What is the starting dose of Lexapro (escitalopram) for anxiety?

Starting Dose of Lexapro for Anxiety

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

Dosing by Anxiety Disorder Type

Generalized Anxiety Disorder (GAD)

• Start with 10 mg once daily in adult patients 1
• If dose escalation is needed to 20 mg, wait a minimum of one week before increasing 1
• Clinical trials demonstrated efficacy at both 10 mg and 20 mg doses, with response rates of 69% at 10-20 mg versus 51% with placebo in older adults 2
• Long-term treatment (24 weeks) showed 92% of completers achieved response (CGI-I ≤2) with continued improvement in anxiety and quality of life measures 3

Social Anxiety Disorder

• Begin with 10 mg once daily 4
• Japanese clinical practice guidelines reference trials using 10 mg and 20 mg doses, with sensitivity analyses showing statistically significant differences between both doses and placebo at 12 weeks 4
• The 20 mg dose showed clearer separation from placebo in post-hoc analyses, though 10 mg remains the appropriate starting dose 4

Panic Disorder

• Start with 5-10 mg daily (flexible dosing) 5
• In a 10-week trial, flexible doses of 5-10 mg/day were significantly more effective than placebo, with 50% of escitalopram recipients experiencing no panic attacks versus 38% with placebo 5
• Escitalopram demonstrated faster onset of action compared to citalopram in panic disorder 5

Special Population Considerations

Elderly Patients (≥60 years)

• 10 mg/day is the recommended dose for most elderly patients 1
• Do not routinely increase beyond 10 mg in this population 1
• In older adults with GAD, 10-20 mg showed significant improvements in anxiety symptoms (effect size 0.93) and role functioning, though adverse effects including fatigue/somnolence (41%), sleep disturbance (14%), and urinary symptoms (9%) were more common than placebo 2

Hepatic Impairment

• 10 mg/day is recommended for patients with hepatic impairment 1

Renal Impairment

• No dosage adjustment needed for mild to moderate renal impairment 1
• Use with caution in severe renal impairment 1

Timing and Administration

• Administer once daily, morning or evening 1
• Can be taken with or without food 1
• Full therapeutic trial requires 4-8 weeks to assess response 4
• Symptom improvement may begin within 1-2 weeks, with escitalopram showing earlier separation from placebo than citalopram at one-quarter to half the dosage 6

Important Clinical Considerations

Dose Escalation Strategy

• If increasing from 10 mg to 20 mg for GAD, wait minimum of one week 1
• Dose increases should use increments of the initial dose every 5-7 days until therapeutic benefits or significant side effects appear 4

Common Pitfalls to Avoid

• Do not start at 20 mg: The FDA label clearly specifies 10 mg as the starting dose for anxiety disorders 1
• Do not escalate too quickly: Premature dose increases before adequate trial duration (minimum 1 week) may increase side effects without additional benefit 1
• Screen for bipolar disorder before initiating treatment to avoid precipitating manic episodes 1

Expected Tolerability

• Most common adverse events include nausea (mild and transient), ejaculatory problems, diarrhea, and insomnia 6
• At 20 mg, side effects are more pronounced initially than at 10 mg, which should be considered when evaluating overall benefit 7
• Only 7-10% of patients withdraw due to adverse events in controlled trials 4, 3

Discontinuation Planning

• When stopping treatment, use gradual dose reduction rather than abrupt cessation to minimize discontinuation symptoms (dizziness, fatigue, headaches, nausea, insomnia, anxiety) 8, 1
• Taper over 10-14 days minimum to limit withdrawal symptoms 4