Formulary
Citalopram: Indications, Dosing, Side Effects and Interactions
For all selective serotonin re-uptake inhibitors Selectively inhibit the re-uptake of serotonin (5-hydroxytryptamine, 5-HT).
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Citalopram: Indications, Dosing, Side Effects and Interactions
For all selective serotonin re-uptake inhibitors Selectively inhibit the re-uptake of serotonin (5-hydroxytryptamine, 5-HT).
Drug action
For all selective serotonin re-uptake inhibitors Selectively inhibit the re-uptake of serotonin (5-hydroxytryptamine, 5-HT).
Indications and dose
**Depressive illness**
- **Adult** (By Mouth Using Tablets): Initially 20 mg once daily, increased if necessary up to 40 mg once daily, dose may be adjusted within 3-4 weeks of initial dose, and at appropriate intervals thereafter.
- **Elderly** (By Mouth Using Tablets): Initially 10 mg once daily, increased if necessary up to 20 mg once daily, dose may be adjusted within 3-4 weeks of initial dose, and at appropriate intervals thereafter.
- **Adult** (By Mouth Using Oral Drops): Initially 16 mg once daily, increased if necessary up to 32 mg once daily, dose may be adjusted within 3-4 weeks of initial dose, and at appropriate intervals thereafter.
- **Elderly** (By Mouth Using Oral Drops): Initially 8 mg once daily, increased if necessary up to 16 mg once daily, dose may be adjusted within 3-4 weeks of initial dose, and at appropriate intervals thereafter.
**Depressive illness [known CYP2C19 poor metabolisers]**
- **Adult** (By Mouth Using Tablets): Initially 10 mg once daily, increased if necessary up to 20 mg once daily, dose may be increased after 2 weeks of initial dose.
- **Adult** (By Mouth Using Oral Drops): Initially 8 mg once daily, increased if necessary up to 16 mg once daily, dose may be increased after 2 weeks of initial dose.
**Panic disorder**
- **Adult** (By Mouth Using Tablets): Initially 10 mg once daily for 7 days, then increased to 20 mg once daily, dose may be gradually increased if necessary in steps of 10 mg up to 40 mg once daily, usual maintenance 20-30 mg once daily.
- **Elderly** (By Mouth Using Tablets): Initially 10 mg once daily, increased if necessary up to 20 mg once daily, dose may be increased after 7 days of initial dose.
- **Adult** (By Mouth Using Oral Drops): Initially 8 mg once daily for 7 days, then increased to 16 mg once daily, dose may be gradually increased if necessary in steps of 8 mg up to 32 mg once daily, usual maintenance 16-24 mg once daily.
- **Elderly** (By Mouth Using Oral Drops): Initially 8 mg once daily, increased if necessary up to 16 mg once daily, dose may be increased after 7 days of initial dose.
**Panic disorder [known CYP2C19 poor metabolisers]**
- **Adult** (By Mouth Using Tablets): Initially 10 mg once daily, increased if necessary up to 20 mg once daily, dose may be increased after 2 weeks of initial dose.
- **Adult** (By Mouth Using Oral Drops): Initially 8 mg once daily, increased if necessary up to 16 mg once daily, dose may be increased after 2 weeks of initial dose.
**Major depression for citalopram**
- **Child 12-17 years** (By mouth using tablets): Initially 10 mg once daily, increased if necessary to 20 mg once daily, dose to be increased over 2-4 weeks, doses up to 40 mg per day may be considered.
- **Child 12-17 years** (By mouth using oral drops): Initially 8 mg once daily, increased if necessary to 16 mg once daily, dose to be increased over 2-4 weeks, doses up to 32 mg per day may be considered.
