Citalopram

Citalopram is used to treat depression. It may improve your energy level and feelings of well-being. Citalopram is known as a selective serotonin reuptake inhibitor (SSRI). This medication works by helping to restore the balance of a certain natural substance (serotonin) in the brain. This medication may also be used to treat other mental conditions (such as obsessive-compulsive disorder, panic disorder). It may also be used to treat hot flashes that occur with menopause.

• Citalopram is available under the following different brand names: Celexa

Dosages of Citalopram:

Adult Dosage Forms and Strengths

Tablet

• 10 mg
• 20 mg
• 40 mg

Oral solution

• 10 mg/5mL

Dosage Considerations – Should be Given as Follows:

Depression

Adult:

• Depression in patients whose diagnosis corresponds most closely to the DSM-III and DSM-III-R category of major depressive disorder
• Initial dose: 20 mg orally once/day
• If needed, may increase to 40 mg/day after at least 1 week
• Doses above 40 mg/day are not recommended, because of the risk for QT prolongation without additional benefit for treating depression

Pediatric, Off-label:

Younger than 12 years:

• 10 mg orally once/day; may increase by 5 mg/day every 2 weeks to 40 mg orally once/day; doses greater than 40 mg not recommended (may increase risk of QT prolongation)

12 years and older:

• 20 mg orally once/day; may increase by 10 mg/day every 2 weeks to 40 mg orally once/day; doses greater than 40 mg not recommended (may increase risk of QT prolongation)

Geriatric: Older than 60 years: Do not exceed 20 mg orally once/day

Dosing Modifications

Poor CYP2C19 metabolizers or co-administration with CYP2C19 inhibitors (e.g., cimetidine, fluconazole, omeprazole): Do not exceed 20 mg/day

Hepatic impairment decreases clearance and therefore increases the risk of QT prolongation; do not exceed 20 mg/day

MAO inhibitors

• Not for administration within 14 days of administering an MAO inhibitor

Linezolid or Methylene Blue Therapy

• Not for administration to patients that are receiving linezolid or IV methylene blue; consider other forms of therapy; if therapy required and benefits outweigh risks discontinue citalopram therapy, administer linezolid or methylene blue and monitor for serotonin syndrome for 2 weeks or 24 hours after the last dose of linezolid or methylene blue

Renal impairment

• Mild to moderate renal impairment: No dosage adjustment is required
• Severe renal impairment (CrCl less than 20 mL/min): Not studied; use with caution

Alcoholism (Off-label)

• 20-40 mg orally once/day

Binge-eating Disorder (Off-label)

• 20-60 orally once/day

Generalized Anxiety Disorder (Off-label)

• Initial: 10 mg orally once/day; may titrate to 40 mg/day

Panic Disorder (Off-label)

• 20 mg orally once/day initially; after 1 week, may increase to 40 mg/day if warranted
• Not to exceed 40 mg/day because of increased risk for QT prolongation

Hot Flashes (Off-label)

• Initial: 10 mg orally once/day; may increase to 20 mg/day after 1 week

Obsessive-Compulsive Disorder (Off-label)

• Initial: 20 mg orally once/day; may titrate to 40-60 mg/day; improvement may be seen 4-6 weeks after initiating therapy

Premenstrual Dysphoric Disorder (Off-label)

• 5 mg orally on the estimated day of ovulation; increase the dose by 5 mg each day thereafter to a maximum 30 mg; continue thereafter until menstruation begins; decrease dose to 20 mg on the first day of menstruation; the next day, decrease to 10 mg; stop the treatment from day 3 until ovulation begins

Impulsive Aggressive Behavior, Pediatric (Off-label)

• 10 mg orally once/day; titrate by 10 mg/week, as tolerated to a maximum of 40 mg/day

Dosing Considerations

• The elderly are more prone to SSRI/SNRI-induced hyponatremia and risk for QT prolongation

Side effects of citalopram include:

• Dry mouth
• Nausea
• Drowsiness
• Insomnia
• Increased sweating
• Tremor
• Diarrhea
• Ejaculation disorder
• Runny nose
• Upper respiratory infection
• Indigestion
• Fatigue
• Vomiting
• Anxiety
• Loss of appetite
• Abdominal pain
• Agitation
• Impotence
• Sinusitis
• Painful menstrual periods
• Decreased sex drive
• Yawning
• Joint pain
• Muscle pain
• Absence of menstrual periods (amenorrhea)
• Confusion
• Cough
• Gas (flatulence)
• Increased saliva
• Migraine
• Dizziness upon standing
• Numbness and tingling
• Increased urination
• Itching
• Rash
• Fast heart rate
• Weight changes

This document does not contain all possible side effects and others may occur. Check with your physician for additional information about side effects.

If your doctor has directed you to use this medication, your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor, health care provider, or pharmacist first.

• Severe Interactions of citalopram include:
  • dronedarone
  • goserelin
  • isocarboxazid
  • leuprolide
  • phenelzine
  • pimozide
  • procarbazine
  • selegiline
  • selegiline transdermal
  • tranylcypromine
  • ziprasidone
• Citalopram has serious interactions with at least 79 different drugs.
• Citalopram has moderate interactions with at least 208 different drugs.
• Mild Interactions of citalopram include:
  • simeprevir

This information does not contain all possible interactions or adverse effects. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share this information with your doctor and pharmacist. Check with your health care professional or doctor for additional medical advice, or if you have health questions, concerns, or for more information about this medicine.

