Lexapro (Escitalopram) Dosing Guidelines
For most adults with depression or anxiety, Lexapro (escitalopram) should be started at 10 mg once daily, with the option to increase to 20 mg after at least one week if needed. 1
Initial Dosing for Different Conditions
Major Depressive Disorder (MDD)
- Adults: 10 mg once daily
- May increase to 20 mg after minimum of one week
- Clinical trials showed both 10 mg and 20 mg are effective, but failed to demonstrate greater benefit of 20 mg over 10 mg 1
- Adolescents: 10 mg once daily
- May increase to 20 mg after minimum of three weeks 1
Generalized Anxiety Disorder (GAD)
- Adults: 10 mg once daily
- May increase to 20 mg after minimum of one week 1
- Efficacy beyond 8 weeks has not been systematically studied
Social Anxiety Disorder
- 10-20 mg daily has shown efficacy in controlled studies 2
- Maintenance treatment reduces risk of relapse compared to placebo
Special Populations
- Elderly patients: 10 mg/day is recommended 1
- Hepatic impairment: 10 mg/day is recommended 1
- Renal impairment:
- Mild to moderate: No dosage adjustment necessary
- Severe: Use with caution 1
Administration Guidelines
- Administer once daily, in the morning or evening
- Can be taken with or without food 1
- For optimal outcomes, maintain treatment for at least 4-12 months after first episode of depression 3
Maintenance Treatment
- For MDD: Systematic evaluation has demonstrated benefit of continuing escitalopram 10 or 20 mg/day in patients who responded during acute treatment 1
- Patients with recurrent depression may benefit from prolonged treatment, as the risk of recurrence increases with each episode (50% after first episode, 70% after second, 90% after third) 3
- Periodic reassessment is recommended to determine continued need for maintenance treatment 1
Discontinuation
- Gradual dose reduction rather than abrupt cessation is recommended
- Monitor for discontinuation symptoms (dizziness, sensory disturbances, anxiety, etc.)
- If intolerable symptoms occur during discontinuation, consider resuming the previously prescribed dose and decreasing more gradually 1
Safety Considerations
- Screen for bipolar disorder prior to initiating treatment 1
- Allow at least 14 days between discontinuing MAOIs and starting escitalopram (and vice versa) 1
- Do not use escitalopram with linezolid or intravenous methylene blue due to risk of serotonin syndrome 1
Efficacy and Tolerability
- Long-term studies (12 months) show favorable safety and tolerability profile with continued improvement in patient response 4
- In elderly patients with comorbid depression and anxiety, escitalopram 10-20 mg/day has shown significant improvements in both conditions 5
- Higher doses (above 20 mg) have been studied in treatment-resistant depression, with some patients requiring up to 50 mg to achieve remission, but tolerability may decline above 40 mg 6
Common Side Effects
- Headache, nausea, diarrhea, and nasopharyngitis are most common (25-35% incidence) 6
- Side effects tend to decrease over time with continued treatment 4
Remember that while higher doses (above 20 mg) have been studied in research settings, the FDA-approved maximum dose is 20 mg daily, and doses above this level would be considered off-label use.