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

Starting Dose of Lexapro (Escitalopram)

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

Standard Adult Dosing

• Initial dose: 10 mg once daily for most 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) with no significant difference in efficacy, and food does not affect absorption 3, 1, 4
• If dose escalation is needed, increase to 20 mg daily after a minimum of one week for generalized anxiety disorder or major depressive disorder in adults 1
• The maximum recommended dose is 20 mg daily; doses above this are not FDA-approved and carry increased risk of side effects, particularly QT prolongation 5

Special Populations Requiring Lower Starting Doses

Elderly patients (≥65 years) and those with hepatic impairment should start at a reduced dose:

• Recommended starting dose: 10 mg daily (which is already the standard dose, but importantly, this is also the maximum recommended dose for elderly patients) 1
• Older adults have significantly greater risk of adverse drug reactions and may benefit from starting at approximately 50% of the standard adult dose in some cases 2
• No dosage adjustment is necessary for patients with mild or moderate renal impairment, but use caution in severe renal impairment 1

Clinical Response Timeline

• Clinical response may take 4-8 weeks to fully manifest 3
• Some studies show significant improvement over placebo as early as the first week of treatment 6, 7
• Steady-state plasma concentrations are achieved within 7-10 days of administration 4

Important Prescribing Considerations

• Screen for bipolar disorder (personal or family history of bipolar disorder, mania, or hypomania) prior to initiating treatment 1
• When discontinuing, taper gradually over 10-14 days rather than stopping abruptly to minimize withdrawal symptoms (dizziness, fatigue, headaches, nausea, insomnia, anxiety) 3, 2, 1
• Allow at least 14 days between discontinuation of an MAOI and initiation of escitalopram 1

Dose Escalation Strategy

If 10 mg daily proves insufficient after adequate trial duration:

• Increase to 20 mg daily (the maximum FDA-approved dose) 5, 1
• If 20 mg is insufficient, consider augmentation strategies rather than exceeding the maximum dose, such as adding bupropion or mirtazapine 5, 8
• Alternatively, consider switching to an SNRI (venlafaxine or duloxetine) rather than exceeding 20 mg 5