Anup J. et al. J Sci Res Pharm, 2017;6(12):147-149

© 2012, JSRP. All Rights Reserved http://www.worldinventiapublishers.com/

World Inventia Publishers

Journal of Scientific Research in Pharmacy http://www.jsrponline.com/

Vol. 6, Issue 12, 2017 ISSN: 2277-9469

USA CODEN: JSRPCJ

Case Report

ESCILATOPRAM INDUCED EMESIS, WORD FINDING DIFFICULTY AND HYPONATREMIA: A CASE REPORT

Anup Jagarlamudi *, Asma Begum, and Mahalakshmi Teegala Department of Clinical Pharmacy Practice, Pullareddy Institute of Pharmacy, Hyderabad, Telangana, INDIA .

Received on: 29-11-2017; Revised and Accepted on: 14-12-2017

ABSTRACT

Escilatopram is an orally administered selective serotonin reuptake inhibitor (SSRI). The ADRs associated with Escilatopram are- abnormal

bleeding, Hyponatremia, activation of Mania/Hypomania, Seizures, Interference with Cognitive and Motor Performance. Also it has got serious Drug-

Drug Interactions with a variety of drugs. A female patient of age 60 years was brought to casualty with hypertensive urgency . She was put on

metoprolol, amlodipine, telmisartan and hydrochlorthiazide combination, escilatopram and clonazepam combination, along with other drugs. On day 2

her lab reports stated dyselectrolytemia and upon analysing the prescription, it was found that there were many drug- drug interactions. By avoiding

such combination of drugs and also by choosing an appropriate antidepressant, such adverse effects could have been averted.

KEYWORDS: Escilatopram, Hyponatremia, Elderly people, Antidepressants, SSRI.

INTRODUCTION

Upon induction of escilatopram into the market, it was

thought that this compound has got less ADRs when compared to the parent compound, citalopram, but many case reports keep on appearing over the adverse effects of escilatopram, of which the most frequent ones are Hyponatremia and SIADH. We would like to report one more case of Escilatopram-induced hyponatremia, word finding difficulty and of course emesis. Recurrent vomiting was never attributed to escilatopram before, but we have got a case of recurrent vomiting along with hyponatremia and word finding difficulty.

Escilatopram is an orally administered selective serotonin reuptake inhibitor (SSRI). Escitalopram is the pure S-enantiomer (single isomer) of the racemic bicyclic phthalane derivative citalopram. Escitalopram oxalate is designated S-(+)-1-[3-(dimethyl-amino)propyl]-1-(p-fluorophenyl)-5-phthalancarbonitrile. The mechanism of antidepressant action of escitalopram, the S-enantiomer of racemic citalopram, is presumed to be linked to potentiation of serotonergic activity in the central nervous system (CNS) resulting from its inhibition of CNS neuronal reuptake of serotonin (5-HT). Escitalopram has no or very low affinity for serotonergic (5-HT1-7) or other receptors including alpha- and beta-adrenergic, dopamine (D1-5), histamine (H1-3), muscarinic (M1-5), and benzodiazepine receptors. Escitalopram also does not bind to, or has low affinity for, various ion channels including Na+ , K+ , Cl- , and Ca++ channels [1]. Escilatopram is indicated in major depressive disorder, generalised anxiety disorder and obssessive compulsive disorder in the dose of 10mg once daily and can be increased to a maximum of 20 mg once daily after at least one week. It's

*Corresponding author: Anup Jagarlamudi Assistant Professor, Department of Clinical Pharmacy Practice, Pulla reddy Institue of Pharmacy, Domadugu village, Near Annaram Air Force Academy, Jinnaram Mandal, Medak District, Telengana - 502313, INDIA. * E-Mail: anupjagarlamudi@gmail.com

DOI: https://doi.org/10.5281/zenodo.1115884

off label indications include- Hot flashes (initially 10 mg once daily then increasing the dose to 20 mg once daily after 4 weeks) and Panic disorder (initial 5mg once daily for 7 days, then increase dose to 10 mg once daily, Consider further dosage adjustments based on response and tolerability up to 20 mg once daily) [2].

