brands

Class

• Neuroscience-based Nomenclature: serotonin reuptake inhibitor (S-RI)
• SSRI (selective serotonin reuptake inhibitor); often classified as an antidepressant, but it is not just an antidepressant

CITALOPRAM commonly prescribed for

(Bold for FDA approved)

How CITALOPRAM works

• Boosts neurotransmitter serotonin

• Blocks serotonin reuptake pump (serotonin transporter)

• Desensitizes serotonin receptors, especially serotonin 1A autoreceptors

• Presumably increases serotonergic neurotransmission

• Citalopram also has mild antagonist actions at H1 histamine receptors

• Citalopram’s inactive R enantiomer may interfere with the therapeutic actions of the active S enantiomer at serotonin reuptake pumps

How long until CITALOPRAM works

• Onset of therapeutic actions usually not immediate, but often delayed 2–4 weeks

• If it is not working within 6–8 weeks, it may require a dosage increase or it may not work at all

• May continue to work for many years to prevent relapse of symptoms

Notable Side Effects

• Sexual dysfunction (dose-dependent; men: delayed ejaculation, erectile dysfunction; men and women: decreased sexual desire, anorgasmia)

• Gastrointestinal (decreased appetite, nausea, diarrhea, constipation, dry mouth)

• Mostly CNS (dose-dependent insomnia but also sedation, agitation, tremors, headache, dizziness)

• Activation (short-term; patients with diagnosed or undiagnosed bipolar or psychotic disorders may be more vulnerable to CNS-activating actions of SSRIs)

• Sweating (dose-dependent)

• Bruising and rare bleeding

• Rare hyponatremia (mostly in elderly patients and generally reversible on discontinuation of citalopram)

• Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

Life Threatening Side Effects

• Rare seizures

• Rare induction of mania

• Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo beyond age 24)

weight gain

unusual

sedation

not usual

What to do about CITALOPRAM side effects

• Wait

• Wait

• Wait

• Take in the morning if nighttime insomnia

• Take at night if daytime sedation

• In a few weeks, switch to another agent or add other drugs

usual dosage range

• 20–40 mg/day

Dosage Forms

• Tablet 10 mg, 20 mg scored, 40 mg scored

• Solution 10 mg/5 mL

long term use

• Safe

habit forming

• No

Renal Impairment

• No dose adjustment for mild to moderate impairment

• Use cautiously in patients with severe impairment

Hepatic Impairment

• Should not be used at doses greater than 20 mg/day

• May need to dose cautiously at the lower end of the dose range in some patients for maximal tolerability

Cardiac Impairment

• May cause abnormal changes in the electrical activity of the heart at doses greater than 40 mg/day

• Treating depression with SSRIs in patients with acute angina or following myocardial infarction may reduce cardiac events and improve survival as well as mood

Elderly

• Doses greater than 20 mg/day should not be used in patients over age 60 years

• May need to dose at the lower end of the dose range in some patients for maximal tolerability

• Risk of SIADH with SSRIs is higher in the elderly

• Citalopram may be an especially welltolerated SSRI in the elderly

• Reduction in the risk of suicidality with antidepressants compared to placebo in adults age 65 and older

Children and Adolescents

• Carefully weigh the risks and benefits of pharmacological treatment against the risks and benefits of nontreatment with antidepressants and make sure to document this in the patient’s chart

• Monitor patients face-to-face regularly, particularly during the first several weeks of treatment

• Use with caution, observing for activation of known or unknown bipolar disorder and/or suicidal ideation, and inform parents or guardians of this risk so they can help observe child or adolescent patients

• Not specifically approved, but preliminary data suggest citalopram is safe and effective in children and adolescents with OCD and with depression

Pregnancy

• Effective June 30, 2015, the FDA requires changes to the content and format of pregnancy and lactation information in prescription drug labels, including the elimination of the pregnancy letter categories; the Pregnancy and Lactation Labeling Rule (PLLR or final rule) applies only to prescription drugs and will be phased in gradually for drugs approved on or after June 30, 2001

• Controlled studies have not been conducted in pregnant women

• Not generally recommended for use during pregnancy, especially during first trimester

• Nonetheless, continuous treatment during pregnancy may be necessary and has not been proven to be harmful to the fetus

• At delivery there may be more bleeding in the mother and transient irritability or sedation in the newborn

• Must weigh the risk of treatment (first trimester fetal development, third trimester newborn delivery) to the child against the risk of no treatment (recurrence of depression, maternal health, infant bonding) to the mother and child

• For many patients, this may mean continuing treatment during pregnancy

• Exposure to SSRIs early in pregnancy may be associated with increased risk of septal heart defects (absolute risk is small)

• SSRI use beyond the 20th week of pregnancy may be associated with increased risk of pulmonary hypertension in newborns, although this is not proven

• Exposure to SSRIs late in pregnancy may be associated with increased risk of gestational hypertension and preeclampsia

• Neonates exposed to SSRIs or SNRIs late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding; reported symptoms are consistent with either a direct toxic effect of SSRIs and SNRIs or, possibly, a drug discontinuation syndrome, and include respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying

Breast Feeding

• Some drug is found in mother’s breast milk

• Trace amounts may be present in nursing children whose mothers are on citalopram

• If child becomes irritable or sedated, breast feeding or drug may need to be discontinued

• Immediate postpartum period is a high-risk time for depression, especially in women who have had prior depressive episodes, so drug may need to be reinstituted late in the third trimester or shortly after childbirth to prevent a recurrence during the postpartum period

• Must weigh benefits of breast feeding with risks and benefits of antidepressant treatment versus nontreatment to both the infant and the mother

• For many patients, this may mean continuing treatment during breast feeding