Lexapro (Escitalopram) Starting Dose and Titration
Start escitalopram at 10 mg once daily for most adult patients, and if dose escalation is needed, increase to 20 mg after a minimum of one week. 1
Starting Dose
- Standard adult dose: 10 mg once daily (morning or evening, with or without food) 2, 1
- Elderly patients: 5 mg once daily (approximately 50% of the adult starting dose due to significantly greater risk of adverse drug reactions) 3, 2
- Patients with hepatic impairment: 10 mg/day maximum 1
- Adolescents with major depressive disorder: 10 mg once daily 1
Titration Schedule
- If increasing to 20 mg in adults: Wait a minimum of one week at 10 mg before escalating 1
- If increasing to 20 mg in adolescents: Wait a minimum of three weeks at 10 mg before escalating 1
- Evidence supports dose escalation over switching: In patients who fail to respond to 10 mg after 2 weeks, up-titrating to 20 mg provides better efficacy than switching to another antidepressant (54% vs 42% remission rates) 4
Maximum Dosing Considerations
- Standard maximum dose: 20 mg/day for most patients 1
- Elderly patients (>60 years): Lower maximum dose recommended due to QT-interval prolongation concerns 3
- Severe renal impairment: Use with caution at standard doses 3, 1
Important Clinical Pearls
- Steady-state concentrations are achieved within 7-10 days of administration 5
- Therapeutic plasma concentration range: 15-80 ng/mL 3
- Both 10 mg and 20 mg doses are effective, though clinical trials failed to demonstrate greater benefit of 20 mg over 10 mg in some studies 1
- Absorption is not affected by food, so timing can be based on patient preference 5
Discontinuation Protocol
- Taper gradually over a minimum of 10-14 days to avoid withdrawal symptoms (irritability, agitation, dizziness, sensory disturbances, anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania) 3, 2
- If intolerable symptoms occur during taper: Resume the previous dose and decrease more gradually 3, 1