What is the recommended starting dose of Lexapro (escitalopram) for an adult patient with depression or anxiety?

Lexapro Starting Dose

The recommended starting dose of Lexapro (escitalopram) for adults with depression or anxiety is 10 mg once daily, taken in the morning or evening with or without food. 1

Standard Adult Dosing

• Start with 10 mg once daily for both major depressive disorder and generalized anxiety disorder 1
• The dose may be increased to 20 mg daily after a minimum of one week if needed 1
• Both 10 mg and 20 mg doses have demonstrated effectiveness, though the 20 mg dose did not show greater benefit than 10 mg in fixed-dose trials for depression 1

Special Population Adjustments

For elderly patients (≥65 years) and those with hepatic impairment, the recommended dose is 10 mg daily with no routine increase. 1

• Older adults should remain at 10 mg daily due to increased sensitivity to adverse effects and cardiac risks 2, 3
• No dosage adjustment is necessary for mild to moderate renal impairment, but use caution in severe renal impairment 1

Timing of Response and Dose Titration

• Allow 4-8 weeks for a full therapeutic trial before concluding treatment is ineffective 4, 3
• Symptom improvement may begin within 1-2 weeks, but full response takes longer 3, 5
• If dose increases are needed, use increments of the initial dose every 5-7 days until therapeutic benefits or significant side effects appear 4

Safety Considerations

• Obtain a baseline ECG in patients over 40 years or with cardiac history before starting treatment, as doses above 20 mg daily increase QT interval prolongation risk 2
• The maximum recommended dose is 20 mg daily for most patients; regulatory agencies have restricted higher doses due to cardiac safety concerns 2
• Avoid combining escitalopram with other QT-prolonging medications without careful monitoring 2

Common Adverse Effects

• Most common side effects include nausea (5.8%), ejaculatory problems, diarrhea (2.3%), dizziness (2.7%), and insomnia 5, 6
• Only 7-10% of patients withdraw due to adverse events in controlled trials 3
• Most adverse events are mild to moderate and transient, particularly nausea 5

Discontinuation Protocol

When stopping escitalopram, use gradual dose reduction over 10-14 days minimum rather than abrupt cessation to minimize withdrawal symptoms. 4, 3, 1

• If intolerable symptoms occur after dose reduction, resume the previous dose and taper more gradually 1
• Monitor patients for discontinuation symptoms including dizziness, sensory disturbances, and mood changes 1

Screening Before Initiation

• Screen all patients for personal or family history of bipolar disorder, mania, or hypomania before starting treatment to avoid precipitating manic episodes 1