What is the recommended dosing for Lexapro (escitalopram)?

Lexapro (Escitalopram) Dosing Guidelines

For adults with depression, Lexapro should be started at 10 mg once daily, with potential increase to 20 mg daily after at least one week if needed. 1

Adult Dosing

Major Depressive Disorder

• Initial dose: 10 mg once daily
• Maximum dose: 20 mg once daily
• Timing: Can be taken morning or evening, with or without food
• Dose adjustment: If increasing to 20 mg, wait at least one week after starting treatment 1
• Maintenance: Continue treatment for several months beyond acute response; periodic reassessment recommended 1

Generalized Anxiety Disorder

• Initial dose: 10 mg once daily
• Maximum dose: 20 mg once daily
• Dose adjustment: If increasing to 20 mg, wait at least one week after starting treatment 1
• Duration: Efficacy beyond 8 weeks has not been systematically studied 1

Special Populations

Elderly Patients

• Recommended dose: 10 mg once daily 1
• Rationale: Lower doses recommended due to greater risk of adverse drug reactions 2

Hepatic Impairment

• Recommended dose: 10 mg once daily 1
• Caution: Escitalopram should be used with caution in patients with severe hepatic impairment 1

Renal Impairment

• Mild to moderate impairment: No dosage adjustment necessary
• Severe impairment: Use with caution 1

Therapeutic Plasma Concentration

• Recommended therapeutic range: 15-80 ng/mL 2
• Level of recommendation: 4 (probably useful) 2

Discontinuation

• Method: Gradual dose reduction rather than abrupt cessation
• Monitoring: Watch for discontinuation symptoms (dizziness, sensory disturbances, sleep disturbances, agitation, anxiety, nausea, headache) 1
• Management: If intolerable symptoms occur during dose reduction, consider resuming previous dose and decreasing more gradually 1

Important Precautions

• Screen for bipolar disorder prior to initiating treatment 1
• Drug interactions: Allow at least 14 days between discontinuing MAOIs and starting escitalopram, and vice versa 1
• Serotonin syndrome risk: Avoid concurrent use with other serotonergic drugs including linezolid or methylene blue 1

Clinical Pearls

• Fixed-dose trials demonstrated effectiveness of both 10 mg and 20 mg doses, but failed to show greater benefit of 20 mg over 10 mg in depression 1
• Escitalopram is well tolerated with lower rates of discontinuation due to adverse events compared to some other antidepressants 2
• Common adverse events include nausea, insomnia, ejaculation disorder, diarrhea, dry mouth, and somnolence 3
• Escitalopram has linear pharmacokinetics with a half-life of 27-32 hours, consistent with once-daily dosing 3
• For anxiety disorders, escitalopram has shown efficacy at 10-20 mg/day with significant improvements often seen within 1-2 weeks 4

Remember that proper dosing is crucial for optimizing treatment outcomes while minimizing adverse effects. The FDA-approved dosing guidelines should be followed for best results in terms of morbidity, mortality, and quality of life outcomes.