Maximum Dose of Lexapro in Older Adults
The maximum recommended daily dose of Lexapro (escitalopram) for patients aged 60 years and older is 10 mg/day. 1, 2
FDA-Approved Dosing for Elderly Patients
The FDA drug label explicitly states that 10 mg/day is the recommended dose for elderly patients, based on pharmacokinetic studies showing approximately 50% increased half-life in elderly subjects compared to younger patients, though Cmax remained unchanged. 2
The FDA defines "elderly" or "geriatric" patients as those aged 60 years or older for escitalopram dosing purposes. 2
Guideline-Based Recommendations
The American Family Physician guidelines specify that for patients older than 60 years, the maximum recommended dose is 10 mg/day for escitalopram, which is half the standard adult maximum of 20 mg/day. 1
This dose reduction is mandatory due to increased risk of QT interval prolongation in elderly patients, not merely a suggested starting point. 1
Starting doses should be approximately 50% of standard adult doses (consider 5 mg/day initially), then titrate to the maximum of 10 mg/day if clinically indicated. 3, 1
Critical Safety Rationale
QT prolongation risk increases with age and dose, making the 10 mg/day ceiling particularly important in patients over 60 years. 4, 1
Elderly patients face significantly greater risk of adverse drug reactions, including hyponatremia (occurring in 0.5-12% of older adults taking SSRIs), which supports conservative dosing. 4, 2
The European Heart Journal reports that elderly patients face increased risks of QT interval prolongation, necessitating strict dose limitation. 1
Treatment Duration and Monitoring
Allow at least 4-6 weeks at the maximum tolerated dose (up to 10 mg/day) before declaring treatment failure in elderly patients. 1
Continue treatment for 4-9 months after remission for first episode of major depression; for recurrent depression (≥2 episodes), consider maintenance therapy for years to lifelong. 3
Monitor closely for hyponatremia, falls risk, and cardiac effects, as elderly patients may be at greater risk for these adverse events. 2
Common Pitfalls to Avoid
Do not exceed 10 mg/day in patients ≥60 years without cardiac monitoring, as higher doses increase QT prolongation risk without demonstrated additional benefit in this population. 1, 2
Do not assume that lack of response at 10 mg/day warrants dose escalation to 20 mg/day—instead, consider switching medication classes or augmentation strategies. 3, 1
Avoid premature dose increases before allowing adequate trial duration (minimum 4-6 weeks at therapeutic dose). 1