What is the recommended dosing for Lexapro (escitalopram) in adults with major depressive disorder or generalized anxiety disorder?

Lexapro (Escitalopram) Dosing for Major Depressive Disorder and Generalized Anxiety Disorder

For adults with major depressive disorder (MDD) or generalized anxiety disorder (GAD), the recommended starting dose of escitalopram is 10 mg once daily, with a maximum dose of 20 mg once daily. 1

Dosing Guidelines for Adults

Major Depressive Disorder

• Initial dose: 10 mg once daily
• Maximum dose: 20 mg once daily
• Dose adjustment timing: If increasing to 20 mg, wait a minimum of one week 1
• Administration: Can be taken 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 increasing to 20 mg, wait a minimum of one week 1
• Administration: Can be taken morning or evening, with or without food 1

Special Populations

• Elderly patients: Maximum recommended dose is 10 mg once daily 1, 2
• Hepatic impairment: Maximum recommended dose is 10 mg once daily 1, 2
• Renal impairment:
  • Mild to moderate: No dosage adjustment necessary
  • Severe: Use with caution 1

Efficacy Considerations

• For MDD, 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
• For moderate depression (MADRS score 22-29), 10 mg is typically sufficient 3
• For severe depression (MADRS score ≥30), 20 mg may be more effective 3
• In GAD, doses of 10-20 mg/day have demonstrated continued efficacy in long-term treatment 4, 5

Treatment Duration

• Acute treatment phase: 8-12 weeks
• Maintenance treatment:
  • MDD: Several months or longer of sustained pharmacological therapy beyond response to the acute episode 1
  • GAD: Long-term treatment is often necessary as GAD is recognized as a chronic condition 1
  • Systematic evaluation supports continued treatment for patients who responded during the acute phase 1

Discontinuation

• Gradual dose reduction rather than abrupt cessation is recommended 1
• Monitor for discontinuation symptoms (dizziness, sensory disturbances, anxiety, sleep disturbances) 1
• If intolerable symptoms occur during discontinuation, resuming the previously prescribed dose may be considered before attempting 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 adverse effects include headache, nausea, diarrhea, dizziness, dry mouth, fatigue, and sexual dysfunction 2
• Escitalopram has fewer drug interactions compared to other SSRIs due to minimal effects on CYP450 enzymes 2

Clinical Pearls

• Escitalopram is the S-enantiomer of citalopram and is considered one of the preferred agents for depression and anxiety due to its favorable side effect profile 6
• Response can be expected within 2-4 weeks, with maximal response typically achieved within 8-12 weeks 2
• Long-term studies show continued improvement in anxiety and quality-of-life scores with extended treatment 4
• Escitalopram has demonstrated efficacy in preventing relapse in both MDD and GAD in placebo-controlled studies 5

By following these dosing guidelines, clinicians can optimize treatment outcomes while minimizing adverse effects for patients with major depressive disorder and generalized anxiety disorder.