Escitalopram intoxication

Dear Editor,

Selective serotonin re-uptake inhibitors are now used as the first choice for depression treatment. SSRIs have strong effects as well as a positive side effect profile [2]. Citalopram, which is a racemic drug, shows antidepressant effect through inhibiting serotonin re-uptake. Escitalopram is the S-enantiomer of citalopram and is the main agent of pharmacologic effect. [4] Escitalopram, is the most selective molecule for serotonin receptors compared to other antidepressants (including citalopram) [6]. Its side effects are easily tolerated, are slight and temporary [3]. Since the risk of suicide is high for the patients suffering depression, it is very important for pharmacologic agents to have lower toxicity levels. Citalopram overdose data noted in literature suggests that the safety interval of the drug is high [7]. However, it is not possible to find about anything in literature about the overdose of escitalopram, which is a new product. The patient reported in this letter took 190 mg escitalopram impulsively in order to commit suicide.

A 32 year-old female patient was admitted to our emergency service clinic 10 h after she had taken impulsively 19 tablets of escitalopram (190 mg). At admission: patient had nausea, vertigo, palpitation and drowsiness; her temperature was minimally high (37.4 °C), she had tacychardia (120 pulse/min) and her blood pressure was low (100/70 mmHg); she was confused and cooperation was partially maintained, her deep tendon reflexes were reduced, no pathologic reflex was noticed; slight leucocytosis (12.5 K/ul) was found; biochemical results were normal; in electrocardiogram, increased QT interval and sinus tacychardia were noticed. And then gastrological lavage and active charcoal were applied. After 12 h, she became conscious, cooperation was established, and her place-time-person orientations were full. The vital data turned to stable; electrocardiographic data were within the normal limits and leucocytosis decreased (11.3 K/ul). After 24 h examination she was discharged after the recommendation for a psychiatric examination in the outpatient clinic. Then 1 week later laboratory examinations were reperformed; complete blood counting, biochemical examinations, electrocardiographic data and vital signs were all in normal range.

The general pharmacological, pharmacokinetic and toxiologic characteristics of escitalopram and citalopram are similiar [1]. Thus, the symptoms in the overdose of escitalopram could be similar to those of citalopram. In the use of citalopram lower than 600 mg, nausea, dizziness, tacychardia, tremor, drowsiness, somnolence and non-specific ECG changes could be seen, but in doses over 600 mg convulsion and death could also occur [5,7]. As for our case, the main symptoms were hyperthermia, hypotension, confusion, slight leucoyctosis, increased QT interval and sinus tacychardia when 190 mg escitalopram was taken and no other symptom was seen. These turned to normal limits 22 h after the drug had been taken. In its treatment, a method similar to the treatment of the overdose of citalopram could be applied. There is no specific antidote; supportive and symptomatic treatment should be made. In the shortest time possible after oral intake, gastrological lavage and cardiologic and vital monitorization as well as supportive measures should be taken.