Escitalopram (Lexapro) Dosing for Anxiety Disorders
For anxiety disorders, escitalopram should be initiated at 10 mg once daily, with potential increase to 20 mg after a minimum of one week if needed for optimal symptom control. 1
Initial Dosing and Titration
- Starting dose: 10 mg once daily (morning or evening, with or without food) 1
- Dose adjustment: If insufficient response after at least one week, may increase to 20 mg once daily 1
- Administration: Can be taken in the morning or evening, with or without food 1
Specific Anxiety Disorder Considerations
Generalized Anxiety Disorder (GAD)
- FDA-approved starting dose: 10 mg once daily 1
- Efficacy has been demonstrated at both 10 mg and 20 mg daily doses 2, 3
- Studies show 10 mg may be as effective as 20 mg for most patients, with 20 mg not consistently showing superior efficacy 2
- Treatment effect can begin as early as 1-2 weeks but full response may take 4-8 weeks 3
Social Anxiety Disorder
- Effective dose range: 5-20 mg daily 4
- All doses (5 mg, 10 mg, and 20 mg) have shown efficacy compared to placebo 4
- Long-term treatment (24 weeks) shows continued improvement in symptoms 4
Special Populations
- Elderly patients: Recommended dose is 10 mg/day 1
- Hepatic impairment: Recommended dose is 10 mg/day 1
- Renal impairment:
- Mild to moderate: No dosage adjustment necessary
- Severe: Use with caution 1
Monitoring and Management
- Assess response after 1-2 weeks of treatment
- Allow at least 4-8 weeks at therapeutic dose to evaluate full efficacy
- Monitor for common side effects: nausea, headache, somnolence, sexual dysfunction, dry mouth, constipation, dizziness, and sweating
Discontinuation
- Never discontinue abruptly due to risk of withdrawal symptoms 1
- Implement gradual dose reduction when discontinuing treatment
- If intolerable symptoms occur during discontinuation, consider resuming the previously prescribed dose and then decrease more gradually 1
Important Considerations and Precautions
- Screen for bipolar disorder prior to initiating treatment to avoid precipitating mania 1
- Do not use concurrently with MAOIs or within 14 days of stopping/starting an MAOI 1
- For acute anxiety symptoms while waiting for escitalopram to take effect, short-term use of benzodiazepines may be considered, but should be limited to 2-4 weeks due to dependence risk 5
- Maintenance treatment should be periodically reassessed for continued necessity 1
Clinical Pearls
- Escitalopram has demonstrated efficacy across multiple anxiety disorders including GAD, social anxiety disorder, panic disorder, and OCD 6
- The 10 mg dose is often sufficient for most patients with anxiety disorders, with limited additional benefit from higher doses in many cases 2
- Escitalopram has a favorable side effect profile compared to some other SSRIs, making it a good first-line option for anxiety disorders 6