What is the recommended dosing for Lexapro (escitalopram)?

Recommended Dosing for Escitalopram (Lexapro)

The recommended dosing for escitalopram (Lexapro) is 10 to 20 mg once daily, with 10 mg being the standard starting dose for most adults. 1

Initial Dosing

• Standard adult starting dose: 10 mg once daily 1
• Administration: Can be taken in the morning or evening, with or without food 1
• Special populations requiring lower dosing:
  • Elderly patients: 10 mg/day recommended 1
  • Patients with hepatic impairment: 10 mg/day recommended 1
  • Patients with severe renal impairment: Use with caution 1

Dose Titration

• If increasing to 20 mg, this should occur after a minimum of one week on the 10 mg dose 1
• A fixed-dose trial demonstrated effectiveness of both 10 mg and 20 mg doses, but failed to demonstrate a greater benefit of 20 mg over 10 mg for most patients 1

Dosing by Indication

Major Depressive Disorder

• Starting dose: 10 mg once daily 1
• Maximum dose: 20 mg once daily 1
• Maintenance treatment: Continue at effective dose (10-20 mg) 1, 2
• Duration: Several months or longer of sustained therapy beyond acute response is generally recommended 1

Generalized Anxiety Disorder

• Starting dose: 10 mg once daily 1
• Maximum dose: 20 mg once daily 1
• Duration: Efficacy beyond 8 weeks has not been systematically studied, but periodic reassessment is recommended 1

Assessing Response

• Evaluate efficacy and tolerability at least monthly for the first 3 months and at least quarterly thereafter 3
• Early responders (typically defined as >5% improvement after 3 months) tend to have better long-term outcomes 3
• If insufficient response after 3 months, consider alternative treatment options 3

Discontinuation

• Gradual dose reduction rather than abrupt cessation is recommended to minimize discontinuation symptoms 1
• If intolerable symptoms occur during discontinuation, resuming the previously prescribed dose may be considered, followed by a more gradual taper 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
• Common side effects include headache (11-17%), back pain, upper respiratory tract infection, rhinitis, and nausea 2
• Long-term studies (12 months) have shown favorable safety and tolerability profiles with continued improvement in patient response 2

Higher Doses

While the FDA-approved maximum dose is 20 mg daily, some research suggests that doses up to 50 mg may benefit certain treatment-resistant patients, though tolerability appears to decline above 40 mg 4. However, these higher doses are not FDA-approved and should be considered only in specialized settings with close monitoring.

Monitoring

• Regular reassessment to determine continued need for maintenance treatment 1
• Monitor for emergence of serotonin syndrome, especially if combined with other serotonergic agents 1
• Be vigilant for emergence of suicidal thoughts, particularly in younger patients 3

Escitalopram has demonstrated efficacy in both short-term and long-term treatment of depression and anxiety disorders, with a generally favorable side effect profile compared to other antidepressants.