Recommended Initial Dosage of Lexapro (Escitalopram) for Adults

Start with 10 mg once daily for both depression and generalized anxiety disorder, taken in the morning or evening with or without food. 1

Initial Dosing for Major Depressive Disorder

The FDA-approved starting dose is 10 mg once daily for adult patients with major depressive disorder 1
Fixed-dose trials demonstrated effectiveness of both 10 mg and 20 mg, but failed to show greater benefit of 20 mg over 10 mg 1
If dose escalation is needed, increase to 20 mg only after a minimum of one week at 10 mg 1
Symptom improvement may begin within 1-2 weeks, though a full therapeutic trial requires 4-8 weeks to assess response 2, 3

The recommended starting dose is 10 mg once daily for GAD 1
The 10 mg dose has been shown to be effective as monotherapy, with pooled trial data demonstrating significant superiority over placebo beginning at week 1-2 4
If increasing to 20 mg, wait a minimum of one week 1
Both 10 mg and 20 mg doses showed statistically significant differences from placebo at 12 weeks in anxiety disorder trials 2

Dose increases should use increments of the initial dose (10 mg) every 5-7 days until therapeutic benefits or significant side effects appear 2
For most patients, the 10 mg dose maintained throughout treatment is sufficient, as mean change in anxiety scores was significantly greater even for patients maintained at 10 mg compared to placebo 4
The 20 mg dose may show clearer separation from placebo in some patients, particularly in social anxiety disorder, though 10 mg remains the appropriate starting point 5, 2

Critical dosing adjustments are required for certain populations:

Elderly patients (>60 years): Maximum recommended dose is 10 mg daily due to increased sensitivity to adverse effects and cardiac risks 6, 1
Hepatic impairment: 10 mg daily is the recommended dose 1
Severe renal impairment: Use with caution; no adjustment needed for mild-moderate renal impairment 1

Obtain baseline ECG in patients over 40 years or with cardiac history before starting treatment, as doses above 20 mg daily increase risk of QT interval prolongation 6
The FDA and EMA have limited maximum recommended doses due to QT prolongation risk, with regulatory agencies specifically restricting dosing to reduce cardiac risk 6
Do not combine escitalopram with other QT-prolonging medications without careful monitoring 6
The maximum dose for most adults should not exceed 20 mg daily 6, 1

Only 7-10% of patients withdraw due to adverse events in controlled trials 2
Most common adverse events include nausea (typically mild and transient), ejaculatory problems, diarrhea, and insomnia 2, 3
In Chinese patients with depression and anxiety, 25.7% reported at least one treatment-emergent adverse event, with nausea (5.8%), dizziness (2.7%), and diarrhea (2.3%) being most frequent 7

Use gradual dose reduction over 10-14 days minimum rather than abrupt cessation to minimize discontinuation symptoms 2, 1
Monitor patients for withdrawal symptoms when discontinuing treatment 1
If intolerable symptoms occur following dose decrease, resume the previously prescribed dose and taper more gradually 1

Do not start at 20 mg: The FDA label clearly indicates 10 mg as the starting dose for both depression and GAD 1
Do not increase dose before one week: Premature dose escalation increases adverse event risk without additional benefit 1
Do not ignore cardiac risk factors: Failure to obtain baseline ECG in at-risk patients can miss QT prolongation 6
Do not use higher doses in elderly patients: The 10 mg maximum for elderly patients is based on safety, not just efficacy 6, 1