What is the maximum daily dose of Lexapro (escitalopram) for a typical adult, for patients aged ≥ 65 years, and for those with significant liver impairment?

Maximum Dose of Lexapro (Escitalopram)

The maximum daily dose of escitalopram is 20 mg for typical adults, 10 mg for patients aged ≥60 years, and 10 mg for those with hepatic impairment. 1

Standard Adult Dosing (Age <60 Years)

• The FDA-approved maximum dose is 20 mg once daily for adults under 60 years of age. 1
• The recommended starting dose is 10 mg once daily, with dose increases to 20 mg permitted after a minimum of one week for major depressive disorder or generalized anxiety disorder. 1
• Both 10 mg and 20 mg doses have demonstrated effectiveness, though clinical trials failed to show greater benefit of 20 mg over 10 mg in some studies. 1

Elderly Patients (Age ≥60 Years)

• The maximum recommended dose is strictly limited to 10 mg per day in patients aged 60 years and older due to dose-dependent QT interval prolongation risk. 2, 1
• Initiation should begin at approximately 5 mg per day (50% of the standard adult starting dose) with careful titration up to the 10 mg ceiling. 2
• This 10 mg limit in elderly patients is non-negotiable because the risk of QT prolongation rises significantly with both advancing age and increasing escitalopram dose. 2
• Hyponatremia occurs in approximately 0.5–12% of older adults receiving SSRIs, supporting the need for conservative dosing and regular electrolyte monitoring. 3, 2

Hepatic Impairment

• 10 mg per day is the recommended dose for patients with hepatic impairment, with no further dose escalation. 1
• This represents both the starting and maximum dose in this population. 1

Renal Impairment

• No dosage adjustment is necessary for patients with mild or moderate renal impairment. 1
• Escitalopram should be used with caution in patients with severe renal impairment, though specific dose reductions are not mandated by the FDA label. 1

Adolescents (Age 12–17 Years)

• The recommended starting dose is 10 mg once daily, with a maximum dose of 20 mg once daily after at least three weeks at the lower dose. 2, 1
• Escitalopram is FDA-approved for treating major depressive disorder in adolescents aged 12 years and older. 2

Critical Safety Consideration: QT Prolongation

• QT interval prolongation is dose-dependent and represents the primary safety rationale for limiting escitalopram doses, particularly in older adults and at higher daily doses. 3, 2
• The risk is markedly increased at doses exceeding the recommended maximums, making adherence to these limits essential. 2
• Compared with citalopram (maximum 40 mg in adults <60 years and 20 mg in elderly), escitalopram has lower maximum doses across all populations. 2

Discontinuation Protocol

• When stopping escitalopram at any dose, taper gradually over at least 10–14 days to minimize withdrawal symptoms including irritability, dizziness, sensory disturbances, and anxiety. 2, 4, 1
• If intolerable withdrawal symptoms emerge during taper, resume the previous dose and then decrease more slowly. 2, 4