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Citalopram

Class
Antidepressants
Subclass
Selective serotonin reuptake inhibitors
Substance name
Citalopram hydrobromide
Brand names
Celexa®
Common formulations
Film-coated tablet
Dosage and administration
Adults patients
Major depressive disorder
•
Maintenance: 20 mg PO daily
•
Maximum: 40 mg per day
Taken with or without food. Consider titrating to 40 mg daily at an interval of no less than 1 week.
OCD • Off-label
•
Start at: 20 mg PO daily
•
Maintenance: 40 mg PO daily
•
Maximum: 40 mg per day
Alternative
•
Start at: 20 mg PO daily
•
Maintenance: 40-60 mg PO daily
•
Maximum: 80-120 mg per day
Panic disorder • Off-label
•
Start at: 10 mg PO daily
•
Maintenance: 20-40 mg PO daily
Premenstrual dysphoric disorder • Off-label
•
5-20 mg PO daily
Vasomotor symptoms with menopause • Off-label
•
Start at: 10 mg PO daily
•
Maintenance: 10-20 mg PO daily
Other off-label uses
•
Symptomatic relief of behavioral and psychological symptoms of dementia
•
Treatment of emotional lability in patients with ALS
•
Treatment of generalized anxiety disorder
Indications for use
Labeled indications
Adults
•
Treatment of major depressive disorder
Off-label indications
Adults
•
Symptomatic relief of behavioral and psychological symptoms of dementia
•
Treatment of emotional lability in patients with ALS
•
Treatment of generalized anxiety disorder
•
Treatment of OCD
•
Treatment of panic disorder
•
Treatment of premenstrual dysphoric disorder
•
Treatment of vasomotor symptoms with menopause
Safety risks
Boxed warnings
Suicidal ideation
•
Use extreme caution in patients with major depressive disorder or other psychiatric disorders, particularly in children, adolescents, and young adults. Monitor closely for suicidality and unusual changes in behavior.
Contraindications
Hypersensitivity to citalopram or its components or escitalopram
Concomitant use of MAOIs
•
Do not use citalopram with or within 14 days of stopping MAOIs, including reversible MAOIs, such as linezolid and methylene blue.
Concomitant use of pimozide
•
Do not use citalopram with pimozide because of the risk of QT prolongation.
Warnings and precautions
Antidepressant discontinuation syndrome
•
Do not discontinue abruptly in any patient.
Bleeding
•
Use caution in patients taking aspirin, NSAIDs, antiplatelet or anticoagulant therapy. Monitor INR in patients on warfarin.
Exacerbation of acute angle-closure glaucoma
•
Use caution in patients with untreated anatomically narrow angles. Avoid use if possible.
Exacerbation of seizure
•
Use caution in patients with seizure disorder.
Hyponatremia, SIADH
•
Use caution in all patients, especially in the elderly and in patients with volume depletion or taking diuretics.
Prolonged QT interval
•
Use caution in all patients, as citalopram causes dose-dependent QT prolongation. Do not exceed 40 mg once daily.
•
Use caution in patients aged > 60 years, CYP2C19 poor metabolizers, or patients taking other CYP2C19 inhibitors, as higher citalopram exposures would be expected. Do not exceed 20 mg once daily.
Reactivation of mania
•
Use caution in patients with bipolar disorder. Screen patients for any personal or family history of bipolar disorder, mania, or hypomania before initiating citalopram.
Serotonin syndrome
•
Use caution in patients taking other serotonergic drugs (including triptans, TCAs, fentanyl, lithium, tramadol, meperidine, methadone, tryptophan, buspirone, amphetamines, and St. John's Wort). Monitor all patients for signs and symptoms of serotonin syndrome.
Sexual dysfunction
•
Maintain a high level of suspicion, as SSRIs have been associated with decreased libido, erectile dysfunction, and ejaculatory delay or failure in males, and decreased libido and delayed or absent orgasm in females.
Torsades de pointes, ventricular arrhythmias
•
Use extreme caution in patients with congenital long QT syndrome, bradycardia, hypokalemia, hypomagnesemia, recent acute myocardial infarction, uncompensated HF, or taking other QT-prolonging drugs. Avoid use unless the benefits outweigh the risks. Obtain ECG monitoring when used.
Specific populations
Renal impairment
CrCl ≥ 20 mL/min
•
Use acceptable. No dose adjustment required.
CrCl < 20 mL/min
•
No guidance available.
Renal replacement therapy
Continuous renal replacement
•
No guidance available.
Intermittent hemodialysis
•
No guidance available.
Peritoneal dialysis
•
No guidance available.
