What would you do with a patient on Lexapro (escitalopram) 20mg?

Management of Patient on Lexapro (Escitalopram) 20mg

For a patient on Lexapro (escitalopram) 20mg, maintain this dose if it is effective and well-tolerated, as it is the maximum recommended dose with proven efficacy for depression and anxiety disorders.

Efficacy and Dosing Considerations

Escitalopram is an effective selective serotonin reuptake inhibitor (SSRI) with FDA approval for treatment of major depressive disorder and generalized anxiety disorder. The FDA label indicates:

• 10mg is the recommended starting dose for most adults
• 20mg is the maximum recommended dose
• Dose increases should occur after a minimum of one week 1

The efficacy of escitalopram has been established in multiple clinical trials:

• Fixed-dose studies showed both 10mg and 20mg are effective for depression, though 20mg did not demonstrate greater benefit than 10mg in some trials 1
• For social anxiety disorder, a Japanese study found that 20mg showed statistically significant improvement compared to placebo in post-hoc analyses 2

Duration of Treatment

For patients responding well to escitalopram 20mg:

• For depression: Maintenance treatment beyond the acute phase is recommended. Studies demonstrate that continued escitalopram treatment significantly reduces relapse risk compared to switching to placebo 3, 4
• For anxiety disorders: Long-term treatment (24 weeks or longer) has shown continued efficacy with significantly lower relapse rates compared to placebo 5

The FDA label states: "Patients should be periodically reassessed to determine the need for maintenance treatment" 1

Monitoring for Adverse Effects

Common adverse effects to monitor include:

• Diarrhea, dizziness, dry mouth, fatigue, headache, sexual dysfunction, sweating, tremor, and weight gain
• Nausea and vomiting (most common reasons for discontinuation) 2

More serious adverse effects to watch for:

• Serotonin syndrome (especially if combined with other serotonergic medications)
• QT prolongation (particularly in elderly or those with cardiac conditions)
• Increased risk of suicidal thoughts and behaviors, especially in young adults 2

Special Populations

Dose adjustments may be necessary for:

• Elderly patients: 10mg/day is the recommended dose
• Patients with hepatic impairment: 10mg/day is recommended
• No dosage adjustment is necessary for mild to moderate renal impairment 1

The American Family Physician guidelines note that preferred agents for older patients with depression include escitalopram, with paroxetine and fluoxetine generally avoided due to higher rates of adverse effects 2

Discontinuation Considerations

If discontinuation is planned:

• Implement gradual dose reduction rather than abrupt cessation
• Monitor for discontinuation symptoms (dizziness, sensory disturbances, anxiety, sleep disturbances)
• If intolerable symptoms occur, resume the previously prescribed dose and decrease more gradually 1

Clinical Pitfalls to Avoid

1. Abrupt discontinuation: Always taper escitalopram to avoid withdrawal symptoms
2. Overlooking drug interactions: Be cautious with concomitant medications that may interact with escitalopram, particularly MAOIs (require 14-day washout period) 1
3. Missing bipolar disorder: Screen for bipolar disorder before continuing treatment, as antidepressants can precipitate mania 1
4. Inadequate duration of treatment: Continuing treatment beyond acute symptom resolution is crucial for preventing relapse 3, 4

Remember that escitalopram 20mg is the maximum recommended dose, and maintaining this dose is appropriate if the patient is responding well without significant adverse effects.