What is the next dose increase for a patient on Lexapro (escitalopram) 10 mg?

Increasing Escitalopram (Lexapro) Dosage

For a patient currently on escitalopram 10 mg, the next appropriate dose increase is to 20 mg daily, which should occur after a minimum of one week on the current dose. 1

Dosing Guidelines for Escitalopram

• The FDA-approved dosing for escitalopram in adults with major depressive disorder starts at 10 mg once daily, with the option to increase to 20 mg once daily after a minimum of one week 1
• The maximum recommended dose of escitalopram is 20 mg daily, as doses above this are not FDA-approved and carry increased risk of side effects, particularly QT prolongation 2
• Clinical trials have demonstrated the effectiveness of both 10 mg and 20 mg doses, though some studies failed to demonstrate a greater benefit of 20 mg over 10 mg 1

Dose Escalation Process

• When increasing from 10 mg to 20 mg, wait at least one week on the current dose before making the change 1
• Escitalopram can be administered once daily, in the morning or evening, with or without food 1
• Escitalopram has linear pharmacokinetics, meaning plasma levels increase proportionately and predictably with increased doses 3
• Steady-state concentrations are achieved within 7-10 days of administration 3

Special Populations

• For elderly patients and those with hepatic impairment, 10 mg/day is the recommended maximum dose 1
• No dosage adjustment is necessary for patients with mild or moderate renal impairment, though escitalopram should be used with caution in patients with severe renal impairment 1

Clinical Evidence for Dose Increases

• A randomized, double-blind study showed that dose escalation of escitalopram up to 30 mg per day may be beneficial for the treatment of depressive symptoms in non-remitters after standard (10-20 mg/day) treatment 4
• However, tolerability appeared to decline above a dose of 40 mg with 26% of patients unable to tolerate 50 mg in an open-label pilot study 5

Common Side Effects to Monitor

• The most common adverse events associated with escitalopram include nausea (>10% of patients), insomnia, ejaculation disorder, diarrhea, dry mouth, and somnolence 6
• Higher doses may increase the likelihood of these common SSRI side effects 2

Important Considerations

• QT prolongation risk increases in a dose-dependent manner with escitalopram 2
• If 20 mg is insufficient, consider augmentation strategies rather than exceeding the maximum recommended dose, such as addition of another agent (e.g., bupropion, mirtazapine) 2
• Alternatively, consider switching to an SNRI such as venlafaxine (maximum 225 mg daily) or duloxetine if response is inadequate at 20 mg 2

Follow-up Recommendations

• Patients should be periodically reassessed to determine the need for maintenance treatment 1
• Monitor for side effects and therapeutic response after dose increases 1
• The elimination half-life of escitalopram is about 27-33 hours, consistent with once-daily administration 3