Many warnings, disease related concerns and ADRs are associated with escilatopram. Major psychiatric warnings are suicidal thinking and behaviour. Disease related concerns are Cardiovascular disease, Hepatic impairment, Mania/hypomania, Metabolic disease, Renal impairment, Seizure disorders. The ADRs associated with escilatopram are many, to list a few - Abdominal cramps, abnormal gait, acute renal failure, aggressive behavior, agitated depression, hypertension, hypertensive crisis, hypoesthesia, hypoglycemia, hypokalemia, hyponatremia, hypoprothrombinemia, hypotension, serotonin syndrome, SIADH, etc [2].

Nahshoni E et al appears to be the pioneers in reporting the hyponatremic effects of ecsilatopram, followed by many [3].

Po-Hsin Tsai et al had reported recurrent hyponatremia in an elderly patient [4].

Susan Jacob et al had reported that age, female gender, concomitant use of diuretic agents, low body weight, lower baseline serum sodium concentrations are all the risk factors for development of hyponatremia with SSRIs [5].

Ho-Ming Yang et al had reported about the escitalopram-induced word finding difficulty, which may be attributed to the ADR- confusion [6].

CASE REPORT

A female patient of 60 years was brought to casualty ward

with complaints of vomiting, abdominal distension, headache, neck pain and pain in the chest (burning type). On examination the patient was conscious and coherent, pulse rate was 65, respiratory rate was 18, Blood Pressure was 180/90 and Temperature was normal and GRBS 207 mg/dl. The preliminary diagnosis was Hypertensive Urgency. Upon interviewing the patient's attendee, we came to know that the patient was just discharged from another secondary care centre and was brought to this hospital directly. The discharge medication of previous hospital included the following drugs- Tab. Prolomet-XL BD, Tab. Zofer 8 mg BD, Tab. Pan 40 mg BD, Tab. Nexito Plus H/S, Tab. Telsartan-H 40 mg OD. The lab investigations performed at the other hospital were as

Anup J. et al. J Sci Res Pharm, 2017;6(12):147-149

© 2012, JSRP. All Rights Reserved http://www.worldinventiapublishers.com/

follows-serum sodium levels were 100 mmol/L(normal range is 135-155 mmol/L), serum potassium levels were 4.8 mmol/L(normal range is 3.5-5.5.mmol/L).

In the casualty ward, the General Physician prescribed the following medications-

Inj. Pan 40 mg IV BD{pantoprazole}, Inj. Zofer 4 mg IV BD (Ondansetron), IVF- NS, RL @ 75ml/hr, Tab. Prolomet-XL 50 mg PO BD (Metoprolol), Tab. Stamlo 5 mg PO OD (Amlodipine), Tab. Telsartan-H 40 mg PO OD (Telmisartan and Hydrochlorthiazide), Syrup Sucrafil 15 ml PO TID (Sucralfate), Tab. Nexito Plus PO H/S (Escilatopram oxalate 5mg+ clonazepam 0.5mg).

And later on the same day, the general physician had also added the following medications to the already existing medications:

Inj. Xciti 500mg IV BD (Citicholine), Tab. Clopitab-A 75mg OD (clopidogrel 75mg+aspirin 75mg).

On the same day, several blood tests were performed at the present hospital and abnormalities were found in some specific investigations-

WBC-22,000; serum sodium 98mmol/L; serum potassium 4.7mmol/L; serum chloride 65mmol/L.

On the same day at around 11pm the patient started experiencing headache and her BP was 180/90, and was advised by the physician, to shift the patient to ICU and also to add the following medications in addition to the existing ones-

Tab. Depin 10mg S/L if BP˃180 (nifidepine), Infusion 3% NaCl 15ml/hr, monitor BP 2nd hourly.

On day2 the lab investigations revealed the following abnormal values-

WBC-20,500; serum sodium 97 mmol/L; serum potassium 3.2 mmol/L, serum chloride 60 mmol/L. Also the CT scan of brain reported the presence of hypodense lesions in the right parietal lobe in the white mater suggestive of INFARCTS.

On the same day the patient started experiencing recurrent vomiting and hiccups. It was observed that the BP came down to 150/80 and also the patient was feeling drowsy. The GRBS was noted to be 268mg/dL.

Nephrologist intervened and prescribed Tab. Tolvaptan 15mg OD (Tolvaptan- vasopressin antagonist).

On the same day the patient was also put on human actrapid insulin injection as per sliding scale and was also advised to take Ceftriaxone 1 g IV BD and metronidazole 500mg IV TID.

