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
Standard Adult Dosing
- Start at 10 mg once daily for adults with major depressive disorder or generalized anxiety disorder 2, 1
- The medication can be taken at any time of day (morning or evening) and does not require food 1
- If dose escalation is needed to 20 mg daily, wait a minimum of 1 week before increasing 1
- The therapeutic dose range is 10-20 mg per day for outpatient treatment 2
Special Populations Requiring Lower Starting Doses
Elderly patients (≥65 years) should start at a reduced dose:
- Recommended starting dose is approximately 50% of the standard adult dose (around 5 mg daily) due to significantly greater risk of adverse drug reactions 2, 3
- The FDA label specifically recommends 10 mg/day as the maximum dose for most elderly patients 1
Patients with hepatic impairment:
- Start at 10 mg/day as the recommended dose (which serves as both starting and maximum dose) 1
Patients with severe renal impairment:
- Use standard 10 mg starting dose but exercise caution throughout treatment 1
- No adjustment needed for mild to moderate renal impairment 1
Adolescents (12-17 years)
- Starting dose is 10 mg once daily for major depressive disorder 1
- If increasing to 20 mg, wait a minimum of 3 weeks (longer than the 1-week wait for adults) 1
Important Safety Considerations
QT interval prolongation:
- The maximum dose should be limited due to QT-interval prolongation concerns, with further dose reduction recommended in patients older than 60 years 3
- Exercise particular caution in patients with pre-existing QT prolongation 3
Bipolar disorder screening:
- Screen all patients for personal or family history of bipolar disorder, mania, or hypomania before initiating treatment 1
Clinical Pearls
- Fixed-dose escitalopram 10 mg/day has demonstrated equivalent efficacy to flexibly-dosed sertraline 50-200 mg/day (mean 144 mg/day) 4
- Steady-state plasma concentrations are achieved within 7-10 days of once-daily administration 5
- The therapeutic plasma concentration range is 15-80 ng/mL 3
- Clinical studies demonstrate significant superiority over placebo as early as the first week of treatment 6