Cautions
For all selective serotonin re-uptake inhibitors Cardiac disease; concurrent electroconvulsive therapy; diabetes mellitus; epilepsy (discontinue if convulsions develop); history of bleeding disorders (especially gastro-intestinal bleeding); history of mania; susceptibility to angle-closure glaucoma Cautions, further information Elderly Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria to aid medication reviews (see Prescribing in the elderly for information): potentially inappropriate with current or recent significant hyponatraemia i.e. serum sodium less than 130 mmol/L (risk of exacerbating or precipitating hyponatraemia). Cautions For citalopram Susceptibility to QT-interval prolongation
Contraindications
For all selective serotonin re-uptake inhibitors Poorly controlled epilepsy; SSRIs should not be used if the patient enters a manic phase Contra-indications For citalopram QT-interval prolongation
Side effects
For all selective serotonin re-uptake inhibitors Common or very common Anxiety; appetite abnormal; arrhythmias; arthralgia; asthenia; concentration impaired; confusion; constipation; depersonalisation; diarrhoea; dizziness; drowsiness; dry mouth; fever; gastrointestinal discomfort; haemorrhage; headache; hyperhidrosis; malaise; memory loss; menstrual cycle irregularities; myalgia; mydriasis; nausea (dose-related); palpitations; paraesthesia; QT interval prolongation; sexual dysfunction; skin reactions; sleep disorders; taste altered; tinnitus; tremor; urinary disorders; visual impairment; vomiting; weight changes; yawning Uncommon Alopecia; angioedema; behaviour abnormal; hallucination; leucopenia; mania; movement disorders; photosensitivity reaction; postural hypotension; seizure; suicidal behaviours; syncope Rare or very rare Galactorrhoea; hepatitis; hyperprolactinaemia; hyponatraemia; serotonin syndrome; severe cutaneous adverse reactions (SCARs); SIADH; thrombocytopenia Frequency not known Increased risk of fracture; withdrawal syndrome Side-effects, further information Symptoms of sexual dysfunction may persist after treatment has stopped. Overdose Symptoms of poisoning by selective serotonin re-uptake inhibitors include nausea, vomiting, agitation, tremor, nystagmus, drowsiness, and sinus tachycardia; convulsions may occur. Rarely, severe poisoning results in the serotonin syndrome, with marked neuropsychiatric effects, neuromuscular hyperactivity, and autonomic instability; hyperthermia, rhabdomyolysis, renal failure, and coagulopathies may develop. For details on the management of poisoning, see Selective serotonin re-uptake inhibitors, under Emergency treatment of poisoning . Side-effects For citalopram Common or very common Acute angle closure glaucoma; apathy; flatulence; hypersalivation; migraine; rhinitis Uncommon Oedema Rare or very rare Cough; generalised tonic-clonic seizure Frequency not known Hypokalaemia
Interactions
**Other interactions (14):**
- Interactions to be considered The anticoagulant effect may be potentiated by concomitant administration of the following drugs: allopurinol; anabolic steroids; androgens; anti-arrhythmic...
- Therapeutic doses of the specific serotonin reuptake inhibitors, fluoxetine, sertraline, paroxetine and citalopram do not inhibit CYP1A2.
- Examples include: Class IA antiarrhythmics (e.g.
- The dosage of the following drugs may have to be adjusted to clinical requirement: Analgesics, anti-inflammatory agents: buprenorphine, methadone, paracetamol (long term administration of...
- Weak CYP2C19 inhibitor (e.g., cimetidine, citalopram, omeprazole b , esomeprazole) No dose adjustment.
- Examples of medicinal products which are metabolised by CYP2C19 are diazepam, citalopram and imipramine.
Pregnancy
For all selective serotonin re-uptake inhibitors Specialist sources indicate SSRIs may be suitable for use in pregnancy, but the risks and benefits of use must be considered, and the lowest effective dose should be used. The available data regarding malformation risk for all SSRIs are conflicting and confounded, and a causal association between the use of SSRIs in pregnancy, and spontaneous miscarriage, preterm delivery, low birth weight, and adverse effects on infant neurodevelopment remains unconfirmed. Published data on first trimester use of fluoxetine and paroxetine are contradictory. Some studies suggest a small increased risk of cardiovascular malformations with the use of fluoxetine, and congenital malformations (particularly cardiovascular) with the use of paroxetine, however other studies do not support an association. There may be a small increased risk of persistent pulmonary hypertension in the newborn with the use of SSRIs beyond 20 weeks' gestation, and use in the later stages of pregnancy may result in neonatal withdrawal syndrome-neonates should be monitored for associated central nervous system, motor, respiratory, and gastro-intestinal symptoms. There may also be a small increased risk of postpartum haemorrhage when used in the month before delivery (see Important safety information ).
Breast feeding
For all selective serotonin re-uptake inhibitors Specialist sources indicate that sertraline and paroxetine are the SSRIs of choice in breast-feeding based on passage into milk, half-life, and published evidence of safety. However, all SSRIs can be used in breast-feeding with caution, and since there are risks with switching an SSRI, it may be more clinically appropriate to continue treatment with an SSRI that has been effective, or restart treatment with an SSRI that has previously been effective. With all SSRIs, infants should be monitored for drowsiness, poor feeding, adequate weight gain, gastro-intestinal disturbances, irritability, and restlessness. Breast feeding For citalopram Specialist sources indicate use with caution. Present in milk in small to moderate amounts; long half-life increases risk of accumulation in the infant.
Hepatic impairment
For all selective serotonin re-uptake inhibitors In general, manufacturers advise caution (prolonged half-life). Hepatic impairment For citalopram Dose adjustments For tablets manufacturer advises initial dose of 10 mg daily for the first two weeks in mild to moderate impairment-dose may be increased to max. 20 mg daily; use with extra caution and careful dose titration in severe impairment. For oral drops manufacturer advises initial dose of 8 mg daily for the first two weeks in mild to moderate impairment-dose may be increased to max. 16 mg daily; use with extra caution and careful dose titration in severe impairment.
Renal impairment
Use with caution; no information available for creatinine clearance less than 20 mL/minute. M See Prescribing in renal impairment .
Medicinal forms
Tablet,Drops
Clinical governance
**Author:** MedNext Clinical Team. **Clinical reviewer:** Dr Shameer Deen, MBBS, MS, MRCS. **Sources:** BNF, Indian Pharmacopoeia, CIMS India. **Correction:** Report errors at support@mednext.academy.
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