On day 3 when the patient was interviewed, she appeared to be confused and could not explain her condition or she was searching for words to describe her condition and her lab investigations reported the following-

WBC-15,100; serum potassium 2.9mmol/L; serum sodium 112mmol/L; serum chloride 67mmol/L.

Syrup Potklor 5ml TID was also added to her already existing prescription, in view of decreasing serum potassium levels. But recurrent vomiting persisted.

On day 4 the patient's BP was 130/70, GRBS was 126mg/dL, serum sodium levels were 118mmol/L, serum potassium levels were 3mmol/L, serum chloride levels were 82mmol/L and recurrent vomiting persisted.

On day 5 the lab investigations revealed that the patient's serum sodium levels were 124mmol/L,serum potassium levels were 4.1 mmol/L and serum chloride levels were 86mmol/L.

On day 6 the lab investigations revealed that the serum sodium levels were 135mmol/L and serum potassium levels were 4.5 mmol/L and serum chloride levels were 97mmol/L. Also the patient had only 1 episode of vomiting.

On day 7 the patient was discharged with the following medication-

Tab. telasrtan 80mh OD x 15 days (telmesartan), Tab. Prolomet-XL 50mg BD (Metoprolol), Tab.Stamlo 5mg OD (Amlodipine), Cap. Roler-D OD x 10 days (Rabeprazole along with Domperidone), Syrup Duphalac 15ml H/S (Lactulose), Tab. Triglimsave-2 OD (Pioglitazone15mg+Metformin 500mg+Glimepiride2mg), Suspension Sucrafil 15ml TID x1 bottle (Sucralfate), Tab. Ecosprin 75mg OD x 15 days, Tab.Xciti 500mg BD x 5 days.

The patient was advised to review after 5 days in OPD. On the day of discharge, the Clinical Pharmacist intervened

and advised the Physician to remove Escilatopram and Hydrochlorthiazide from the prescription.

DISCUSSION

Escitalopram interacts with a wide variety of drugs and

concomitant use of escitalopram is contrindicated with drugs that prolong QTc like Ondansetron [7-10]. Also CNS Depressants may enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Specifically, the risk of psychomotor impairment may be enhanced11. Selective Serotonin Reuptake Inhibitors may enhance the hyponatremic effect of Thiazide and Thiazide-Like Diuretics [11].

CONCLUSION

Escitalopram is the latest drug in SSRIs and it was thought

that this drug will be having less adverse effects when compared to the parent molecule, but many case reports keep appearing over the hyponatremic effect of escitalopram and even new side effects are being attributed to this drug, as in this case report. It appears and the even all the doctors associated with this case are of the common opinion that escitalopram is responsible for Hyponatremia and word finding difficulty and may be even responsible for Emesis in this patient. While prescribing SSRIs for the elderly, the physicians should be more cautious and should encourage monitoring of serum electrolytes more frequently and if emesis is present, should consider changing of medication to another class of drug. Also Escitalopram interacts with a wide variety of drugs, more frequently on pharmacokinetic parameters, hence extreme caution should be exercised where ever polypharmacy is unavoidable. Physicians should always remember that each and every drug has its own ADRs which are inherent to the molecule and each and every symptom that arises during therapeutic management of the patient does not require another pill.

ACKNOWLEDGEMENT

The author acknowledges the support given by the

department of Clinical pharmacy practice, Pullareddy institute of pharmacy and also the administration of Ram Dev Rao hospital, Kukkatpally, Hyderabad.

Abbreviation used: ADR - adverse drug reaction; SSRIs - selective serotonin reuptake inhibitors; SIADH - syndrome of inappropriate antidiuretic hormone; CNS - central nervous system; 5-HT - 5- hydroxy tryptamine; GRBS - general random blood sugar; ICU - intensive care unit; QTc- Q-T interval of ECG.

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Anup J. et al. J Sci Res Pharm, 2017;6(12):147-149

© 2012, JSRP. All Rights Reserved http://www.worldinventiapublishers.com/

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How to cite this article:

Anup Jagarlamudi et al. ESCILATOPRAM INDUCED EMESIS, WORD FINDING DIFFICULTY AND HYPONATREMIA: A CASE REPORT. J Sci Res Pharm 2017;6(12):147-149.

Conflict of interest: The authors have declared that no conflict of interest exists.

Source of support: Nil