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Escitalopram vs citalopram - review of dosage, forms and effectiveness between drugs
Drug reviews: use, side effects, effectiveness

Escitalopram vs Citalopram – WHAT is the difference?

Citalopram is a popular antidepressant prescribed in the UK. It is also one of the most prescribed medicines in the UK. Although escitalopram is ‘related’ to citalopram, it significantly less prescribed. Today I will review differences between escitalopram and citalopram. Escitalopram vs citalopram, a summary of the post:

  • Escitalopram vs citalopram: legal status
  • Escitalopram vs citalopram: licensed use
  • Prescribing statistics for escitalopram and citalopram
  • Depression: what is the recommended drug treatment?
  • Comparison of side effects between escitalopram and citalopram
  • Which drug is better? Comparison of the effectiveness
  • Why is escitalopram less commonly prescribed?

Escitalopram vs citalopram: legal status

Both citalopram and escitalopram are prescription-only medications (POM). With this, both drugs need to be prescribed, for supply to be made to patients. An NHS doctor or other independent prescriber can produce a prescription. It is also possible to get a private prescription for both drugs. In this case, medication (s) would be prescribed outside of NHS, for example, in a private clinic or hospital.

Escitalopram vs citalopram: licensed use

Escitalopram and citalopram belong to a group of drugs called antidepressants. More specifically, both drugs belong to a class of antidepressant called Selective Serotonin Re-uptake Inhibitors (SSRIs), a class of antidepressants, which is considered as first-line treatment of depression.

Citalopram is used in the treatment of:

  • Depression
  • Panic disorder

Escitalopram has a wider licensed used than citalopram:

  • Depression
  • Generalised anxiety disorder
  • Obsessive-compulsive disorder
  • Panic disorder
  • Social anxiety disorder

Forms and dosages for citalopram and escitalopram

Forms

Both citalopram and escitalopram come in the form of tablets (most prescribed) and oral drops.

Citalopram comes in the following strengths:

  • Citalopram 10mg tablets
  • Citalopram 20mg tablets
  • Citalopram 40mg tablets
  • Cipramil Drops 40 mg/ml (8 drops = 16mg of citalopram)

Escitalopram comes as:

  • Escitalopram 5 mg tablets
  • Escitalopram 10 mg tablets
  • Escitalopram 20 mg tablets

Escitalopram oral drops 20mg/ml (brand name Cipralex).

Dosages

The licensed dosages for drugs which are used in the treatment of conditions depend on many factors, for example:

  • Patients age
  • Condition itself
  • Drug form and strength

Citalopram’s licensed range for depression in adults is 10mg-40mg per day (gradually increased if needed).

Escitalopram has wider licensed use. The dose, therefore, is different between different age groups and conditions that are treated.

For depression, escitalopram dose is 10-20mg daily (for an adult) and 5mg-10mg for elderly.

Remember to follow the directions given by your GP.

Dosages are not interchangeable between drugs. Each drug has a licensed range for treatment of conditions. One should not compare the dose of one medicine to another. For example, citalopram 20mg tablets do not equal to escitalopram 20mg tablets.

Depression: what is the recommended drug treatment?

The National Institute for Health and Care Excellence (NICE) which sets guidelines for the treatment of diseases in the UK does not recommend the use of an antidepressant in people with mild symptoms of depression. Instead, psychological interventions, such as cognitive behavioural therapy are usually recommended.

Patients with persistent symptoms of mild to moderate symptoms who failed to benefit from psychological interventions may be recommended an antidepressant.

What is the preferred antidepressant?

The choice of antidepressant is driven by the severity of patient’s depression, side effects, any other medications taken and conditions that the patient may have. Selective serotonin reuptake inhibitors are recommended as first-line treatment drugs due to similar effectiveness with other antidepressants and a low cost.

NICE base their recommendations on the evidence available from clinical trials and large comparison studies (known as a meta-analysis). In their reference for the selection of the first-choice antidepressant, NICE mentions Cochrane review as supporting evidence. In the reference paper, Cochrane review concluded that escitalopram ‘seems to be less effective than citalopram’ (Cipriani et al., 2012).

Nevertheless NICE looks at the cost-effectiveness of the treatment (cost of the drug vs treatment benefit). In this case, citalopram and sertraline are cheaper options for the treatment of depression (NICE, 2015).  

Which drug is better? Comparison of the effectiveness

Several studies compared the effectiveness of escitalopram and citalopram.

One meta-analysis (a large review of different clinical studies) looked and compared the effectiveness of escitalopram vs citalopram in the treatment of a major depressive disorder. Four clinical trials were included with 1262 patients.

The effectiveness was assessed on the depression rating score (MADRS). It was concluded that escitalopram provided a better response to the treatment at week 1 and week 8 of the treatment. The benefits of therapy with escitalopram was more evident in people with severe depression. Overall, it was concluded that escitalopram offered a significant advantage in the treatment as compared to citalopram (Auquier et al., 2003).

