Duloxetine (Cymbalta) vs Escitalopram (Lexapro)

Based on "Essential Psychopharmacology"
written by Stephen M. Stahl, MD, PhD

Escitalopram advantages over Duloxetine

Generally escitalopram is better tolerated than duloxetine3.
Escitalopram does not cause high blood pressure or urinary retention.
Safe for patients with elevated intraocular pressure and glaucoma.
Escitalopram has low potential for drug interactions. Duloxetine can produce significant changes in pharmacokinetics of medications metabolized by cytochrome P450 2D6 enzyme2.

Duloxetine advantages over Escitalopram

Incidence of antidepressant-induced sexual side effects is somewhat lower with duloxetine1. Escitalopram is associated with more frequent sexual problems.
Duloxetine is useful for patients with concomitant chronic pain syndromes.

Duloxetine	Escitalopram
Brand names
• Cymbalta®	Lexapro®
Drug class
Antidepressant, Serotonin-norepinephrine reuptake inhibitor	Antidepressant, Selective Serotonin Reuptake Inhibitor
Mechanism of action
• Escitalopram is the most selective serotonin reuptake inhibitor antidepressant. In contrast, duloxetine inhibits both serotonin and norepinephrine reuptake.
FDA-approved indications
• Major depression • Generalized anxiety disorder
• Social anxiety disorder • Chronic musculoskeletal pain • Fibromyalgia • Diabetic peripheral neuropathic pain
Contraindications
• Use of Monoamine Oxidase Inhibitors
• Hypersensitivity to duloxetine • Uncontrolled narrow-angle glaucoma (risk of increased intraocular pressure)	• Hypersensitivity to escitalopram
Side effects
• Nausea • Dry mouth • Somnolence • Constipation • Decreased appetite • Excessive sweating • Urinary retention	• Nausea • Insomnia • Delayed ejaculation • Increased sweating • Fatigue • Somnolence • Decreased libido

Duloxetine vs Escitalopram for Depression

Escitalopram may be superior to duloxetine in the treatment of major depression and at least as effective and better tolerated in long-term treatment of major depressive disorder4. Withdrawal due to the side effects occurs more frequently with duloxetine6.

Results of the study comparing escitalopram versus duloxetine in major depressive disorder4	Duloxetine	Escitalopram
Regimen	60 mg/day for 24 weeks	20 mg/day for 24 weeks
Mean change from baseline in total MADRS score at week 8	-17.4	-19.5
Proportion of responders at week 8	58%	69%
Mean change from baseline in total MADRS score at week 24	-21.7	-23.4
Withdrawal rates due to side effects	17%	9%
Adverse events: - insomnia - constipation	12.6% 8.6%	4.9% 2.8%

Results of randomized, double-blind, placebo-controlled trial in patients with major depressive disorder5	Duloxetine	Escitalopram
Regimen	120 mg/day for 8 months	20 mg/day for 8 months
Probability of remission at 8 months	70%	75%
Sleep improvement		escitalopram had a statistically significant advantage over duloxetine in improving sleep.
Rates of discontinuation due to side effects	12.8%	12.0%
Adverse events	tended to emerge early in treatment (e.g., nausea, dry mouth)	tended to emerge later in treatment (e.g., diarrhea, weight increase)
Mean changes from baseline to study endpoint for:
pulse	+3.05 beats per minute	-0.89 beats per minute
systolic blood pressure	+3.73 mmHg	+0.31 mmHg
diastolic blood pressure	+0.81	-0.24
Change in weight	+0.61 kg	+1.83 kg

Duloxetine vs Escitalopram for Low back pain

Duloxetine is licensed for chronic musculoskeletal pain. Escitalopram is not indicated for the treatment of chronic pain states.

One study demonstrated that both escitalopram and duloxetine are useful for patients suffering from chronic low back pain 7.

References

1. Clayton A, Kornstein S, Prakash A, Mallinckrodt C, Wohlreich M. Changes in sexual functioning associated with duloxetine, escitalopram, and placebo in the treatment of patients with major depressive disorder. J Sex Med. 2007 Jul;4(4 Pt 1):917-29. PubMed
2. Preskorn SH, Greenblatt DJ, Flockhart D, Luo Y, Perloff ES, Harmatz JS, Baker B, Klick-Davis A, Desta Z, Burt T. Comparison of duloxetine, escitalopram, and sertraline effects on cytochrome P450 2D6 function in healthy volunteers. J Clin Psychopharmacol. 2007 Feb;27(1):28-34.
3. Khan A, Bose A, Alexopoulos GS, Gommoll C, Li D, Gandhi C. Double-blind comparison of escitalopram and duloxetine in the acute treatment of major depressive disorder. Clin Drug Investig. 2007;27(7):481-92.
4. Wade A, Gembert K, Florea I. A comparative study of the efficacy of acute and continuation treatment with escitalopram versus duloxetine in patients with major depressive disorder. Curr Med Res Opin. 2007 Jul;23(7):1605-14. PubMed
5. Pigott TA, Prakash A, Arnold LM, Aaronson ST, Mallinckrodt CH, Wohlreich MM. Duloxetine versus escitalopram and placebo: an 8-month, double-blind trial in patients with major depressive disorder. Curr Med Res Opin. 2007 Apr 27. PubMed
6. Khan A, Bose A, Alexopoulos GS, Gommoll C, Li D, Gandhi C. Double-blind comparison of escitalopram and duloxetine in the acute treatment of major depressive disorder.Clin Drug Investig. 2007;27(7):481-92. PubMed
7. Mazza M, Mazza O, Pazzaglia C, Padua L, Mazza S. Escitalopram 20 mg versus duloxetine 60 mg for the treatment of chronic low back pain. Expert Opin Pharmacother. 2010 May;11(7):1049-52.