What is the recommended dosing for escitalopram (Lexapro)?

Escitalopram (Lexapro) Dosing Guidelines

The recommended starting dose of escitalopram is 10 mg once daily, with the option to increase to 20 mg daily after a minimum of one week if clinically indicated. 1

Adult Dosing

Major Depressive Disorder

• Initial dose: 10 mg once daily
• Maximum dose: 20 mg once daily
• Dose adjustment timing: If needed, increase to 20 mg after minimum of one week
• Administration: Can be taken in the morning or evening, with or without food 1

Generalized Anxiety Disorder

• Initial dose: 10 mg once daily
• Maximum dose: 20 mg once daily
• Dose adjustment timing: If needed, increase to 20 mg after minimum of one week 1

Special Populations

Elderly Patients (≥65 years)

• Recommended dose: 10 mg once daily
• Caution: Lower starting doses recommended due to increased risk of side effects 1, 2

Hepatic Impairment

• Recommended dose: 10 mg once daily
• Rationale: Reduced metabolism requires lower dosing 1

Renal Impairment

• Mild to moderate impairment: No dosage adjustment necessary
• Severe impairment: Use with caution 1

Efficacy Considerations

• Fixed-dose trials demonstrated effectiveness of both 10 mg and 20 mg doses, with no clear additional benefit of 20 mg over 10 mg in general depression treatment 1
• However, in severe depression (MADRS scores ≥30), 20 mg shows better efficacy with clinically significant response, while 10 mg is optimal for moderate depression (MADRS scores 22-29) 3
• Response can be seen as early as 1-2 weeks in moderate depression with 10 mg, while severe depression may require 4 weeks at 20 mg to show significant response 3

Maintenance Treatment

• For major depressive disorder, continued treatment beyond acute response is recommended
• Systematic evaluation supports maintenance treatment with 10 or 20 mg/day 1
• Patients should be periodically reassessed to determine the need for ongoing maintenance treatment 1

Discontinuation

• Important: Do not discontinue abruptly
• Recommended approach: Gradual dose reduction rather than abrupt cessation
• If intolerable discontinuation symptoms occur, resuming the previously prescribed dose may be considered, followed by a more gradual taper 1

Clinical Pearls

• Screen for bipolar disorder prior to initiating treatment to avoid precipitating mania/hypomania 1
• Escitalopram has been shown to be at least as effective as citalopram 40 mg at the 10 mg dose, with potentially better tolerability 4
• In open-label naturalistic settings, escitalopram has demonstrated robust response rates (approximately 68%) with a mean dose of 11.6 mg/day 5
• For long-term treatment of generalized anxiety disorder, escitalopram continues to show improvement in anxiety symptoms and quality of life measures over 24 weeks 6

By following these dosing guidelines and considering patient-specific factors, escitalopram can be effectively used to treat major depressive disorder and generalized anxiety disorder with optimal clinical outcomes.