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

Lexapro (Escitalopram) Dosing Guidelines

For adults with major depressive disorder or generalized anxiety disorder, start Lexapro at 10 mg once daily and increase to 20 mg after a minimum of one week if needed; for adolescents (12+ years) with depression, start at 10 mg daily and wait at least three weeks before increasing to 20 mg; elderly patients and those with hepatic impairment should remain at 10 mg daily. 1

Adult Dosing

Major Depressive Disorder

• Starting dose: 10 mg once daily (morning or evening, with or without food) 1
• Dose escalation: May increase to 20 mg daily after a minimum of 1 week 1
• Effective dose range: Both 10 mg and 20 mg are effective, though clinical trials failed to demonstrate greater benefit of 20 mg over 10 mg 1
• Maintenance: Continue for several months or longer beyond acute response; periodically reassess need for continued treatment 1

Generalized Anxiety Disorder

• Starting dose: 10 mg once daily 1
• Dose escalation: May increase to 20 mg daily after a minimum of 1 week 1
• Typical dose range: 10-20 mg/day, with mean doses around 11.6 mg/day in naturalistic settings 2
• Evidence: Escitalopram 10-20 mg/day demonstrates significant improvement beginning at week 1, with response rates of 58-68% versus 38-41% for placebo 3, 4

Adolescent Dosing (Ages 12-17 Years)

• Starting dose: 10 mg once daily 5, 1
• Dose escalation: May increase to 20 mg daily after a minimum of 3 weeks 1
• Maximum dose: 20 mg daily 5
• FDA approval: Escitalopram is FDA-approved for adolescents aged 12 years and older with major depressive disorder 5
• Important safety note: Start at normal starting doses (not higher) to reduce risk of deliberate self-harm and suicide-related events 5

Elderly Patients (≥65 Years)

• Recommended dose: 10 mg daily 5, 1
• Rationale: Elderly patients are at significantly greater risk of adverse drug reactions, though pharmacokinetic differences are not clinically relevant 6
• Dose adjustment: Generally, no dose increase is recommended for most elderly patients 1
• Evidence: In elderly patients with comorbid depression and anxiety, escitalopram 10-20 mg/day for 12 weeks showed significant improvements with good tolerability 7

Special Populations

Hepatic Impairment

• Recommended dose: 10 mg daily 5, 1
• No dose escalation is typically recommended 1

Renal Impairment

• Mild to moderate: No dosage adjustment necessary 1
• Severe: Use with caution; no specific dose adjustment provided but monitoring is advised 1

Pharmacokinetic Considerations

• Time to steady state: 7-10 days 6
• Half-life: 27-33 hours, supporting once-daily dosing 6
• Time to peak concentration: 3-4 hours after administration 6
• Food effect: Absorption not affected by food 1, 6
• Protein binding: Low (56%), minimizing drug interaction risk 6

Discontinuation

• Taper gradually rather than stopping abruptly to minimize withdrawal symptoms 1
• If intolerable symptoms occur during dose reduction, resume the previous dose and decrease more gradually 1
• All SSRIs should be slowly tapered when discontinued due to risk of withdrawal effects 5

Drug Interactions and Contraindications

• MAOIs: Allow at least 14 days between discontinuing an MAOI and starting escitalopram, and vice versa 1
• Linezolid or IV methylene blue: Do not start escitalopram in patients receiving these agents due to serotonin syndrome risk; if urgent treatment needed, stop escitalopram and monitor for 2 weeks or 24 hours after last dose of linezolid/methylene blue 1
• CYP2C19 inhibitors: Cimetidine and omeprazole increase escitalopram exposure by 72% and 51% respectively, though not considered clinically relevant 6

Common Pitfalls to Avoid

• Do not increase to 20 mg too quickly in adolescents—wait the full 3 weeks minimum 1
• Do not exceed 10 mg daily in elderly patients or those with hepatic impairment without careful consideration 5, 1
• Do not start at higher than recommended doses in adolescents, as this increases suicide risk 5
• Do not forget to screen for bipolar disorder before initiating treatment 1
• Monitor closely during initial weeks for emergence of adverse events, behavioral activation, or suicidality, especially in adolescents 5