Safe Lexapro (Escitalopram) Dosing
Standard Adult Dosing
For adults with depression or generalized anxiety disorder, the safe and effective starting dose of Lexapro is 10 mg once daily, with a maximum dose of 20 mg daily after at least one week at the initial dose. 1
- The 10 mg dose has demonstrated effectiveness comparable to 20 mg in fixed-dose trials for major depressive disorder, with no clear additional benefit from the higher dose in most patients 1
- For generalized anxiety disorder, 10 mg daily is effective, and pooled analyses show that patients maintained at 10 mg/day had significantly greater improvement than placebo 2
- Dose increases to 20 mg should occur only after a minimum of one week at 10 mg 1
Adolescent Dosing (Ages 12-17)
For adolescents with depression, start with 10 mg once daily, with a maximum of 20 mg daily only after a minimum of three weeks at the initial dose. 1
- The flexible-dose trial (10-20 mg/day) demonstrated effectiveness in adolescents ages 12-17 with major depressive disorder 1
- The longer waiting period before dose escalation (three weeks versus one week in adults) is critical for safety in this age group 1
- Lexapro is not FDA-approved for anxiety disorders in adolescents, only for depression in patients 12 years and older 1
Special Populations Requiring Dose Reduction
Elderly patients (>60 years) and those with hepatic impairment should receive a maximum dose of 10 mg daily. 1
- This reduced maximum dose applies regardless of indication 1
- No dosage adjustment is necessary for mild or moderate renal impairment 1
- Use with caution in severe renal impairment, though specific dose adjustments are not provided 1
Critical Safety Considerations
Bipolar Disorder Screening
- Screen all patients for personal or family history of bipolar disorder, mania, or hypomania before initiating Lexapro, as antidepressants can trigger manic episodes. 1
QTc Prolongation Risk
- Both the FDA and EMA have limited maximum doses of escitalopram due to QT-interval prolongation risk 3
- The dose restrictions (10 mg maximum for elderly patients) were implemented specifically to minimize cardiac risk 3
Drug Interactions
- Escitalopram has low potential for drug interactions due to metabolism by three CYP isozymes 4
- Exercise caution when coadministering with drugs metabolized by CYP2D6 (such as metoprolol) 4
- At least 14 days must elapse between discontinuation of an MAOI and initiation of escitalopram, and vice versa 1
Administration and Timing
- Administer once daily, morning or evening, with or without food 1
- The timing flexibility allows optimization based on individual side effect profiles (e.g., evening dosing if sedating, morning if activating) 1
Discontinuation Protocol
When stopping Lexapro, taper gradually rather than stopping abruptly to minimize discontinuation symptoms. 1
- If intolerable symptoms occur during taper, resume the previous dose and decrease more gradually 1
- Discontinuation symptoms are well-documented with SSRIs and require monitoring 1
Maintenance Treatment Duration
- Acute episodes of major depressive disorder require several months or longer of sustained pharmacological therapy beyond response to the acute episode 1
- Systematic evaluation demonstrated benefit of maintenance treatment with escitalopram 10 or 20 mg/day in adults who responded during acute treatment 1
- Periodically reassess patients to determine the need for continued maintenance treatment 1
Common Pitfalls to Avoid
- Do not exceed 10 mg daily in elderly patients or those with hepatic impairment, as this increases cardiac risk without additional benefit 1, 3
- Do not escalate doses too rapidly in adolescents—wait the full three weeks before considering increase to 20 mg 1
- Do not start escitalopram in patients currently taking MAOIs or within 14 days of MAOI discontinuation due to serotonin syndrome risk 1
- Do not abruptly discontinue—always taper to minimize withdrawal symptoms 1