What is the recommended starting dose of escitalopram (Lexapro)?

Recommended Starting Dose of Escitalopram (Lexapro)

The recommended starting dose of escitalopram for adults is 10 mg once daily, taken in the morning or evening with or without food. 1

Adult Dosing Guidelines

• The FDA-approved starting dose for adults with major depressive disorder (MDD) is 10 mg once daily 1
• A fixed-dose trial demonstrated effectiveness of both 10 mg and 20 mg doses, but failed to show greater benefit of 20 mg over 10 mg in the treatment of depression 1, 2
• If dose increase is needed, this should occur after a minimum of one week of treatment at the starting dose 1
• The maximum FDA-approved dose is 20 mg daily 1

Special Populations

• For elderly patients (>65 years), 10 mg/day is the recommended dose 1, 3
• For patients with hepatic impairment, 10 mg/day is the recommended dose 1
• No dosage adjustment is necessary for patients with mild or moderate renal impairment 1
• Escitalopram should be used with caution in patients with severe renal impairment 1

Clinical Considerations

• Escitalopram is generally well-tolerated at the starting dose of 10 mg/day, with discontinuation rates due to adverse events similar to placebo (4.2% vs. 2.5%) 2
• Common adverse events include headache (35%), nausea, diarrhea, and nasopharyngitis (all 25%) 4
• Starting at higher doses may increase the risk of adverse events without providing additional therapeutic benefit for most patients 2
• Fixed-dose studies have shown that 10 mg/day of escitalopram is at least as effective as 40 mg/day of citalopram for depression 2

Dose Titration

• If increasing to 20 mg, this should occur after a minimum of one week of treatment 1
• Tolerability appears to decline above 40 mg, with 26% of patients unable to tolerate 50 mg in studies exploring higher doses 4
• While some studies have explored higher doses (up to 50 mg) for treatment-resistant depression, these doses exceed FDA recommendations and should be considered only in specialized settings 4

Important Monitoring Considerations

• Prior to initiating treatment, screen patients for personal or family history of bipolar disorder, mania, or hypomania 1
• Monitor for emergence of adverse events, particularly during the first few weeks of treatment 1
• QTc prolongation can occur with escitalopram, though this does not appear to be strongly dose-related at standard doses 5

Common Pitfalls to Avoid

• Avoid starting at doses higher than 10 mg/day, as this increases side effects without clear evidence of greater efficacy 1, 2
• Avoid rapid dose escalation (less than one week between dose increases) 1
• Do not use escitalopram concurrently with MAOIs due to risk of serotonin syndrome 1
• When discontinuing treatment, taper gradually rather than stopping abruptly to minimize discontinuation symptoms 1

Remember that while some clinicians may use higher doses in practice for treatment-resistant cases, the evidence-based starting dose that balances efficacy and tolerability is 10 mg once daily for adults.