Lexapro (Escitalopram) Dosing for Adults
For adults with depression or generalized anxiety disorder, start Lexapro at 10 mg once daily, which can be increased to a maximum of 20 mg daily after at least one week if needed. 1
Standard Dosing Regimen
Major Depressive Disorder
- Starting dose: 10 mg once daily 1
- Dose escalation: May increase to 20 mg after a minimum of 1 week 1
- Maximum dose: 20 mg daily 2, 3
- Administration: Once daily, morning or evening, with or without food 1
Generalized Anxiety Disorder
- Starting dose: 10 mg once daily 1
- Dose escalation: May increase to 20 mg after a minimum of 1 week 1
- Maximum dose: 20 mg daily 2, 3
The FDA label demonstrates that both 10 mg and 20 mg doses are effective for depression, though the 20 mg dose did not show greater benefit than 10 mg in fixed-dose trials. 1 However, for GAD, Japanese studies showed that 20 mg produced statistically significant superiority over placebo in anxiety symptom reduction. 4
Special Population Adjustments
Elderly Patients (≥65 years)
- Recommended dose: 10 mg daily (maximum) 1
- Lower starting doses minimize adverse effects like agitation or dizziness 2
- Escitalopram is preferred over paroxetine and fluoxetine in older adults due to fewer anticholinergic effects 2
Hepatic Impairment
- Recommended dose: 10 mg daily (maximum) 1
- No dose reduction required for renal impairment (mild to moderate) 2
- Use with caution in severe renal impairment 1
Duration of Treatment
Acute Phase
- Minimum trial duration: 4-8 weeks to assess full response 4, 3
- Most adverse events emerge within the first few weeks and are mild to moderate 3
- Behavioral activation or agitation may occur early, particularly in younger patients, supporting gradual titration 3
Maintenance Treatment
- After first episode: Continue for 4-12 months after achieving remission 2
- Recurrent depression/GAD: Long-term treatment significantly reduces relapse risk 2, 5
- In relapse-prevention studies, escitalopram reduced relapse risk 4-fold compared to placebo (19% vs 56% relapse rate) 5
Dose Optimization Strategy
When to Increase from 10 mg to 20 mg
- If partial response after 4 weeks at 10 mg (e.g., symptoms remain moderate) 4
- Allow at least 4 weeks at the increased dose before evaluating response 4
- Sensitivity analyses suggest potential benefit of dose escalation for GAD 4
Therapeutic Drug Monitoring
- Therapeutic plasma range: 15-80 ng/mL 3
- At 10 mg daily, expected plasma levels are approximately 27-28 ng/mL 3
- Routine monitoring receives a level 4 recommendation (not routinely necessary) 3
Discontinuation Protocol
Never stop escitalopram abruptly—always taper gradually to minimize discontinuation symptoms. 1
- Discontinuation symptoms include: Dizziness, fatigue, headaches, nausea, insomnia, anxiety 6
- Tapering approach: Gradual dose reduction over several weeks 1
- If intolerable symptoms occur during taper, resume previous dose and decrease more slowly 1
- Distinguish discontinuation symptoms from relapse of underlying condition 6
Important Safety Considerations
Before Initiating Treatment
- Screen for bipolar disorder: Assess personal and family history of mania/hypomania before starting 1
- MAOI interactions: Allow 14 days between discontinuing an MAOI and starting escitalopram, and vice versa 1
Monitoring Requirements
- Close monitoring during first months and after dose adjustments, particularly for suicidality risk 3
- Reassess every 2-4 weeks after dose increases 4
- Periodically re-evaluate long-term necessity of treatment 1
Clinical Advantages
Escitalopram is considered a preferred first-line agent due to its favorable adverse effect profile compared to other antidepressants. 2, 3 It has demonstrated efficacy across multiple anxiety disorders (panic disorder, GAD, social anxiety disorder, OCD) with good tolerability in both short-term and long-term studies. 7 The once-daily dosing and favorable drug interaction profile facilitate adherence and use at higher doses when needed. 4