What is the recommended starting dose of Lexapro (escitalopram) for an elderly patient?

Lexapro (Escitalopram) Dosing for Elderly Patients

The recommended starting dose of Lexapro (escitalopram) for elderly patients is 10 mg once daily, which is the standard dose for this population and does not require reduction from the adult starting dose. 1

Initial Dosing

• Start with 10 mg once daily in elderly patients (≥65 years), which is the FDA-recommended dose for most elderly patients. 1
• This dose can be administered in the morning or evening, with or without food. 1
• Unlike some other SSRIs (such as sertraline or fluoxetine), escitalopram does not require a 50% dose reduction from the standard adult starting dose in elderly patients. 1

Rationale for 10 mg Starting Dose

• Escitalopram pharmacokinetics show that AUC and half-life increase by approximately 50% in elderly subjects (≥65 years) compared to younger adults, while Cmax remains unchanged. 1
• The elimination half-life in elderly patients is approximately 27-33 hours, consistent with once-daily dosing. 2
• Despite these pharmacokinetic changes, the FDA specifically recommends 10 mg/day as appropriate for elderly patients rather than requiring dose reduction. 1

Dose Titration

• If dose escalation is needed, increase to 20 mg once daily only after a minimum of one week at 10 mg. 1
• Many elderly patients respond adequately to 10 mg daily without requiring dose escalation. 3
• In clinical trials of elderly patients with depression and anxiety, flexible dosing of 10-20 mg/day was effective and well-tolerated. 4, 5

Monitoring and Safety Considerations

• Elderly patients are at greater risk for SSRI-associated hyponatremia and should be monitored for this adverse event. 1
• Common adverse effects in elderly patients include fatigue/somnolence (41%), sleep disturbance (14%), and urinary symptoms (9%). 5
• The overall withdrawal rate due to adverse events in long-term studies of elderly patients was approximately 9%. 3

Special Populations Within Elderly

• Hepatic impairment: 10 mg/day is also the recommended dose for elderly patients with hepatic impairment (no further reduction needed). 1
• Renal impairment: No dosage adjustment is necessary for mild to moderate renal impairment; use with caution in severe renal impairment. 1

Efficacy Data

• In elderly patients with generalized anxiety disorder, escitalopram 10-20 mg/day showed a 69% cumulative response rate versus 51% for placebo over 12 weeks. 5
• In long-term treatment (52 weeks) of elderly patients with major depressive disorder, remission rates increased from 48% at study entry to 72% by week 52. 3
• Escitalopram demonstrated comparable efficacy to flexibly-dosed sertraline (50-200 mg/day) in mixed-age populations. 6

Key Clinical Pitfall to Avoid

• Do not automatically reduce the starting dose to 5 mg in elderly patients—the FDA label specifically states 10 mg/day is appropriate for this population, unlike fluoxetine or paroxetine which should be avoided or dose-reduced in elderly patients. 7, 8