What is the recommended dosing for Lexapro (escitalopram) in adults and adolescents with depression or anxiety, considering factors such as renal impairment and hepatic impairment?

Escitalopram (Lexapro) Dosing Recommendations

For adults with depression or anxiety, start escitalopram at 10 mg once daily, which is the recommended dose for most patients; increase to 20 mg daily (the maximum FDA-approved dose) only after a minimum of one week if needed, and use 10 mg daily for elderly patients and those with hepatic impairment. 1

Standard Adult Dosing

Major Depressive Disorder

• Initial dose: 10 mg once daily 1
• May be taken morning or evening, with or without food 1
• If dose escalation is needed, increase to 20 mg daily after a minimum of 1 week 1
• Fixed-dose trials demonstrated effectiveness of both 10 mg and 20 mg, but failed to show greater benefit of 20 mg over 10 mg 1

Generalized Anxiety Disorder

• Starting dose: 10 mg once daily 1
• If increasing to 20 mg, wait a minimum of 1 week 1
• Escitalopram 10-20 mg/day demonstrated significant improvements in anxiety symptoms with rapid onset, showing separation from placebo within 1-2 weeks 2, 3

Other Anxiety Disorders

• For panic disorder, social anxiety disorder, and OCD, escitalopram 10-20 mg/day has demonstrated efficacy in controlled trials 2, 3
• In panic disorder specifically, flexible doses of 5-10 mg/day were effective, with 50% of patients experiencing no panic attacks 2

Adolescent Dosing (Ages 12-17)

• Recommended dose: 10 mg once daily for depression 1
• A flexible-dose trial (10-20 mg/day) demonstrated effectiveness 1
• If increasing to 20 mg, wait a minimum of 3 weeks (longer than the 1-week wait for adults) 1

Special Populations

Elderly Patients (≥65 years)

• Recommended dose: 10 mg daily 1, 4
• Lower doses reduce risk of adverse effects while maintaining efficacy 4
• Do not exceed 10 mg daily in this population 1

Hepatic Impairment

• Recommended dose: 10 mg daily 1
• Caution is necessary as escitalopram is metabolized by CYP isozymes 5

Renal Impairment

• No dosage adjustment needed for mild or moderate renal impairment 1
• Use with caution in severe renal impairment 1

Maximum Dosing and Safety Limits

The maximum FDA-approved dose is 20 mg daily; doses above 20 mg are not approved and carry increased risk of QT prolongation in a dose-dependent manner. 4, 6

• Do not exceed 20 mg daily 6, 1
• QT prolongation risk increases with higher doses, similar to citalopram which has a boxed warning 6
• If 20 mg is insufficient, consider augmentation strategies (e.g., adding bupropion or mirtazapine) or switching to an SNRI rather than exceeding the maximum dose 6
• Monitor ECG if patient has cardiac risk factors 6

Maintenance Treatment

• First episode of major depression should be treated for a minimum of 4 months 4
• Recurrent depression may benefit from prolonged treatment 4
• Systematic evaluation demonstrated benefit of maintenance treatment at 10 or 20 mg/day in patients who responded during acute treatment 1
• Long-term studies (24-76 weeks) showed escitalopram significantly reduced relapse rates compared to placebo in GAD, social anxiety disorder, and OCD 2

Discontinuation

Taper gradually rather than stopping abruptly to minimize discontinuation symptoms. 1

• Monitor for discontinuation symptoms including tremor, diarrhea, and other manifestations 4, 1
• If intolerable symptoms occur, resume previous dose and taper more gradually 1
• Consider reducing by 5 mg every 1-2 weeks 6

Common Adverse Effects

• Most frequent: ejaculatory problems, insomnia, headache, nausea, and sexual dysfunction 4
• Nausea is typically mild and transient 3
• Number needed to harm for discontinuation: 20-90 for SSRIs as a class 4
• Most adverse events are mild to moderate in severity 7, 2

Critical Drug Interactions

Do not combine with MAOIs; allow at least 14 days between discontinuing an MAOI and starting escitalopram, and vice versa. 1

• Combining with other serotonergic medications can cause serotonin syndrome (tremor, diarrhea, delirium, neuromuscular rigidity, hyperthermia) 4
• Exercise caution when coadministering with drugs metabolized by CYP2D6 (e.g., metoprolol) 5
• Do not start escitalopram in patients receiving linezolid or IV methylene blue due to serotonin syndrome risk 1

Screening Before Initiation

• Screen all patients for personal or family history of bipolar disorder, mania, or hypomania before starting treatment 1