What are the recommended starting and maximum doses of Lexapro (escitalopram) for adults, elderly patients, patients with hepatic impairment, and adolescents?

Lexapro (Escitalopram) Dosing Guidelines

Standard Adult Dosing

For adults with major depressive disorder or generalized anxiety disorder, start escitalopram at 10 mg once daily (morning or evening, with or without food), and if dose escalation is needed, increase to 20 mg after a minimum of one week. 1

• The 10 mg dose is effective for most patients, and clinical trials failed to demonstrate greater benefit of 20 mg over 10 mg for depression, though both doses were effective 1
• Steady-state plasma concentrations are achieved within 7-10 days of administration 2
• The therapeutic plasma concentration range is 15-80 ng/mL, though routine monitoring is not strongly recommended 3

Elderly Patients

For elderly patients, use 10 mg once daily as both the starting and maximum recommended dose. 1

• Elderly patients are at significantly greater risk of adverse drug reactions and require approximately 50% of the standard adult starting dose 3
• No dose escalation beyond 10 mg is recommended in this population due to increased risk of QT-interval prolongation in patients older than 60 years 3

Hepatic Impairment

For patients with hepatic impairment, use 10 mg once daily as both the starting and maximum recommended dose. 1

• No distinction is made between mild, moderate, or severe hepatic impairment in the FDA labeling—all receive the same 10 mg maximum dose 1

Adolescents (Ages 12-17)

For adolescents with major depressive disorder, start at 10 mg once daily, and if dose escalation is needed after a minimum of three weeks, increase to a maximum of 20 mg daily. 1

• A flexible-dose trial (10-20 mg/day) demonstrated effectiveness in adolescents 1
• The longer waiting period (three weeks vs. one week in adults) before dose escalation reflects greater caution needed in this population 1
• Close monitoring is essential during initiation and dose changes, particularly for behavioral activation, agitation, and suicidal ideation 4

Renal Impairment

No dosage adjustment is necessary for mild or moderate renal impairment, but use escitalopram with caution in severe renal impairment. 1

• The FDA label does not specify a dose reduction for severe renal impairment, only recommends caution 1

Special Safety Considerations

QT Prolongation Risk

• The maximum dose should be limited due to QT-interval prolongation concerns, with further reduction in patients older than 60 years 3
• Escitalopram is classified as having QT-prolongation risk, requiring caution in patients with pre-existing QT interval prolongation 3

Discontinuation Protocol

When stopping escitalopram, taper gradually over a minimum of 10-14 days rather than stopping abruptly. 3

• If intolerable withdrawal symptoms occur during taper (irritability, agitation, dizziness, sensory disturbances, anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania), resume the previous dose and decrease more gradually 3

MAOI Interactions

Allow at least 14 days between discontinuing an MAOI and starting escitalopram, and vice versa. 1

• Do not start escitalopram in patients receiving linezolid or intravenous methylene blue due to serotonin syndrome risk 1
• If urgent treatment with linezolid or IV methylene blue is required in a patient on escitalopram, stop escitalopram promptly and monitor for serotonin syndrome for 2 weeks or until 24 hours after the last dose of linezolid/methylene blue 1

Maintenance Treatment

For patients who respond to acute treatment of major depressive disorder, continue escitalopram for 4-12 months after remission for first episodes; longer maintenance may be beneficial for recurrent depression. 3

• Systematic evaluation demonstrated benefit of maintenance treatment at 10 or 20 mg/day in adults who responded during acute treatment 1
• Periodically reassess patients to determine ongoing need for maintenance treatment 1