What are the recommended dosing levels for escitalopram (Lexapro)?

Recommended Dosing Levels for Escitalopram (Lexapro)

The recommended starting dose of escitalopram for most adults with major depressive disorder is 10 mg once daily, which can be increased to 20 mg after a minimum of one week if needed. 1

Adult Dosing Guidelines

Major Depressive Disorder

• Initial dose: 10 mg once daily (morning or evening, with or without food) 1
• Dose increase: May increase to 20 mg once daily after a minimum of one week if clinically indicated 1
• Maximum dose: 20 mg once daily 1
• Clinical trials have shown no greater benefit of 20 mg over 10 mg in most patients 1

Generalized Anxiety Disorder

• Initial dose: 10 mg once daily 1
• Dose increase: May increase to 20 mg once daily after a minimum of one week if needed 1
• Maximum dose: 20 mg once daily 1
• Efficacy has been demonstrated starting at week 1 or 2 of treatment 2

Special Populations

Elderly Patients

• Recommended dose: 10 mg once daily 1
• Lower starting doses are often recommended (approximately 50% of the adult starting dose) due to greater risk of adverse drug reactions 3
• Dose increases should be made cautiously in this population 3

Hepatic Impairment

• Recommended dose: 10 mg once daily 1
• No dosage adjustment is necessary for mild to moderate hepatic impairment 4
• Use with caution in severe hepatic impairment 1

Renal Impairment

• No dosage adjustment is necessary for mild or moderate renal impairment 1
• Use with caution in severe renal impairment 1

Adolescents (12-17 years) with Major Depressive Disorder

• Initial dose: 10 mg once daily 1
• May increase to 20 mg once daily after a minimum of three weeks if needed 1
• Maximum dose: 20 mg once daily 1

Pharmacokinetic Considerations

• Escitalopram is rapidly absorbed with maximum plasma concentrations reached in approximately 3-4 hours 4
• Elimination half-life is about 27-33 hours, consistent with once-daily dosing 4
• Steady-state concentrations are achieved within 7-10 days of administration 4
• Food does not affect absorption 4

Treatment Duration

• For first episode of major depressive disorder: Continue treatment for 4-12 months after remission 3
• For recurrent depression: Longer maintenance treatment may be beneficial 3
• For generalized anxiety disorder: Efficacy beyond 8 weeks has not been systematically studied 1
• Periodic reassessment is recommended to determine the need for continued treatment 1

Discontinuation

• Gradual dose reduction rather than abrupt cessation is recommended 1
• Monitor for discontinuation symptoms (dizziness, sensory disturbances, anxiety, sleep disturbances, etc.) 1
• If intolerable symptoms occur during discontinuation, consider resuming the previously prescribed dose and decreasing more gradually 1

Clinical Pearls and Cautions

• Screen for bipolar disorder prior to initiating treatment 1
• Allow at least 14 days between discontinuation of an MAOI and initiation of escitalopram 1
• Escitalopram has minimal inhibitory effects on CYP isoenzymes, suggesting a low potential for drug-drug interactions 4
• Fixed-dose escitalopram at 10 mg/day has shown comparable efficacy to sertraline flexibly dosed from 50-200 mg/day 5
• Escitalopram is metabolized by CYP2C19, CYP2D6, and CYP3A4 enzymes 4

Remember that while these are the recommended dosing guidelines, clinical response and tolerability should guide treatment decisions, with careful monitoring for adverse effects, especially during dose adjustments.