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

Lexapro (Escitalopram) Starting Dose

The recommended starting dose of Lexapro (escitalopram) is 10 mg once daily for most adult patients, taken in the morning or evening with or without food. 1, 2

Standard Adult Dosing

• Start at 10 mg once daily for major depressive disorder and generalized anxiety disorder 2
• The medication can be taken at any time of day (morning or evening) and does not require food 2
• If dose escalation is needed to 20 mg, wait a minimum of one week before increasing in adults with major depression or generalized anxiety disorder 2
• The typical dosage range is 10-20 mg per day for outpatient treatment 1

Special Populations Requiring Lower Starting Doses

Elderly patients (≥65 years) should start at a reduced dose:

• 10 mg/day is the maximum recommended dose for most elderly patients 2
• Older adults have significantly greater risk of adverse drug reactions and should receive approximately 50% of the standard adult starting dose 1

Patients with hepatic impairment:

• Start at 10 mg/day as the recommended dose 2

Patients with severe renal impairment:

• Use escitalopram with caution; no specific dosage adjustment provided but monitoring is warranted 2

Adolescent Dosing (Major Depressive Disorder)

• Start at 10 mg once daily for adolescents 2
• If dose increase to 20 mg is needed, wait a minimum of three weeks (longer than the one week required for adults) 2

Important Clinical Considerations

Pharmacokinetic profile supports once-daily dosing:

• Elimination half-life is 27-33 hours 3
• Steady-state concentrations achieved within 7-10 days 3
• Linear and dose-proportional pharmacokinetics in the 10-30 mg/day range 3

Pre-treatment screening requirement:

• Screen all patients for personal or family history of bipolar disorder, mania, or hypomania before initiating escitalopram to avoid precipitating manic episodes 2

Discontinuation precautions:

• Never stop abruptly; taper gradually to avoid withdrawal symptoms including dizziness, fatigue, headaches, nausea, insomnia, and anxiety 1, 2
• If intolerable symptoms occur during taper, resume the previous dose and decrease more gradually 2

MAOI interactions:

• Allow at least 14 days between discontinuing an MAOI and starting escitalopram 2
• Allow at least 14 days after stopping escitalopram before starting an MAOI 2

Common Pitfall to Avoid

Do not start elderly patients or those with hepatic impairment at doses higher than 10 mg/day, as this is both the starting and maximum recommended dose for these populations 2. The evidence shows no clinically relevant pharmacokinetic differences in these groups compared to healthy young adults, but the lower dosing recommendation reflects increased sensitivity to adverse effects 3.