What are the dosing recommendations, contraindications, side effects, monitoring, and tapering guidelines for Lexapro (escitalopram) in adults and older adults?

Lexapro (Escitalopram) Clinical Guide

Dosing Recommendations

Standard Adult Dosing

For major depressive disorder and generalized anxiety disorder, start escitalopram at 10 mg once daily, which can be increased to 20 mg daily after a minimum of one week if needed. 1

• The 10 mg dose is effective for most patients, and while 20 mg is also effective, clinical trials failed to demonstrate clear superiority of 20 mg over 10 mg for depression 1
• Administer once daily, morning or evening, with or without food 1
• Full therapeutic response requires 4-8 weeks, so wait at least 1-2 weeks before dose escalation 2

Elderly Patients (≥60 years)

The maximum recommended dose for elderly patients is 10 mg daily due to increased half-life and adverse event risk. 1

• Start at approximately 50% of standard adult doses (consider 5-10 mg daily initially) 2
• Escitalopram half-life increases by approximately 50% in elderly patients compared to younger adults 1
• Elderly patients are at significantly greater risk for hyponatremia (0.5-12% incidence) with SSRIs 3

Hepatic Impairment

Patients with hepatic impairment should receive a maximum dose of 10 mg daily. 1

Renal Impairment

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

Adolescents (12-17 years)

• Start at 10 mg once daily for major depressive disorder 1
• May increase to 20 mg after a minimum of three weeks if needed 1
• Safety and effectiveness not established in children under 12 years 1

Critical Contraindications and Drug Interactions

Absolute Contraindications

Do not use escitalopram concurrently with MAOIs or within 14 days of discontinuing an MAOI due to risk of serotonin syndrome. 1

QT Prolongation Warning

Escitalopram can cause dose-dependent QT interval prolongation, particularly at higher doses and in the presence of other risk factors. 3

• This risk is similar to citalopram and amitriptyline 3
• Monitor ECG in patients with cardiac risk factors, electrolyte abnormalities, or concurrent QT-prolonging medications 3
• Risk is typically present at initiation but depends on coexisting risk factors 3

Drug Interactions

• CYP2C19 inhibitors (omeprazole, cimetidine) significantly reduce escitalopram clearance and may require dose reduction 2
• Avoid combining with other serotonergic medications due to serotonin syndrome risk 4

Common and Serious Adverse Effects

Most Common Side Effects

The most frequent adverse events include nausea (>10% of patients), insomnia, ejaculation disorder, diarrhea, dry mouth, and somnolence. 5

• Approximately 63% of patients on SSRIs experience at least one adverse effect 2
• Nausea and vomiting are the most common reasons for treatment discontinuation 2
• Sexual dysfunction occurs in approximately 40% of patients (weighted mean across observational studies), with escitalopram showing a trend toward increased risk 3
• Sexual effects typically onset within the first week 3

Serious Adverse Effects Requiring Monitoring

Hyponatremia:

• Occurs in 0.5-12% of older adults taking SSRIs 3
• Odds ratio of 3.3 for SSRIs compared to other drug classes 3
• Typically occurs within the first month of treatment 3

Gastrointestinal Bleeding:

• Odds ratio 1.2-1.5, higher with concurrent antiplatelet or NSAID use 3
• Can occur anytime during treatment 3

Hepatotoxicity:

• 0.5-3% develop asymptomatic mild transaminase elevation 3
• Lower risk with SSRIs compared to TCAs 3
• Typically occurs within six months 3

Serotonin Syndrome:

• Monitor especially when combining with other serotonergic medications 4
• Case reports exist even with escitalopram monotherapy at doses of 30 mg/day 4

Suicidality Risk

Monitor for increased suicidality, particularly in adults 18-24 years (OR 2.30), within 1-2 months of initiation or dose increase. 3

• Risk is neutral for adults 25-64 years 3
• Protective effect in adults ≥65 years (OR 0.06) 3

Monitoring Requirements

Initial and Ongoing Monitoring

• Screen for personal or family history of bipolar disorder, mania, or hypomania before initiating treatment 1
• Monitor for QT prolongation, especially at treatment initiation or dose adjustments 2
• Check sodium levels within the first month, particularly in elderly patients 3
• Assess for suicidality within 1-2 months of starting or dose changes 3
• Monitor for bleeding risk, especially with concurrent antiplatelet or NSAID use 3
• In children and adolescents, regularly monitor weight and growth 1

Breastfeeding Considerations

• Escitalopram is excreted in breast milk at approximately 3.9% of maternal weight-adjusted dose 1
• Two case reports exist of excessive somnolence, decreased feeding, and weight loss in breastfed infants 1
• Exercise caution and observe breastfeeding infants for adverse reactions 1

Treatment Duration

Acute Treatment

Continue treatment for at least 4-12 months after remission for a first episode of major depressive disorder. 2

• Systematic evaluation demonstrated benefit of maintenance treatment at 10-20 mg/day in adults who responded during acute treatment 1
• Patients with recurrent depression may benefit from prolonged treatment 2

Long-term Management

• Periodically re-evaluate the long-term usefulness for individual patients 1
• For generalized anxiety disorder, efficacy beyond 8 weeks has not been systematically studied, but periodic reassessment is recommended 1

Tapering and Discontinuation Guidelines

When discontinuing escitalopram, taper gradually over a minimum of 10-14 days rather than stopping abruptly to minimize withdrawal symptoms. 2

Discontinuation Strategy

• Reduce dose gradually rather than abrupt cessation whenever possible 1
• Monitor patients for discontinuation symptoms including irritability, agitation, dizziness, sensory disturbances, anxiety, confusion, headache, lethargy, emotional lability, insomnia, and hypomania 1
• If intolerable symptoms occur after dose reduction, resume the previously prescribed dose and decrease more gradually 1

Common Pitfalls

• Avoid abrupt discontinuation, which increases risk of withdrawal syndrome 2, 1
• Do not assume all patients need 20 mg; 10 mg is effective for most patients 1
• Remember that elderly patients require lower maximum doses (10 mg) due to pharmacokinetic changes 1
• Do not overlook screening for bipolar disorder before initiating treatment 1
• Be vigilant about drug interactions, particularly with MAOIs (14-day washout required) and CYP2C19 inhibitors 2, 1