The following special warnings and precautions apply to the therapeutic class of SSRIs (Selective Serotonin Reuptake Inhibitors).
Seizures: Use caution with a previous seizure disorder or condition predisposing to seizures such as brain damage, alcoholism, or concurrent therapy with other drugs which lower the seizure threshold.
Hyponatremia: May cause hyponatremia / SIADH (elderly at increased risk); volume depletion (diuretics may increase risk) may occur. Use caution in elderly patients; may be potentially inappropriate in patients with a history of falls or fractures, and may cause or exacerbate syndrome of inappropriate antidiuretic hormone secretion or hyponatremia; monitor sodium closely with initiation or dosage adjustments in older adults.
Mania: Activation of mania and hypomania has occurred in patients receiving escitalopram or citalopram. Escitalopram should be used with caution in patients with a history of mania.
Abnormal bleeding: SNRIs and SSRIs, including escitalopram, may increase the risk of bleeding events. Concurrent use of aspirin, nonsteroidal anti-inflammatory agents (NSAIAs), warfarin, and other anticoagulants may add to this risk. Case reports and epidemiologic studies have demonstrated an association between the use of drugs that interfere with serotonin reuptake and the occurrence of GI bleeding. Bleeding events related to SNRI and SSRI use have ranged from ecchymosis, hematomas, epistaxis, and petechiae to life-threatening hemorrhages.
ECT (electroconvulsive therapy): May increase the risks associated with electroconvulsive therapy.
Serotonin syndrome: Potentially life-threatening serotonin syndrome (SS) has occurred with serotonergic agents (eg, SSRIs, SNRIs), particularly when used in combination with other serotonergic agents (eg, triptans, TCA, fentanyl, lithium , tramadol, buspirone, St John’s wort, tryptophan) or agents that impair metabolism of serotonin (eg, MAO inhibitors intended to treat psychiatric disorders, other MAO inhibitors [ie, linezolid and intravenous methylene blue]). Discontinue treatment (and concomitant serotonergic agent) immediately if signs / symptoms arise.
QT interval prolongation: Use has been associated with dose-dependent QT-interval prolongation with doses of 10mg and 30mg/day in healthy subjects; prolongation of QT interval and ventricular arrhythmia (including torsade de pointes) have been reported, particularly in females with preexisting QT prolongation or other risk factors (eg, hypokalemia, other cardiac disease).
Renal or liver impairment: Use caution with severe renal impairment or liver impairment; concomitant CNS depressants.
Angle-Closure Glaucoma: May cause mild papillary dilation which in susceptible individuals can lead to an episode of narrow-angle glaucoma. Consider evaluating patients who have not had an iridectomy for narrow-angle glaucoma risk factors.
Use in Children: Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18-24 years of age) with major depressive disorder (MDD) and other psychiatric disorders; consider risk prior to prescribing. This risk may persist until clinically important remission occurs. Recommended that all patients being treated with antidepressants for any indication be appropriately monitored and closely observed for clinical worsening, suicidality, and unusual changes in behavior, particularly during initiation of therapy (i.e., the first few months) and during periods of dosage adjustments.