Bilateral peripheral edema as a rare adverse effect of escitalopram.

Sir,

Peripheral edema has been reported as an adverse effect of antibiotics, non-steroidal anti-inflammatory drugs, anti-hypertensive drugs, anti-cancer drugs and others.[1] In psychiatry, peripheral edema has been reported with antipsychotic drugs such as risperidone,[2] olanzapine[3] and quetiapine;[4] with antidepressants such as mirtazapine[5] and trazodone;[6] with anxiolytics such as pregabalin;[7] etc. We herein report a rare case of bilateral peripheral pedal edema with escitalopram.

A 71-year-old woman presented with a progressively worsening, 6-month history of depression, anxiety, loss of confidence and self-esteem, loss of interest, diminished energy, loss of appetite, early and middle insomnia and other symptoms that met ICD-10 criteria for a moderate depressive episode with somatic symptoms. For at least the past 6 months, she had been receiving warfarin and bisoprolol for the management of atrial fibrillation and paroxysmal supraventricular tachycardia.

Physical examination was within the normal limits. Baseline hematological, lipid, renal, thyroid, nutritional and other laboratory profiles were also all within the normal limits; however, her hemoglobin level was 9.8 g/dL.

She was advised escitalopram (10 mg/day) and clonazepam (0.75 mg/day). She returned, 13 days later, with mild, bilateral pedal edema of 4 days duration. Echocardiography and renal function tests (including serum electrolytes) were within the normal limits; no cause for the edema was found. The edema worsened across the next 5 days. Escitalopram was tapered and withdrawn, but clonazepam was continued at 0.5 mg/day. The edema remitted within 10 days of discontinuation of escitalopram.

A PubMed search (conducted on December 2, 2013) using the terms “citalopram” and “escitalopram” with “edema” identified only one case report associating escitalopram monotherapy (30 mg/day) with bilateral ankle edema in a 69-year-old depressed woman; the edema developed after a month of treatment and resolved within a week of drug discontinuation.[8] In our patient, the edema developed after only 9 days of treatment and on a dose of just 10 mg/day. A PubMed search conducted on the same day found no association of fluoxetine, sertraline, paroxetine, or fluvoxamine with peripheral edema.

Mechanisms of drug-induced edema include sodium overload, renal dysfunction and vascular hyperpermeability.[1] The first two were excluded by the normal results of laboratory investigations. It is possible that the strong serotonergic effect of escitalopram was idiosyncratically associated with increased vascular permeability in our patient. We conclude that peripheral edema may be a rare, dose-independent and rapidly reversible adverse effect of escitalopram.