delirium, dyskinesia, ecchymosis, epidermal necrolysis, erythema multiforme, gastrointestinal hemorrhage, grand mal convulsions, hemolytic anemia, hepatic necrosis, myoclonus, neuroleptic malignant syndrome, nystagmus, pancreatitis, priapism, prolactinemia, prothrombin decreased, QT prolonged, rhabdomyolysis, serotonin syndrome, spontaneous abortion, thrombocytopenia, thrombosis, Torsades de pointes, ventricular arrhythmia, and withdrawal syndrome.

DRUG ABUSE AND DEPENDENCE

Controlled Substance Class

LEXAPRO is not a controlled substance.

Physical and Psychological Dependence

Animal studies suggest that the abuse liability of racemic citalopram is low. LEXAPRO has not been systematically studied in humans for its potential for abuse, tolerance, or physical dependence. The premarketing clinical experience with LEXAPRO did not reveal any drug seeking behavior. However, these observations were not systematic and it is not possible to predict on the basis of this limited experience the extent to which a CNS-active drug will be misused, diverted, and/or abused once marketed. Consequently, physicians should carefully evaluate LEXAPRO patients for history of drug abuse and follow such patients closely, observing them for signs of misuse or abuse (e.g., development of tolerance, incrementations of dose, drug seeking behavior).

DRUG INTERACTIONS

CNS Drugs - Given the primary CNS effects of escitalopram, caution should be used when it is taken in combination with other centrally acting drugs.

Alcohol - Although LEXAPRO did not potentiate the cognitive and motor effects of alcohol in a clinical trial, as with other psychotropic medications, the use of alcohol by patients taking LEXAPRO is not recommended.

Monoamine Oxidase Inhibitors (MAOIs) - See Contraindications and Warnings.

Drugs That Interfere With Hemostasis (NSAIDs, Aspirin, Warfarin, etc.)

Serotonin release by platelets plays an important role in hemostasis. Epidemiological studies of the case-control and cohort design that have demonstrated an association between use of psychotropic drugs that interfere with serotonin reuptake and the occurrence of upper gastrointestinal bleeding have also shown that concurrent use of an NSAID or aspirin potentiated the risk of bleeding. Thus, patients should be cautioned about the use of such drugs concurrently with LEXAPRO.

Cimetidine - In subjects who had received 21 days of 40 mg/day racemic citalopram, combined administration of 400 mg/day cimetidine for 8 days resulted in an increase in citalopram AUC and Cmax of 43% and 39%, respectively. The clinical significance of these findings is unknown.

Digoxin - In subjects who had received 21 days of 40 mg/day racemic citalopram, combined administration of citalopram and digoxin (single dose of 1 mg) did not significantly affect the pharmacokinetics of either citalopram or digoxin.

Lithium - Coadministration of racemic citalopram (40 mg/day for 10 days) and lithium (30 mmol/day for 5 days) had no significant effect on the pharmacokinetics of citalopram or lithium. Nevertheless, plasma lithium levels should be monitored with appropriate adjustment to the lithium dose in accordance with standard clinical practice. Because lithium may enhance the serotonergic effects of escitalopram, caution should be exercised when LEXAPRO and lithium are coadministered.

Sumatriptan – There have been rare postmarketing reports describing patients with weakness, hyperreflexia, and incoordination following the use of a selective serotonin reuptake inhibitor (SSRI) and sumatriptan. If concomitant treatment with sumatriptan and an SSRI (e.g., fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, escitalopram) is clinically warranted, appropriate observation of the patient is advised.

Theophylline – Combined administration of racemic citalopram (40 mg/day for 21 days) and the CYP1A2 substrate theophylline (single dose of 300 mg) did not affect the pharmacokinetics of theophylline. The effect of theophylline on the pharmacokinetics of citalopram was not evaluated.

Warfarin - Administration of 40 mg/day racemic citalopram for 21 days did not affect the pharmacokinetics of warfarin, a CYP3A4 substrate. Prothrombin time was increased by 5%, the clinical significance of which is unknown.

Carbamazepine - Combined administration of racemic citalopram (40 mg/day for 14 days) and carbamazepine (titrated to 400 mg/day for 35 days) did not significantly affect the pharmacokinetics of carbamazepine, a CYP3A4 substrate. Although trough citalopram plasma levels were unaffected, given the enzyme inducing properties of carbamazepine, the possibility that carbamazepine might increase the clearance of escitalopram should be considered if the two drugs are coadministered.

Triazolam – Combined administration of racemic citalopram (titrated to 40 mg/day for 28 days) and the CYP3A4 substrate triazolam (single dose of 0.25 mg) did not significantly affect the pharmacokinetics of either citalopram or triazolam.

Ketoconazole – Combined administration of racemic citalopram (40 mg) and ketoconazole (200 mg) decreased the Cmax and AUC of ketoconazole by 21% and 10%, respectively, and did not significantly affect the pharmacokinetics of citalopram.

Ritonavir – Combined administration of a single dose of ritonavir (600 mg), both a CYP3A4 substrate and a potent inhibitor of CYP3A4, and escitalopram (20 mg) did not affect the pharmacokinetics of either ritonavir or escitalopram.

CYP3A4 and -2C19 Inhibitors - In vitro studies indicated that CYP3A4 and -2C19 are the primary enzymes involved in the metabolism of escitalopram. However, coadministration of escitalopram (20 mg) and ritonavir (600 mg), a potent inhibitor of CYP3A4, did not significantly affect the pharmacokinetics of escitalopram. Because escitalopram is metabolized by multiple enzyme systems, inhibition of a single enzyme may not appreciably decrease escitalopram clearance.

Drugs Metabolized by Cytochrome P4502D6 - In vitro studies did not reveal an inhibitory effect of escitalopram on CYP2D6. In addition, steady state levels of racemic citalopram were not significantly different in poor metabolizers and extensive CYP2D6 metabolizers after multiple-dose administration of citalopram, suggesting that coadministration, with escitalopram, of a drug that inhibits CYP2D6, is unlikely to have clinically significant effects on escitalopram metabolism. However, there are limited in vivo data suggesting a modest CYP2D6 inhibitory effect for escitalopram, i.e., coadministration of escitalopram (20 mg/day for 21 days) with the tricyclic antidepressant desipramine (single dose of 50 mg), a substrate for CYP2D6, resulted in a 40% increase in Cmax and a 100% increase in AUC of desipramine. The clinical significance of this finding is unknown. Nevertheless, caution is indicated in the coadministration of escitalopram and drugs metabolized by CYP2D6.

Metoprolol - Administration of 20 mg/day LEXAPRO for 21 days in healthy volunteers resulted in a 50% increase in Cmax and 82% increase in AUC of the beta-adrenergic blocker metoprolol (given in a single dose of 100 mg). Increased metoprolol plasma levels have been associated with decreased cardioselectivity. Coadministration of LEXAPRO and metoprolol had no clinically significant effects on blood pressure or heart rate.

Electroconvulsive Therapy (ECT) - There are no clinical studies of the combined use of ECT and escitalopram.

New Version!

This Page Last Revised 12/31/03