What is the recommended dosing for escitalopram (Lexapro) in patients with depression, including those with hepatic or renal impairment?

Escitalopram Dosing

For major depressive disorder and generalized anxiety disorder, initiate escitalopram at 10 mg once daily, which is the recommended dose for most patients, with a maximum of 20 mg daily after at least one week at 10 mg. 1

Standard Dosing for Depression and Anxiety

Adults

• Starting dose: 10 mg once daily (morning or evening, with or without food) 1
• Maintenance dose: 10 mg daily is effective for most patients 1, 2
• Maximum dose: 20 mg daily, achieved only after minimum of one week at 10 mg 1
• Critical limitation: Doses above 20 mg are not FDA-approved and carry increased risk of QT prolongation 3

Adolescents (12 years and older, for depression only)

• Starting dose: 10 mg once daily 4, 1
• Dose escalation: May increase to 20 mg after minimum of three weeks 4, 1
• Maximum dose: 20 mg daily 4

Important note: Escitalopram is FDA-approved for adolescents aged 12+ with depression, but NOT for children under 12 or for anxiety disorders in adolescents 4

Special Populations Requiring Dose Reduction

Elderly Patients (>60 years)

• Recommended dose: 10 mg daily maximum 1
• Rationale: Increased sensitivity to adverse effects and higher cardiac risk, particularly QT prolongation 3, 5

Hepatic Impairment

• Recommended dose: 10 mg daily 1
• No further escalation recommended regardless of severity of hepatic dysfunction 1

Renal Impairment

• Mild to moderate: No dosage adjustment necessary 1
• Severe renal impairment: Use with caution; consider 10 mg daily maximum 1

Key Safety Considerations

QT Prolongation Risk

• Dose-dependent risk: QT prolongation increases with doses above 20 mg 3, 5
• Baseline ECG: Obtain in patients over 40 years or with cardiac history before initiating treatment 5
• Avoid combinations: Do not combine with other QT-prolonging medications without careful monitoring 5

Common Adverse Effects

• Nausea (typically mild and transient), ejaculatory problems, diarrhea, insomnia 2, 6
• These effects generally occur at similar rates to placebo except for ejaculatory problems and nausea 2

Discontinuation Protocol

Always taper gradually rather than stopping abruptly 1

• Reduce dose incrementally (e.g., by 5 mg every 1-2 weeks) to minimize discontinuation symptoms 3, 1
• Monitor for withdrawal symptoms including dizziness, sensory disturbances, anxiety, and flu-like symptoms 1
• If intolerable symptoms occur, resume previous dose and taper more slowly 1

When Maximum Dose is Insufficient

If 20 mg daily provides inadequate response:

1. Consider augmentation strategies rather than exceeding 20 mg 3

   • Add bupropion or mirtazapine 3

2. Switch to SNRI if somatic symptoms prominent 7, 5

   • Venlafaxine (up to 225 mg daily) 3
   • Duloxetine 3

3. Never exceed 20 mg daily due to lack of FDA approval and increased cardiac risk 3, 1

MAOI Interactions

• Contraindicated: Do not use escitalopram with MAOIs intended to treat psychiatric disorders 1
• Washout period: Allow 14 days between discontinuing MAOI and starting escitalopram, or vice versa 1
• Linezolid/methylene blue: Stop escitalopram before administering; may resume 24 hours after last dose of linezolid or IV methylene blue 1

Common Pitfalls to Avoid

• Do not start at higher doses in attempt to achieve faster response—this increases risk of adverse effects without improving efficacy 4, 1
• Do not exceed 20 mg daily even in treatment-resistant cases; use augmentation or switching strategies instead 3, 1
• Do not abruptly discontinue—always taper to avoid withdrawal syndrome 1
• Do not ignore cardiac risk factors—obtain ECG in at-risk patients before initiating treatment 5