A newer meta-analysis reviewed nine clinical trials which compared escitalopram vs citalopram in terms of their effectiveness in the treatment of a major depressive disorder. It was concluded that escitalopram is more effective in the treatment of moderate to severe depression.

Prescribing statistics for escitalopram and citalopram

Over last 12 months, citalopram was prescribed just over 14 mln times (Oct ’19—Sep ’20 ), making it second most popular antidepressant (after sertraline) and one of the most commonly prescribed drug in the UK. Escitalopram is not as popular, despite its wider licensed use. In the same period, escitalopram was prescribed 1.3 mln times (OpenPrescribing.net, 2020).

Why is escitalopram less commonly prescribed?

The main driver is the price of the drug. Escitalopram is more expensive as compared to citalopram.

For example, a box of 28 citalopram 10mg tablets costs around £1, whereas a pack of 28 escitalopram 10mg tablets cost around £2 (trade prices, taken 11/2020). The price difference may not seem hugely different, however, if you take into consideration number of prescriptions issued, then prescribing a cheaper drug may bring to the NHS millions of pounds of savings in a year.

Escitalopram vs citalopram: what is the difference?

As both names suggest, escitalopram and citalopram have something in common. This is the case when we look at the chemistry of both drugs. Citalopram exists as a mixture of two molecules, which have the same chemical formula, but the different arrangement (of atoms) in ‘space’. You could think about citalopram as being a pair of your hands: both hands look the same but are mirror images of each other. In chemistry, both molecules are called stereoisomers.

Concerning citalopram, both molecules (left and right hand) are called R-citalopram and S-citalopram. Escitalopram, which represents one hand (s-citalopram) was marketed as a separate drug, which is possible in the pharmaceutical industry. 

Another example of a similar application of stereochemistry in pharmaceuticals is esomeprazole and omeprazole drugs, which I previously reviewed. Esomeprazole and omeprazole are used in the treatment and management of symptoms of acid reflux-related conditions.  

Escitalopram vs citalopram: side effects

Selective serotonin reuptake inhibitors as a group of drugs share many common side effects. Common side effects for escitalopram and citalopram are listed below. For more information about side-effects for each drug, please refer to product information leaflet.

Escitalopram vs citalopram: common side effects
EscitalopramCitalopram

Decreased appetite,

Increased appetite

Weight increased (weigh decrease listed as an uncommon side effect)

Appetite decreased weight decreased (uncommon: increase appetite and weight)

Anxiety, abnormal dreams

Decreased libido in men and women

Inability to achieve orgasm in women

Ejaculation disorder in men

Restlessness

Sleeping problems

Abnormal dreams

Anxiety & nervousness

Decreased libido

Abnormal dreams & nervousness

Decreased libido

Abnormal orgasm (women)

Anorexia

Insomnia, tremor, dizziness, drowsinessTremor, dizziness, migraines, amnesia
Sinusitis, yawningYawning, rhinitis, sinusitis, ringing or buzzing in the ears
HeadachePalpitations
Diarrhoea, constipation, dry mouth, nausea and vomitingConstipation, diarrhoea, vomiting, dyspepsia, abdominal pain, flatulence, increased salivation
Increased sweatingItchiness of the skin
Muscle painMuscle pain
 Tiredness

Source: Escitalopram 10mg tablet SPC (Myland) & Citalopram 10mg tablet SPC (Zentiva)

Generally, both escitalopram and citalopram have similar common side effects. Some side effects, such as effect on body weight, are opposite to each other. Escitalopram can commonly cause an increase in appetite or decrease in appetite, but citalopram decreases appetite and weigh. Increase in weight is an uncommon side effect of citalopram.

Conclusion

Escitalopram and citalopram share a number of common features and belong to the same class of drugs. In the UK, sertraline and citalopram are usually prescribed in the treatment of mild to moderate depression. The main driver behind the prescribing pattern for both drugs is cost-effectiveness (the price of drug vs effectiveness) as recommended NICE, by NICE. As discussed in this post, evidence from multiple trials exists, which describes escitalopram as a more effective antidepressant than citalopram.

References

Auquier P, Robitail S, Llorca PM, Rive B (2003). Comparison of escitalopram and citalopram efficacy: A meta-analysis. Int J Psychiatry Clin Pract. 2003;7(4):259-68. doi: 10.1080/13651500310003408. PMID: 24930412. Available at: https://doi.org/10.1080/13651500310003408 Accessed on 23/11/2020

Cipriani A, Purgato M, Furukawa TA, et al. citalopram versus other anti-depressive agents for depression. Cochrane Database Syst Rev. 2012;7(7):CD006534. Published 2012 Jul 11. doi:10.1002/14651858.CD006534.pub2 Available at: https://dx.doi.org/10.1002%2F14651858.CD006534.pub2 Accessed on 23/11/2020

NICE (2015). First-choice antidepressant use in adults with depression or generalised anxiety disorder. Available at: https://www.nice.org.uk/advice/ktt8/chapter/evidence-context Accessed on 23/11/2020

I am a community pharmacist working in UK. I blog about drugs, health and pharmacy.

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