What is the maximum recommended dose of Lexapro (escitalopram) for adults, older adults (≥ 65 years), and adolescents (12–17 years)?

Maximum Dose of Lexapro (Escitalopram)

The maximum recommended dose of escitalopram is 20 mg per day for adults and adolescents (12-17 years), while elderly patients (≥65 years) should not exceed 10 mg per day. 1, 2

Adult Dosing (Ages 18-64)

• Maximum dose: 20 mg daily 1, 2
• The FDA label confirms that escitalopram pharmacokinetics are linear and dose-proportional in the range of 10-30 mg/day, but the approved maximum therapeutic dose remains 20 mg daily 2
• Doses above 20 mg carry increased risk of QT interval prolongation without additional therapeutic benefit 3, 1

Elderly Patients (≥65 Years)

• Maximum dose: 10 mg daily 2
• This reduced maximum is necessary because escitalopram AUC and half-life increase by approximately 50% in elderly subjects compared to younger adults 2
• The European Society of Cardiology specifically recommends further dose reduction in patients older than 60 years due to QT-prolongation concerns 3
• A study in elderly patients with comorbid depression and anxiety demonstrated efficacy and tolerability with 10-20 mg/day dosing, though the FDA-approved maximum remains 10 mg 4

Adolescents (Ages 12-17)

• Maximum dose: 20 mg daily 1
• Initial dosing should start at 10 mg once daily 1
• Dose increases should occur only after a minimum of three weeks 1
• Pharmacokinetic studies show that adolescents have similar steady-state concentrations to adults, with no dosage adjustment needed based on age alone 2

Special Population Considerations

Hepatic Impairment

• Maximum dose: 10 mg daily for most hepatically impaired patients 2
• Citalopram oral clearance was reduced by 37% and half-life doubled in patients with reduced hepatic function 2

Renal Impairment

• Mild to moderate renal impairment: No dose adjustment required 2
• Severe renal impairment (creatinine clearance <20 mL/min): No specific data available; use 10 mg maximum with caution 2

Critical Safety Warnings

• QT prolongation risk increases with doses above 20 mg, making higher doses both unsafe and unapproved 3, 1
• The European Heart Journal classifies escitalopram as having QT-prolongation risk, particularly at maximum doses 3
• When discontinuing, taper gradually over a minimum of 10-14 days to avoid withdrawal symptoms including irritability, agitation, dizziness, and sensory disturbances 3

Common Pitfall to Avoid

Do not exceed 20 mg daily in adults or adolescents, or 10 mg daily in elderly patients, even if therapeutic response appears inadequate—the risk of cardiac adverse events outweighs any potential benefit, and no evidence supports efficacy above these thresholds 1, 2.