Warnings

• In short-term studies, antidepressants increased the risk of suicidal thinking and behavior in children, adolescents, and young adults (younger than 24 years) taking antidepressants for major depressive disorders and other psychiatric illnesses
• This increase was not seen in patients older than 24 years; a slight decrease in suicidal thinking was seen in adults over 65 years
• In children and young adults, the risks must be weighed against the benefits of taking antidepressants
• Patients should be monitored closely for changes in behavior, clinical worsening, and suicidal tendencies; this should be done during initial 1-2 months of therapy and dosage adjustments
• The patient's family should communicate any abrupt changes in behavior to the healthcare provider
• Worsening behavior and suicidal tendencies that are not part of the presenting symptoms may require discontinuation of therapy
• Not FDA approved for the treatment of a bipolar disorder
• This drug is not FDA approved for use in pediatric patients
• This medication contains citalopram. Do not take Celexa if you are allergic to citalopram or any ingredients contained in this drug
• Keep out of reach of children. In case of overdose, get medical help or contact a Poison Control Center immediately

Contraindications

• Hypersensitivity
• Coadministration with pimozide
• Coadministration with serotonergic drugs
  • Concomitant use or within 14 days of MAOIs increases the risk of serotonin syndrome
  • Symptoms include tremor, myoclonus, diaphoresis, nausea, vomiting, flushing, dizziness, hyperthermia with features resembling neuroleptic malignant syndrome, seizures, rigidity, autonomic instability with possible rapid fluctuations of vital signs, and mental status changes that include extreme agitation progressing to delirium and coma
  • Starting citalopram in a patient who is being treated with linezolid or IV methylene blue is contraindicated because of an increased risk of serotonin syndrome
  • If linezolid or IV methylene blue must be administered, discontinue SSRI immediately and monitor for CNS toxicity; may resume 24 hours after last linezolid or methylene blue dose, or after 2 weeks of monitoring (5 weeks for fluoxetine), whichever comes first

Effects of Drug Abuse

• None

Short-Term Effects

• See "What Are Side Effects Associated with Using Citalopram?"

Long-Term Effects

• See "What Are Side Effects Associated with Using Citalopram?"

Cautions

• Pregnancy: Conflicting evidence regarding the use of SSRIs during pregnancy and increased risk of persistent pulmonary hypertension of the newborn, or PPHN
• Neonates exposed to SNRIs/SSRIs late in the third trimester: Risk of complications such as feeding difficulties, irritability, and respiratory problems
• Clinical worsening and suicide ideation may occur despite medication in adolescents and young adults (18-24 years)
• Risk of mydriasis; may trigger angle closure attack in patients with angle-closure glaucoma with anatomically narrow angles without a patent iridectomy
• Risk of hyponatremia, abnormal bleeding (increased if concomitant aspirin, NSAIDs, or anticoagulants, or hemorrhagic diathesis), and impairment of cognitive and motor functions
• Risk of serotonin syndrome or neuroleptic malignant syndrome (NMS)-like reactions have been reported with SSRIs alone or with concomitant use of serotonergic drugs, with drugs that impair metabolism of serotonin, or with antipsychotics or other dopamine antagonists
• Activation of mania/hypomania has been reported; use caution when treating patients with a history of mania
• Increased risk of bone fractures reported with antidepressant use; use caution; consider the possibility of fracture it patient presents with bone pain
• May cause or exacerbate sexual dysfunction
• Use caution when treating patients with a history of seizure disorder
• Rare cases of hyponatremia and development of SIADH were reported with either SSRI or SNRI use
• Consider the risk of serotonin syndrome if administered concomitantly with other serotonergic drugs including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. John's Wort
• Not recommended in patients with uncompensated heart failure
• QT prolongation:
  • Dose-dependent QT prolongation reported; do not exceed the dose of 40 mg/day
  • Correct hypokalemia and hypomagnesemia before initiating and monitor periodically
  • ECG monitoring is recommended in patients with CHF, bradyarrhythmias, or concomitant medications known to prolong QT interval
  • Do not exceed 20 mg/day if administered in CYP2C19 poor metabolizers, or patients taking concomitant cimetidine or another CYP2C19 inhibitor (e.g., fluconazole, omeprazole)
  • Do not exceed 20 mg/day in individuals aged 60 years or older or those with hepatic impairment

Pregnancy and Lactation

Use Citalopram with caution if the benefits outweigh the risks. Animal studies show risk and human studies not available or neither animal nor human studies done. Use of citalopram late in the third trimester is associated with complications in newborns and may require prolonged hospitalization, respiratory support, and tube feeding.

Persistent pulmonary hypertension of the newborn:

• The potential risk of PPHN when used during pregnancy
• Initial public health advisory, in 2006, was based on a single published study; since then, there have been conflicting findings from new studies, making it unclear whether the use of SSRIs during pregnancy can cause PPHN
• FDA has reviewed the additional new study results and has concluded that, given the conflicting results from different studies, it is premature to reach any conclusion about a possible link between SSRI use in pregnancy and PPHN
• FDA recommendation: FDA advises health care professionals not to alter their current clinical practice of treating depression during pregnancy and to report any adverse events to the FDA MedWatch program
• A meta-analysis of 7 observational studies, found exposure to SSRIs in late pregnancy (i.e., greater than 20 weeks gestation) more than doubled the risk of PPHN that could not be explained by other etiologies (e.g., congenital malformations, meconium aspiration)

Citalopram is excreted in breast milk; use caution while breastfeeding.