Lexapro (Escitalopram) Dosing Schedule
Start with 10 mg once daily (morning or evening, with or without food) for both depression and anxiety disorders, and increase to 20 mg daily only after a minimum of one week if needed, though 10 mg is often sufficient for most patients. 1
Standard Dosing Algorithm
Initial Dosing
- Begin at 10 mg once daily for all adult patients with major depressive disorder or generalized anxiety disorder 1
- Administer at a consistent time each day, either morning or evening, with or without food 1
- For adolescents with depression, also start at 10 mg once daily 1
Dose Escalation (If Needed)
- Wait a minimum of one week before considering dose increase in adults 1
- Wait a minimum of three weeks before increasing dose in adolescents 1
- Maximum dose is 20 mg daily for most patients 1
- The American College of Cardiology recommends the 20 mg dose as the upper limit, as it is as effective as higher doses but with better safety 2
Important Dosing Context
- Fixed-dose trials showed that 10 mg and 20 mg are both effective, but failed to demonstrate greater benefit of 20 mg over 10 mg for depression 1
- The European Society of Cardiology specifically recommends against exceeding 20 mg daily due to increased risk of QT interval prolongation 2
- Both FDA and EMA have restricted maximum dosing to reduce cardiac risk 2
Special Population Dosing
Elderly Patients (>60 years)
- Maximum recommended dose is 10 mg daily 1
- Lower doses (10 mg daily) are preferred due to increased sensitivity to adverse effects and cardiac risks 2
- Obtain baseline ECG in patients over 40 years or with cardiac history before continuing treatment 2
Hepatic Impairment
Renal Impairment
- No dosage adjustment necessary for mild or moderate renal impairment 1
- Use with caution in severe renal impairment 1
Maintenance Treatment
Duration Considerations
- Acute episodes of major depressive disorder require several months or longer of sustained pharmacological therapy beyond response 1
- For generalized anxiety disorder, efficacy beyond 8 weeks has not been systematically studied, but long-term use may be appropriate 1
- Periodically re-evaluate the long-term usefulness for individual patients 1
Discontinuation Protocol
Tapering Strategy
- Gradual dose reduction is recommended rather than abrupt cessation 1
- Monitor patients for discontinuation symptoms when stopping treatment 1
- If intolerable symptoms occur after dose reduction, resume the previous dose and taper more gradually 1
Critical Safety Considerations
Cardiac Monitoring
- Do not combine with other QT-prolonging medications without careful monitoring 2
- Risk of cardiac arrest is increased with SSRI treatment, particularly in older patients (mean age 74 years in registry studies) 2
- Obtain baseline ECG in at-risk populations before initiating treatment 2
Pre-Treatment Screening
- Screen for personal or family history of bipolar disorder, mania, or hypomania before initiating treatment 1
MAOI Interactions
- Allow at least 14 days between discontinuation of an MAOI and initiation of escitalopram 1
- Allow at least 14 days after stopping escitalopram before starting an MAOI 1
- Do not start escitalopram in patients being treated with linezolid or intravenous methylene blue due to serotonin syndrome risk 1
Expected Timeline for Response
Onset of Action
- Symptom improvement can be rapid, with some parameters improving within 1-2 weeks of starting treatment 3
- Escitalopram shows earlier separation from placebo than citalopram at one-quarter to half the dosage 3
- Significant improvement in anxiety symptoms begins at Week 1 and continues at each study visit thereafter 4