What is the recommended Lexapro (escitalopram) dosing, titration, administration timing, and tapering schedule for adults with major depressive disorder or generalized anxiety disorder, elderly patients, adolescents, and patients with hepatic or renal impairment?

Lexapro (Escitalopram) Dosing Guidelines

Standard Adult Dosing

For major depressive disorder and generalized anxiety disorder in adults, start Lexapro at 10 mg once daily, which is the recommended therapeutic dose for most patients. 1

Initial Dosing

• Start at 10 mg once daily (morning or evening, with or without food) 1
• This 10 mg dose is effective for most patients and demonstrated efficacy in clinical trials 1, 2
• Wait a minimum of 1 week before increasing to 20 mg if needed 1
• The 20 mg dose did not demonstrate greater benefit than 10 mg in fixed-dose trials for depression, though it may be considered for anxiety disorders 1, 3

Titration Strategy

• Increase dose slowly using 1-2 week intervals for shorter half-life SSRIs when optimizing treatment 3
• For generalized anxiety disorder, if dose escalation to 20 mg is pursued, wait at least 1 week after starting 10 mg 1
• Allow 4-6 weeks at the optimized dose to assess full therapeutic effect before considering the medication inadequate 4

Special Populations

Elderly Patients

Reduce the starting and maximum dose to 10 mg/day in elderly patients. 1

• Do not exceed 10 mg daily in this population 1
• Lower doses (approximately 50% of standard adult dose) are recommended due to increased risk of adverse drug reactions 3

Adolescents (12-17 years)

Start at 10 mg once daily in adolescents with major depressive disorder. 1

• If dose increase to 20 mg is needed, wait a minimum of 3 weeks (longer than the 1-week wait in adults) 1
• Only fluoxetine is FDA-approved for depression in children; escitalopram is approved only for adolescents 12 years and older 3

Hepatic Impairment

Use 10 mg/day as the maximum dose in patients with hepatic impairment. 1

• No upward titration recommended 1

Renal Impairment

• No dosage adjustment needed for mild to moderate renal impairment 1
• Use with caution in severe renal impairment, though specific dose reduction not mandated 1

Administration Timing

• Once daily dosing, either morning or evening 1
• Food does not affect absorption, so can be taken with or without meals 1, 5
• Steady-state concentrations achieved within 7-10 days 5

Maintenance Treatment

Duration

Continue treatment for 4-12 months after first depressive episode response. 3

• For recurrent depression (2+ prior episodes), consider prolonged maintenance treatment 3
• Periodically reassess the need for continued treatment every few months 1

Monitoring During Maintenance

• Escitalopram 10-20 mg/day demonstrated benefit in maintaining response in controlled trials 1
• The 86% remission rate at 52 weeks in long-term studies supports extended treatment 6

Discontinuation and Tapering

Taper escitalopram gradually rather than stopping abruptly to minimize discontinuation syndrome. 1

Tapering Protocol

• Reduce dose gradually over 10-14 days minimum when discontinuing 3
• If intolerable symptoms emerge during taper, resume the previous dose and decrease more slowly 1
• Monitor for discontinuation symptoms including dizziness, sensory disturbances, anxiety, and gastrointestinal symptoms 3

Switching to/from MAOIs

• Allow at least 14 days between stopping an MAOI and starting escitalopram 1
• Allow at least 14 days after stopping escitalopram before starting an MAOI 1
• For linezolid or IV methylene blue, stop escitalopram promptly and wait 24 hours after last dose before resuming 1

Augmentation Strategies (If Initial Treatment Inadequate)

Optimize escitalopram to 20 mg and allow 8-12 weeks before considering augmentation or switching. 4

Short-Term Bridging Only

• Benzodiazepines (clonazepam or lorazepam) may provide temporary relief during the initial 4-6 weeks while escitalopram reaches therapeutic levels 4
• Schedule follow-up every 1-2 weeks during benzodiazepine use to monitor and plan tapering 4
• Taper benzodiazepines once SSRI effects established—long-term use causes tolerance, dependence, and cognitive impairment 4

If Optimization Fails

• Switch to another SSRI or SNRI rather than augmenting if escitalopram 20 mg proves insufficient after 8-12 weeks 4

Critical Safety Considerations

Before Starting Treatment

Screen all patients for personal or family history of bipolar disorder, mania, or hypomania before initiating escitalopram. 1

Common Adverse Effects to Monitor

• Nausea (usually mild and transient) 2
• Ejaculatory dysfunction 2
• Insomnia or somnolence 3
• Gastrointestinal symptoms 3
• Sexual dysfunction 3

Drug Interactions

• Escitalopram has minimal effect on CYP450 enzymes, resulting in lower propensity for drug interactions compared to other SSRIs 3, 5
• Avoid combining with other serotonergic drugs due to serotonin syndrome risk 3
• Citalopram/escitalopram may cause QT prolongation; avoid doses exceeding 20 mg in most patients 3

Common Pitfalls to Avoid

• Never continue benzodiazepines indefinitely without tapering attempts—this leads to dependence without addressing underlying pathophysiology 4
• Never discontinue abruptly—always taper to avoid discontinuation syndrome 4, 1
• Never start at higher than recommended doses (>10 mg)—this increases risk of deliberate self-harm and suicide-related events 3
• Never exceed 10 mg daily in elderly patients or those with hepatic impairment 1