Is Lexapro (escitalopram) 10 mg twice a day a safe and effective dose?

Lexapro (Escitalopram) Dosing: 10 mg Twice Daily is Not a Standard Recommended Regimen

Lexapro (escitalopram) 10 mg twice daily is not a standard recommended dosing regimen and exceeds the typical daily dosage recommendations for most indications.

Standard Dosing for Escitalopram

The standard dosing for escitalopram according to clinical guidelines is:

• Initial dose: 10 mg once daily
• Maintenance dose: 10-20 mg once daily
• Maximum dose: 20 mg daily 1

Specific Dosing by Indication

• Depression: 10 mg once daily initially, may increase to 20 mg once daily after at least one week 2, 3
• Anxiety disorders: 10 mg once daily initially, may increase to 20 mg once daily if needed 4

Why 10 mg Twice Daily is Problematic

1. Exceeds maximum recommended daily dose: The 20 mg total daily dose (10 mg twice daily) exceeds the standard starting dose and immediately puts patients at higher risk for side effects

2. Pharmacokinetic considerations: Escitalopram has a long half-life of 27-33 hours, making once-daily dosing appropriate and sufficient for therapeutic effect 5

3. Increased side effect risk: Higher doses increase the likelihood of adverse effects including:

   • Nausea
   • Insomnia
   • Ejaculation disorder
   • Diarrhea
   • Dry mouth
   • Somnolence 2

Appropriate Dosing Algorithm

1. Start with 10 mg once daily (morning or evening)
2. Assess response after 1-4 weeks
3. If inadequate response and good tolerability: Consider increasing to 20 mg once daily
4. If side effects occur: Consider reducing to 5 mg once daily initially, then titrating up as tolerated

Special Considerations

• Elderly patients: Start with 5 mg once daily, maximum 10 mg once daily 5
• Hepatic impairment: Start with 5 mg once daily, titrate cautiously 5
• Drug interactions: Monitor for potential interactions with other medications that may affect CYP2C19, CYP2D6, or CYP3A4 enzymes 5

Clinical Pearls and Pitfalls

• Common pitfall: Splitting the daily dose does not improve efficacy but may increase side effects
• Important caveat: Abrupt discontinuation can lead to withdrawal symptoms; always taper gradually over 10-14 days when discontinuing 1
• Monitoring: Assess for clinical improvement and side effects regularly during the first few weeks of treatment
• Warning: Escitalopram, like other SSRIs, carries a black box warning for increased risk of suicidal thoughts and behaviors, particularly in young adults and adolescents

In conclusion, the appropriate dosing for escitalopram is 10-20 mg once daily, not 10 mg twice daily. If a patient requires higher doses, it's better to increase to 20 mg once daily rather than splitting the dose.