Management of Agitation in Patients Taking Escitalopram

First-Line Treatment Options

The American College of Cardiology is not applicable here, however, atypical antipsychotics such as quetiapine or olanzapine are the preferred adjunctive medications for patients taking Lexapro (escitalopram) who experience agitation, due to their efficacy and relatively favorable side effect profiles 1, 2
Quetiapine should be started with 25 mg orally once or twice daily, as it is less likely to cause extrapyramidal symptoms (EPS) than other antipsychotics, but may cause orthostatic hypotension and dizziness 1, 2
Olanzapine should be started with 2.5-5 mg orally or subcutaneously daily, usually at bedtime, but may cause drowsiness and orthostatic hypotension, and caution should be used when combining with benzodiazepines due to risk of oversedation 1, 2

Benzodiazepines should be used with caution as they can potentially worsen agitation in approximately 10% of patients, and the American Academy of Family Physicians recommends avoiding regular use due to risks of tolerance, addiction, depression, and cognitive impairment 3, 4
Lorazepam can be used at a dose of 0.5-1 mg orally, sublingually, or parenterally every 1-4 hours as needed, with lower doses recommended in elderly or frail patients 1, 5
Midazolam can be used for severe agitation not responding to other treatments, at a dose of 0.5-2.5 mg subcutaneously or IV hourly as needed 1

The American Academy of Child and Adolescent Psychiatry recommends using caution when combining escitalopram with drugs that prolong QT interval, and when combining with medications metabolized by CYP2D6 enzymes 6
Benzodiazepines combined with high-dose olanzapine can lead to oversedation, respiratory depression, and even fatalities, according to the Annals of Oncology 1, 2
Elderly patients should be started with lower doses of all medications, and patients with renal or hepatic impairment should have their doses reduced and be monitored closely 1, 2