What is a good titration schedule for Lexapro (escitalopram)?

Lexapro (Escitalopram) Titration Schedule

Start escitalopram at 10 mg once daily and maintain this dose for at least 1 week in adults (3 weeks in adolescents) before considering dose escalation to 20 mg daily if needed. 1

Initial Dosing

• Adults with Major Depressive Disorder or Generalized Anxiety Disorder: Begin with 10 mg once daily, taken in the morning or evening with or without food 1
• Adolescents (12-17 years) with Major Depressive Disorder: Start with 10 mg once daily 1
• Elderly patients and those with hepatic impairment: Use 10 mg/day as the maximum recommended dose without titration 1

Dose Escalation Timeline

• Adults: If increasing to 20 mg/day, wait a minimum of 1 week at the 10 mg dose before escalating 1
• Adolescents: If increasing to 20 mg/day, wait a minimum of 3 weeks at the 10 mg dose before escalating 1
• Fixed-dose trials demonstrated effectiveness of both 10 mg and 20 mg in adults, though 20 mg did not show greater benefit than 10 mg for major depression 1

Important Considerations During Titration

• Early response assessment: Escitalopram demonstrates significant superiority over placebo as early as week 1 of treatment 2, with therapeutic effects potentially visible within the first week 3
• Common side effects during initial titration: Nausea (occurring in >10% of patients), insomnia, diarrhea, dry mouth, and somnolence are most common early in treatment 2
• Steady-state concentrations: Achieved within 7-10 days of administration due to the 27-33 hour elimination half-life 4

Special Populations

• Severe renal impairment: Use with caution; no specific dose adjustment provided but careful monitoring warranted 1
• Mild to moderate renal impairment: No dosage adjustment necessary 1

Discontinuation Protocol

• Gradual taper required: Reduce dose gradually rather than stopping abruptly to minimize discontinuation symptoms 1
• If intolerable symptoms occur during taper, resume the previous dose and decrease more slowly 1

Screening Before Initiation

• Bipolar disorder screening mandatory: Assess personal and family history of bipolar disorder, mania, or hypomania before starting treatment to avoid precipitating manic episodes 1

Drug Interactions During Titration

• MAOI washout period: Allow at least 14 days between discontinuing an MAOI and starting escitalopram 1
• Minimal cytochrome P450 enzyme effects suggest low potential for drug-drug interactions 4