Lexapro (Escitalopram) Dosing and Side Effect Management
For adults with depression, Lexapro should be started at 10 mg once daily and may be increased to 20 mg after one week if needed, with most side effects being manageable through timing adjustments, dose modifications, and supportive care. 1
Recommended Dosing
Major Depressive Disorder
Adults:
Adolescents (12-17 years):
- Initial dose: 10 mg once daily
- Maximum dose: 20 mg once daily
- Dose increases should occur after minimum of three weeks 1
Generalized Anxiety Disorder
- Adults:
- Initial dose: 10 mg once daily
- Maximum dose: 20 mg once daily
- Dose increases should occur after minimum of one week 1
Special Populations
- Elderly patients: 10 mg/day recommended
- Hepatic impairment: 10 mg/day recommended
- Renal impairment: No dosage adjustment for mild/moderate impairment; use with caution in severe impairment 1
Administration
- Can be taken morning or evening
- Can be taken with or without food
- Administer once daily 1
Common Side Effects and Management
Gastrointestinal
Nausea (25%):
- Take with food
- Consider temporary dose reduction if severe
- Usually improves within 1-2 weeks
Diarrhea (25%):
- Ensure adequate hydration
- Take with food
- Usually self-limiting
Vomiting:
- Take with food
- Consider temporary dose reduction
Neurological/Psychiatric
Headache (35%):
- Use appropriate analgesics
- Usually diminishes with continued treatment
Insomnia/somnolence:
- For insomnia: Take in morning
- For somnolence: Take in evening
- Avoid alcohol
Dizziness:
- Rise slowly from sitting/lying positions
- Ensure adequate hydration
Anxiety/agitation:
- May occur initially and typically subsides
- Consider temporary dose reduction if severe
Sexual Dysfunction
- Decreased libido, delayed orgasm, erectile dysfunction:
- Discuss openly with patient
- Consider dose reduction if significant impact on quality of life
- Document sexual function before starting treatment to establish baseline 1
Other
- Weight changes:
- Monitor weight regularly
- Encourage healthy diet and exercise
Discontinuation Management
- Never discontinue abruptly
- Implement gradual dose reduction (taper) over 10-14 days to limit withdrawal symptoms 2, 1
- If withdrawal symptoms occur (dizziness, sensory disturbances, anxiety, irritability, insomnia):
- Resume previous dose
- Decrease at a more gradual rate 1
Important Precautions and Monitoring
Drug Interactions
- MAOIs: Allow 14 days between stopping MAOI and starting escitalopram (and vice versa) 1
- Anticoagulants/NSAIDs/Aspirin: Increased risk of bleeding 1
- Linezolid/Methylene blue: Risk of serotonin syndrome 1
Special Warnings
- Suicidality: Monitor closely, especially in adolescents and young adults
- Serotonin syndrome: Watch for agitation, hallucinations, rapid heart rate, fever, excessive sweating, shivering, tremor
- Hyponatremia: Monitor elderly patients for signs (headache, difficulty concentrating, memory impairment, confusion, weakness)
- Angle-closure glaucoma: Risk of acute attack in anatomically narrow angles 1
Duration of Treatment
- For major depression: Continue for several months beyond acute response
- Periodically reassess need for maintenance treatment 1
- For generalized anxiety disorder: Efficacy beyond 8 weeks not systematically studied 1
Escitalopram's pharmacokinetic profile shows it reaches maximum plasma concentrations in 3-4 hours, with a half-life of 27-33 hours, supporting once-daily dosing. Steady-state concentrations are achieved within 7-10 days 3.