What is the recommended dosing for Lexapro (escitalopram)?

Recommended Dosing for Lexapro (Escitalopram)

The recommended initial dose of Lexapro (escitalopram) is 10 mg once daily, with potential increase to 20 mg once daily after a minimum of one week if clinically indicated. 1

Standard Dosing Guidelines

Major Depressive Disorder

• Adults:

  • Initial dose: 10 mg once daily
  • Maximum dose: 20 mg once daily
  • Dose increases should occur after a minimum of one week 1
  • A fixed-dose trial demonstrated effectiveness of both 10 mg and 20 mg, but failed to show greater benefit of 20 mg over 10 mg 1

• Adolescents:

  • Initial dose: 10 mg once daily
  • Maximum dose: 20 mg once daily
  • Dose increases should occur after a minimum of three weeks 1

Generalized Anxiety Disorder

• Initial dose: 10 mg once daily
• Maximum dose: 20 mg once daily
• Dose increases should occur after a minimum of one week 1

Special Populations

• Elderly patients: 10 mg/day is the recommended dose 1
• Hepatic impairment: 10 mg/day is the recommended dose 1
• Renal impairment:
  • Mild to moderate: No dosage adjustment necessary
  • Severe: Use with caution 1

Administration Guidelines

• Can be taken in the morning or evening
• Can be taken with or without food 1
• Tablets should be swallowed whole

Treatment Duration

• Acute episodes of major depressive disorder require several months or longer of sustained pharmacological therapy beyond response to the acute episode
• Maintenance treatment has demonstrated benefit in patients who responded during acute treatment 1
• For generalized anxiety disorder, efficacy beyond 8 weeks has not been systematically studied 1
• Patients should be periodically reassessed to determine the need for continued treatment 1

Discontinuation

• Gradual reduction in dose rather than abrupt cessation is recommended
• Monitor for discontinuation symptoms (irritability, agitation, dizziness, sensory disturbances, anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania)
• If intolerable symptoms occur during discontinuation, consider resuming the previously prescribed dose and decreasing at a more gradual rate 1

Higher Dose Considerations

While the FDA-approved maximum dose is 20 mg daily, some research suggests potential benefit from higher doses in treatment-resistant cases. In one open-label pilot study, doses up to 50 mg were used for patients who had not responded to adequate treatment with citalopram, with 35% achieving remission. However, tolerability appeared to decline above 40 mg, with 26% of patients unable to tolerate 50 mg 2.

Comparative Efficacy

Fixed-dose escitalopram at 10 mg/day has shown comparable efficacy to flexibly dosed sertraline (50-200 mg/day) in the treatment of major depressive disorder, with similar response rates (75% vs 70%) 3.

Common Side Effects

• Headache (35%)
• Nausea (25%)
• Diarrhea (25%)
• Nasopharyngitis (25%) 2
• Sexual dysfunction

Important Precautions

• Screen for bipolar disorder prior to initiating treatment 1
• Allow at least 14 days between discontinuing MAOIs and starting escitalopram, or between stopping escitalopram and starting an MAOI 1
• Do not use with linezolid or intravenous methylene blue due to risk of serotonin syndrome 1

By following these dosing guidelines and monitoring for efficacy and side effects, escitalopram can be effectively used to treat major depressive disorder and generalized anxiety disorder with optimal outcomes for morbidity, mortality, and quality of life.