Escitalopram vs. citalopram : one enantiomer’s dominance reflects marketing, not evidence

Background: Citalopram is a racemic selective serotonin reuptake inhibitor (SSRI). Its S-enantiomer, escitalopram, was introduced as an “evergreened” product to extend patent life. Despite a higher cost, escitalopram has become the most prescribed SSRI in British Columbia, largely due to marketing claims of faster onset, superior efficacy, and fewer adverse effects. This shift in prescribing occurred despite clear evidence that escitalopram is no more efficacious, nor safer, than citalopram. Aims: This Therapeutics Letter reassesses the comparative efficacy and safety of escitalopram and citalopram for treatment of major depressive disorder and anxiety disorders through a systematic review of head-to-head randomized controlled trials (RCTs). We appraised study quality, publication bias, and reported outcomes to determine whether any clinically meaningful differences in efficacy or safety justify escitalopram’s market dominance, despite its higher cost. Recommendations: A review of 17 RCTs (all at high risk of bias) showed that escitalopram has no clinically meaningful advantage over citalopram. For new prescriptions, citalopram is the recommended choice, as it is significantly less expensive. To achieve cost savings for patients, clinicians should consider switching escitalopram prescriptions to citalopram at a 2:1 equipotent dose.