Wednesday, May 16, 2012

Cipralex - Escitalopram

I've been prescribing Lundbeck Pharmaceutical's, Cipralex, (Escitalopram) since it first became available in the last few years.  Finally it's covered by our provincial formulary.
Prozac or fluoxetine, the first of the SSRI, Serotonin Specific Reuptake Inhibitors,  was truly a break through in pharmaceutical therapeutics. Prior to it's introduction the tricyclics, such as Amitriptylline,  were all that was available. I remember the horrors of seeing acutely suicidal patients and beginning them on one of the tricyclics knowing that the medications had unpleasant side effects. They would have to be titrated upwards slowly because of toxicity and would take at least 6 weeks to become psychoactive. The tricyclics further had a narrow window of benefit versus danger. A small amount of medication, usually less than a week or twos supply was all that was necessary to cause cardiac arrest if taken as an overdose. If the patient didn't die they had to be admitted to an intensive care units for days to protect against lethal arrythmias.
Having faced all of those risks as a clinician I was thankful for the SSRI"s.  The first generation brought rapid onset of action, with patients experiencing benefits in as little as 2 weeks though the full benefits of the medication could still take 1-2 months.  The side effects were far less and each generation has resulted in a medication with fewer and fewer side effects.  Finally the risk of suicide by overdose is very little and much less with later generations of SSRI.
Cipralex is the latest of the SSRI generations. It's advantage over the previous SSRI"s is it's short action. Prozac could accumulated in the system because of it's long half life, half life being the length of time it took to remove half of a compound from the system.  Cipralex clears out of the system in a day or two. This is important in case there are any reactions to the medication by itself or in combination with others. In comparison consider that alcohol clears in less time and marijuana is psychoactive for 6 weeks or sometimes more.
The second generation of SSRI"s included two I found very useful and beneficial.  Zoloft or sertraline was specifically used for PTSD whereas Paxil or Paroxetine was an amazing anti anxiety medication for generalized anxiety disorders and panic attacks.  Zoloft continues to be used extensive as does Prozac.  The difficulty with paxil was that it was most likely to cause sexual side effects, delayed ejaculation, decreased desire and erectile failure in as many as 40 per cent of patients at higher dosages. This could be counteracted first with ginkgo biloba and secondly with viagra or cialis.
Trazadone anothe second generation SSRI still tends to be used more for an interesting side effect. It's extremely good for keeping people asleep so that it can be combined with most of the other antidepressants in those people who have difficulty with insomnia, a common sympton in depression.
Celexa , or citalopram, a third generation SSRI, was extremely useful in the elderly and in treatment of patients who had other medical conditions especially a history of myocardial infarction or cardiac concerns in general.  It was a surprisingly safe medication with a very 'clean' profile in its being least likely to interact negatively with medications used in other specialities. It commonly was beneficial for patients with major medical illness and post surgical depressions without having any signficant down side. Celexa is essentially the closest precurser of Cipralex.
Cipralex in contrast to Celexa, while retaining it's benefits, had specific superiority in the treatment of anxious depression, anxiety disorders with panic attacks and interestingly Obsessive Compulsive Disorder.
Clomipramine the tricyclic antidepressant was shown before Prozac to be almost essential to the treatment of OCD.  High dosage of medication was commonly needed too. Whereas a person with depression or general anxiety might benefit from 10 mg of prozac , the ocd patient would often need more than 60 mg to get the full benefit.  Cipralex appears almost equally beneficial for OCD but again at higher dosage that presently recommended.
Both Celexa and Cipralex have another interesting clinical significance. Of all the antidepressants I've used treating head injured patients, patient with traumatic brain injury it's been these two and wellbutrin or buproprion that my patients have literally sworn by.  I think it's interesting that these cipralex has benefit in brain injured patients and OCD because these are considered more 'biological' than what can be described as the more psychological depressions that tend to respond to a wide variety of therapies.  That the patients and their families see the benefit so significantly is what is most exciting.
Cipralex is a good antidepressant and really shines as a long term anti anxiety medication.  It's beneficial in TBI and in OCD. It's also beneficial in patients who have mood disorder but the diagnosis is Bipolar.  Because of the safety and cleaness of it's pharmaceutical proflie and relatively short half life it's also one of the safest medication that can be used with patients who use drugs or alcohol but may well not be open about this with the doctor. It's been well tried in a street clinic I work at with much benefit and no serious side effects of concern.  Safety is appreciated and the pharmaceutical companies are most concerned that their medications are safe simply because they pay the costs when things go wrong.
Prozac is the only antidepressant that is said to be acceptable for the treatment of childhood depression in Canada.  The research on patients whose mother was on an SSRI when they were intrauterine is now in 30 year follow up with one of the safest profiles in the history of pharmaceutical treatment.
Depression is a life threatening disease. Anxiety is a horror to live with. It's not just something that goes away. OCD is wholly disabling for some patients.  Suicide is a major cause of death and medications like Cipralex are truly beneficial adjuncts to the armentarium of ways we successfully and effectively treat cases mild to severe to save patients from hospitalization.
I thank Dr. Tsung, a colleague for 'picking my brain' and causing me to think of the thousands of prescriptions I've written over the years for SSRI and how I chose which medications. I do choose the latest medication which usually is the best in the way that the newest of cars incorporates the latest science and technology in those who have not responded or only had a partial response to previously available treatments. Further I will use the latest medication in those who are well off and can afford it and have moderate to severe symptons.  I was very thankful when cipralex became part of the formulary, which means it was available to all patients on disability or pensions or even welfare.  It's a recognition by the decision makers of the benefit of the medication and a testimony to the pharmaceutical company to bring in a new and very beneficial product at a price where most people can afford it and governments can see the benefit of providing coverage. It makes it that much easier for clinicians.


Anonymous said...

Hi. :)
You mention ginko biloba. I read somewhere that ginko biloba , mixed with ssris could trigger serotonin syndrome. I was wondering if this is true. I take 20 mg cipralex and I noticed that my red berries powder has some ginko biloba in it.
Should I avoid anything that has ginko biloba in it while on cipralex?Thank you.

haykind said...

You should always discuss prescription medication with your prescriber. Personally I've found serotonin syndrome over rated. It's dangerous and I've treated a couple of cases in my asylum practice with high dose mixture of medication. It's rare however considering the thousands of patients I've treated with ssri's . I would not see the two contraindicated in standard dosage and practice. My patients certainly haven't had a problem with these combinations of meds.