Hepatic impairment
Any severity
•
Maximal dose of 20 mg per day.
Pregnancy and breastfeeding
Pregnancy
First trimester • Australia Category: C
•
Use only if benefits outweigh potential risks.
Second trimester • Australia Category: C
•
Use only if benefits outweigh potential risks.
Third trimester • Australia Category: C
•
Consider safer alternatives. Monitor neonates for direct toxic effects of the drug, serotonin syndrome and discontinuation syndrome. The use of SSRIs in late pregnancy is associated with an increased risk of postpartum hemorrhage, persistent pulmonary hypertension of the newborn, and symptoms of poor adaptation in the neonate.
•
The American College of Obstetrics and Gynecology recommends SSRIs as first-line pharmacotherapy for perinatal depression and anxiety, with citalopram being a reasonable option. The Canadian Network for Mood and Anxiety Treatments recommends citalopram as a second-line option for major depressive disorder during pregnancy.
Breastfeeding
Use only if benefits outweigh potential risks.
Very low levels in breastfed infants (< 5%).
May potentially cause adverse effects in breastfed infants.
Some adverse effects on lactation reported.
Adverse reactions
Very common > 10%
•
Hyperhidrosis, dry mouth, insomnia, nausea, somnolence
Common 1-10%
•
Hypotension, migraine, orthostatic hypotension, abdominal pain, erectile dysfunction, amenorrhea, anorgasmia, anxiety, arthralgia, myalgia, confusion, cough, ↓ libido, diarrhea, dysgeusia, dysmenorrhea, agitation, dyspepsia, ejaculation difficulties, fatigue, fever, flatulence, hypersalivation, itching, difficulty concentrating, apathy, memory impairment, loss of appetite, paresthesia, polyuria, skin rash, suicidal ideation, tremor, vomiting, weight gain, ↑ appetite, weight loss, yawning, rhinitis, sinusitis, tachycardia, upper respiratory tract infections
Uncommon < 1%
•
Abnormal oral glucose tolerance test, anemia, ataxia, bradycardia, breast enlargement, conjunctivitis, ↓ WBC count, ↑ WBC count, dystonia, gait disturbance, hypoesthesia, esophagitis, gastritis, gingivitis, ↑ libido, heart failure, hemorrhoids, hypertension, hypertonia, leg cramps, hypokinesia, ↑ liver enzymes, ↑ thirst, ↑ serum ALP, dry eyes, skin dryness, lymphadenopathy, myocardial infarction, peripheral edema, photosensitivity of skin, pneumonia, psychosis, purpura, bone pain, bruxism, chest pain, dysphagia, dyspnea, dysuria, euphoria, eye pain, galactorrhea, breast pain, hair loss, hallucinations, delusions, emotional lability, mania, muscle cramps, muscle weakness, nosebleed, seizure, skin flushing, hot flashes, rigors, syncope, syncope, tinnitus, urinary frequency, urinary incontinence, urinary retention, vaginal bleeding, vertigo, hyperkinesia, skin discoloration, stomatitis, belching, stroke, urticaria
Rare < 0.1%
•
Atrial fibrillation, acute cholecystitis, colitis, peptic ulcer disease, cholelithiasis, angioedema, bronchospasm, cardiac arrest, acute diverticulitis, cataract, pyelonephritis, coagulopathy, gingival bleeding, ↓ blood lymphocyte count, ↓ serum potassium, ↓ urine output, dehydration, gastroesophageal reflux, mydriasis, glossitis, goiter, gynecomastia, hyperesthesia, hypothyroidism, ↑ blood lymphocyte count, ↑ serum TBIL, jaundice, keratitis, osteoporosis, acute bursitis, pulmonary embolism, cellulitis, pruritus ani, phlebitis, pneumonitis, ptosis, stupor, diplopia, flank pain, hematuria, facial edema, hiccups, ↓ blood glucose, incoordination, photophobia, transient ischemic attack
Unknown frequency
•
Acute angle-closure glaucoma, Stevens-Johnson syndrome, acute pancreatitis, anaphylaxis, antidepressant discontinuation syndrome, choreoathetosis, ↓ platelet count, ↓ serum sodium, delirium, dyskinesia, ecchymosis, erythema multiforme, gastrointestinal bleeding, hemolytic anemia, hepatic necrosis, hyperprolactinemia, ventricular arrhythmia, myoclonus, ↑QT interval, renal failure, akathisia, nystagmus, anosmia, priapism, rhabdomyolysis, syndrome of inappropriate antidiuretic hormone secretion, serotonin syndrome, torsade de pointes, toxic epidermal necrolysis
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