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

Maximum Dose of Lexapro (Escitalopram)

The maximum recommended dose of escitalopram is 20 mg/day for adults, 10 mg/day for elderly patients (≥60 years), and 20 mg/day for adolescents (12-17 years). 1, 2, 3

Adult Dosing (Ages 18-59)

• The standard starting dose is 10 mg daily, with a therapeutic range of 10-20 mg/day for outpatient treatment 1
• The FDA-approved maximum dose is 20 mg/day for adults under 60 years of age 3
• Clinical trials established efficacy using 10-20 mg/day dosing in adults aged 18-65 years with major depressive disorder 3

Important Cardiac Safety Consideration

• The European Heart Journal and European Society of Cardiology recommend limiting the maximum dose due to QT-interval prolongation concerns, particularly in patients with pre-existing cardiac risk factors 4
• Escitalopram carries a dose-dependent risk of QT prolongation that becomes clinically significant at higher doses 4

Elderly Patients (≥60 Years)

The maximum recommended dose is strictly limited to 10 mg/day in patients 60 years and older 2, 3

• Start at approximately 50% of the adult starting dose (5 mg daily) due to significantly greater risk of adverse drug reactions 1, 2
• The half-life increases by approximately 50% in elderly subjects compared to younger adults, justifying the lower maximum dose 3
• Elderly patients face increased risks of both QT interval prolongation and hyponatremia (occurring in 0.5-12% of cases), necessitating conservative dosing 2
• The 10 mg/day maximum applies regardless of indication (depression or generalized anxiety disorder) 2, 3

Adolescents (Ages 12-17)

• The FDA has established safety and efficacy in adolescents using 10-20 mg/day dosing 3
• Maximum dose is 20 mg/day, same as younger adults 3
• An 8-week placebo-controlled study demonstrated efficacy with flexible dosing of 10-20 mg/day in adolescents with major depressive disorder 3
• Regular monitoring of weight and growth is required, as decreased appetite and weight loss have been observed with SSRI use in this age group 3

Pediatric Limitation

• Escitalopram is not approved for children under 12 years of age with major depressive disorder 3
• Safety and effectiveness have not been established in pediatric patients under 18 years for generalized anxiety disorder 3

Special Population Adjustments

Hepatic Impairment

• Maximum dose should be reduced to 10 mg/day in patients with severe hepatic impairment 4

Renal Impairment

• Use with caution in severe renal impairment, though specific dose adjustments are not definitively established 4

Critical Dosing Pitfalls

• Never abruptly discontinue: Taper gradually over a minimum of 10-14 days to avoid withdrawal symptoms (irritability, dizziness, sensory disturbances, anxiety, headache, insomnia) 4, 1
• Do not exceed 10 mg/day in elderly patients: The risk of QT prolongation and hyponatremia increases substantially with both age and dose 2
• Avoid dose escalation beyond FDA-approved limits: While one open-label pilot study explored doses up to 50 mg/day in treatment-resistant depression 5, this is off-label, carries unknown cardiac risks, and should only be considered in exceptional circumstances under specialist supervision
• Ensure adequate treatment duration (4-6 weeks at maximum tolerated dose) before declaring treatment failure 2