What is the recommended dosing of escitalopram (Selective Serotonin Reuptake Inhibitor - SSRI) in the elderly population?

From the Guidelines

Escitalopram dosing in elderly patients should typically start at 5 mg once daily, which is half the usual adult starting dose, to minimize the risk of adverse effects such as QT prolongation, hyponatremia, and falls. After 1-2 weeks of treatment, if the medication is well-tolerated but not sufficiently effective, the dose may be increased to 10 mg daily 1. The maximum recommended dose for elderly patients is generally 10 mg daily, rather than the 20 mg maximum used in younger adults, due to decreased hepatic metabolism and renal clearance associated with aging, leading to higher blood levels of the medication and increased risk of side effects 1.

Key Considerations

• Elderly patients are more susceptible to adverse effects, and regular monitoring for side effects, particularly during the initial weeks of treatment and after dose increases, is essential 1.
• When discontinuing escitalopram, the dose should be tapered gradually over at least 2 weeks to minimize withdrawal symptoms.
• Escitalopram should be taken at the same time each day, with or without food, to maintain consistent blood levels.
• A study published in the European Heart Journal found that selective serotonin re-uptake inhibitors (SSRI) and serotonin–norepinephrine reuptake inhibitors (SNRI) are widely used, but may have a QT-interval prolonging effect, especially in elderly patients 1.

Dosing Recommendations

• Start with 5 mg once daily and increase to 10 mg daily if necessary and well-tolerated.
• Do not exceed 10 mg daily in elderly patients.
• Monitor for side effects and adjust dosing accordingly.
• Taper dose gradually when discontinuing escitalopram to minimize withdrawal symptoms.

From the FDA Drug Label

2.4 Special Populations 10 mg/day is the recommended dose for most elderly patients and patients with hepatic impairment.

8.5 Geriatric Use 10 mg/day is the recommended dose for elderly patients [see Dosage and Administration (2.3)].

Age Elderly - Escitalopram pharmacokinetics in subjects ≥ 65 years of age were compared to younger subjects in a single-dose and a multiple-dose study. Escitalopram AUC and half-life were increased by approximately 50% in elderly subjects, and Cmax was unchanged. 10 mg is the recommended dose for elderly patients [see Dosage and Administration (2.3)].

The recommended dose of escitalopram for elderly patients is 10 mg/day 2, 2, 2.

From the Research

Escitalopram Dosing in Elderly

• The study 3 examined the efficacy and tolerability of escitalopram in elderly patients with major depressive disorder (MDD) and found that escitalopram was well tolerated by elderly patients with a dose of 10 mg/day.
• The mean age of the patients in the study 3 was 75 years, with a range of 65 to 93, indicating that escitalopram can be used in elderly patients.
• There is no specific information on dosing adjustments for elderly patients in the other studies 4, 5, 6, 7, but it is generally recommended to start with a lower dose and adjust as needed due to potential age-related changes in drug metabolism and sensitivity.
• The study 3 did not demonstrate superior efficacy of escitalopram over placebo in elderly patients, but it did show that escitalopram was well tolerated and had a similar efficacy profile to fluoxetine.

Comparison with Other Antidepressants

• The study 6 compared escitalopram with other antidepressants, including SSRIs, and found that escitalopram was more effective than citalopram and fluoxetine in achieving acute response and remission.
• The study 5 compared escitalopram with paroxetine and sertraline and found that escitalopram had a more favorable tolerability profile and was more effective than paroxetine.
• The study 7 compared the effectiveness of second-generation antidepressants, including escitalopram, for accompanying anxiety, insomnia, and pain in depressed patients and found that the evidence guiding the selection of an SGA based on accompanying symptoms of depression is limited.

Tolerability and Safety

• The study 3 found that escitalopram was well tolerated by elderly patients, with no single adverse event occurring at an incidence of 10% or more.
• The study 4 discussed the potential side effects of SSRIs, including initial lack of response to treatment, drowsiness, nausea, and sexual dysfunction, but did not provide specific information on escitalopram.
• The study 5 found that escitalopram had a more favorable tolerability profile compared to paroxetine, which was associated with cholinergic muscarinic antagonism and potent inhibition of CYP2D6.