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

Starting Dose of Lexapro (Escitalopram)

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

Standard Adult Dosing

• Start at 10 mg daily for the majority of adult patients with major depressive disorder or generalized anxiety disorder 2, 1
• The medication can be administered at any time of day (morning or evening) and food does not affect absorption 1
• This 10 mg starting dose is also the target therapeutic dose for many patients, as clinical trials demonstrated effectiveness at both 10 mg and 20 mg, though 20 mg did not show greater benefit than 10 mg in fixed-dose trials for major depression 1

Dose Adjustments Based on Severity

The starting dose may need modification based on depression severity:

• For moderate depression: 10 mg daily is the optimal dose and shows clinical response within 2 weeks 3
• For severe depression (MADRS score ≥30): While starting at 10 mg is still appropriate, patients may require titration to 20 mg after a minimum of one week for adults (or three weeks for adolescents) to achieve adequate response 1, 3

Special Populations Requiring Lower Starting Doses

Reduce the starting dose to approximately 50% of the standard adult dose (around 5 mg daily) in:

• Elderly patients - who have significantly greater risk of adverse drug reactions 2
• Patients with hepatic impairment - 10 mg/day is the maximum recommended dose 1
• Patients with severe renal impairment - use with caution 1

Adolescent Dosing

• Adolescents (ages 12-17) with major depressive disorder should start at 10 mg once daily 1
• If dose escalation is needed, wait a minimum of three weeks before increasing to 20 mg 1

Important Clinical Considerations

Common pitfalls to avoid:

• Do not increase the dose too rapidly - allow at least one week in adults (three weeks in adolescents) before considering dose escalation to 20 mg 1
• Screen all patients for personal or family history of bipolar disorder, mania, or hypomania before initiating treatment, as antidepressants can precipitate manic episodes 1
• When discontinuing, taper gradually rather than stopping abruptly to minimize withdrawal symptoms (dizziness, fatigue, headaches, nausea, insomnia, anxiety) 2, 1

Drug interactions requiring caution:

• Allow at least 14 days between discontinuing an MAOI and starting escitalopram, and vice versa, due to serotonin syndrome risk 1
• Do not initiate escitalopram in patients receiving linezolid or intravenous methylene blue 1