What is the recommended initial dose of Lexapro (escitalopram) for adults, elderly patients, and adolescents?

Recommended Starting Dose of Lexapro (Escitalopram)

The recommended starting dose of escitalopram is 10 mg once daily for adults, 10 mg once daily for adolescents (ages 12+), and 5 mg once daily (maximum 10 mg/day) for elderly patients (≥60 years). 1

Adult Dosing

• Start at 10 mg once daily, administered in the morning or evening, with or without food 1
• If dose escalation is needed to 20 mg/day, wait a minimum of one week before increasing 1
• Fixed-dose trials demonstrated effectiveness of both 10 mg and 20 mg, but failed to show greater benefit of 20 mg over 10 mg for major depressive disorder 1
• For generalized anxiety disorder, the starting dose is also 10 mg once daily, with potential increase to 20 mg after at least one week 1
• Pooled trial data confirm that 10 mg/day is effective and well-tolerated, with many patients achieving response without dose escalation 2

Adolescent Dosing (Ages 12-17)

• Start at 10 mg once daily for adolescents with major depressive disorder 3, 1
• If dose increase to 20 mg is considered, wait a minimum of three weeks (longer than the one-week wait for adults) 3, 1
• Only fluoxetine and escitalopram are FDA-approved for adolescent depression, with escitalopram approved for ages 12 and older 3
• Critical safety consideration: Starting at higher-than-recommended doses increases the risk of deliberate self-harm and suicide-related events 3

Elderly Patients (≥60 Years)

• Start at 5 mg once daily with a maximum dose of 10 mg/day for patients 60 years and older 4, 5, 1
• Lower starting doses (approximately 50% of adult starting dose) are recommended due to significantly greater risk of adverse drug reactions in geriatric populations 4, 5
• The standard adult dosing range of 10-20 mg/day does not apply to elderly patients 5
• QT interval prolongation risk increases with both age and dose, necessitating stricter dose limits in this population 4, 5
• Elderly patients also face increased risk of hyponatremia (0.5-12% incidence), justifying conservative dosing 5

Special Populations

• Hepatic impairment: Use 10 mg/day as the maximum recommended dose 1
• Severe renal impairment: Use with caution; no specific dose adjustment provided but lower doses may be prudent 1
• Mild to moderate renal impairment: No dosage adjustment necessary 1

Pharmacokinetic Considerations

• Steady-state concentrations are achieved within 7-10 days of once-daily administration 6
• The elimination half-life is 27-33 hours, supporting once-daily dosing 6
• Escitalopram exhibits linear and dose-proportional pharmacokinetics in the 10-30 mg/day range 6
• Food does not affect absorption 6

Common Pitfalls to Avoid

• Do not start elderly patients at 10 mg/day—this is the maximum dose for this population, not the starting dose 5, 1
• Do not escalate doses too quickly in adolescents—wait three weeks before considering increase to 20 mg 3, 1
• Do not abruptly discontinue—taper gradually over a minimum of 10-14 days to avoid withdrawal symptoms including irritability, dizziness, sensory disturbances, and anxiety 4
• Screen for bipolar disorder before initiating treatment to avoid precipitating mania 1
• Monitor closely during the first few months and after dose changes for clinical worsening, suicidality, and unusual behavioral changes, especially in adolescents 3

Treatment Duration Considerations

• Ensure adequate trial duration of at least 4-6 weeks at maximum tolerated dose before declaring treatment failure 5
• For first episode major depressive disorder, continue treatment for 4-12 months after remission 4
• Long-term studies demonstrate continued efficacy and favorable tolerability over 12 months, with remission rates increasing from 46% at 8 weeks to 86% at 52 weeks 7