What is the recommended dosage of Lexapro (escitalopram) for adults with depression or anxiety disorders, considering factors such as age, liver or kidney impairment, and potential interactions with other medications?

Lexapro (Escitalopram) Dosing

For adults with depression or anxiety disorders, start escitalopram at 10 mg once daily, which can be increased to a maximum of 20 mg daily after at least one week for adults or three weeks for adolescents, with dose reductions required for elderly patients (maximum 10 mg daily) and those with hepatic impairment. 1

Standard Adult Dosing

Major Depressive Disorder

• Initial dose: 10 mg once daily (morning or evening, with or without food) 1
• May increase to 20 mg daily after minimum of 1 week in adults 1
• Both 10 mg and 20 mg doses are effective, though 20 mg did not demonstrate greater benefit than 10 mg in fixed-dose trials 1
• The standard dosage range is 10-20 mg per day for outpatient treatment 2

Generalized Anxiety Disorder

• Initial dose: 10 mg once daily 1
• May increase to 20 mg daily after minimum of 1 week 1
• Pooled analysis of three trials demonstrated significant superiority over placebo beginning at weeks 1-2, with both 10 mg and 20 mg doses effective 3

Other Anxiety Disorders

• Panic disorder: Flexible dosing of 5-10 mg/day showed efficacy, with 10 mg demonstrating faster onset than citalopram 4
• Social anxiety disorder: 10-20 mg/day effective in 12- and 24-week studies 4
• Obsessive-compulsive disorder: 20 mg/day for 12 weeks more effective than placebo 4

Special Population Dosing

Elderly Patients (>60 years)

• Maximum dose: 10 mg daily 1, 5
• Elderly patients have increased sensitivity to adverse effects and higher cardiac risk, particularly QT prolongation 5
• Lower starting doses (approximately 50% of adult dose) recommended due to significantly greater risk of adverse drug reactions 2

Hepatic Impairment

• Recommended dose: 10 mg daily 1
• Caution necessary when coadministered with drugs metabolized by CYP2D6 or in patients with severe hepatic impairment 6

Renal Impairment

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

Adolescents (12 years and older)

• Initial dose: 10 mg once daily for depression 1, 5
• May increase to maximum 20 mg daily after minimum of 3 weeks 1, 5
• FDA-approved for adolescents aged 12+ with depression, but not for children under 12 or for anxiety disorders in adolescents 5

Critical Safety Considerations

QT Prolongation Risk

• Obtain baseline ECG in patients over 40 years or with cardiac history before initiating treatment 5
• Risk of QT prolongation increases with doses above 20 mg 5
• Avoid combining with other QT-prolonging medications without careful monitoring 5
• Never exceed 20 mg daily due to lack of FDA approval and increased cardiac risk 5

Drug Interactions

• Low potential for drug interactions due to low protein binding and metabolism by three CYP isozymes 6
• Exercise caution with CYP2D6-metabolized drugs (e.g., metoprolol) 6
• At least 14 days must elapse between discontinuation of an MAOI and initiation of escitalopram, and vice versa 1

Discontinuation Protocol

• Gradual dose reduction recommended rather than abrupt cessation 1
• Reduce incrementally (e.g., by 5 mg every 1-2 weeks) to minimize discontinuation symptoms 5
• Monitor for discontinuation symptoms including dizziness, fatigue, lethargy, headaches, nausea, insomnia, and anxiety 2
• If intolerable symptoms occur, resume previously prescribed dose and decrease more gradually 1

When Maximum Dose is Insufficient

Augmentation Strategies (Rather Than Exceeding 20 mg)

• Add bupropion or mirtazapine for augmentation 5
• Switch to SNRI if somatic symptoms are prominent:
  • Venlafaxine (up to 225 mg daily) 5
  • Duloxetine 5

Maintenance Treatment

• Acute episodes of major depressive disorder require several months or longer of sustained pharmacological therapy beyond response 1
• Systematic evaluation demonstrated benefit of maintenance treatment at 10 or 20 mg/day in adults who responded during acute treatment 1
• For GAD, periodically re-evaluate long-term usefulness, as efficacy beyond 8 weeks has not been systematically studied 1
• Relapse prevention studies showed escitalopram recipients had significantly longer time to relapse (22% vs 50% placebo in social anxiety; 23% vs 52% placebo in OCD) 4

Common Pitfalls to Avoid

• Do not increase dose too rapidly: Wait minimum 1 week in adults, 3 weeks in adolescents before increasing to 20 mg 1
• Do not exceed 20 mg daily: No additional benefit and increased cardiac risk 5, 1
• Do not abruptly discontinue: Taper gradually to avoid withdrawal symptoms 1, 5
• Do not overlook elderly dosing: Maximum 10 mg daily regardless of indication 1, 5