Classification: Selective serotonin reuptake inhibitor (SSRI) antidepressant.
Common usage: Citalopram is indicated for the treatment of depression in adults.
Contraindications: Do not take citalopram if you are taking or have recently taken a monoamine oxidase inhibitor (MAOI), if you are taking a type of antipsychotic medication called pimozide (Orap), if you are being treated with methylene blue injection, or if you have ever had an allergic reaction to citalopram (see “Interactions with Other Medications”).
Warnings and precautions:
Clinical worsening and suicide risk: Antidepressants may increase suicidal thoughts or behavior in some children, adolescents, and young adults, especially during the first few months of treatment or when changing the dose. No increased risk of these events has been shown for adults over 24 years of age, and the risk is decreased for adults over 65 years of age. All patients starting treatment with antidepressants should be observed closely for new or worsening symptoms of depression, suicidal thoughts or behavior, or unusual changes in behavior.
Bipolar disorder: Before starting antidepressant treatment, patients should be screened for bipolar disorder. Antidepressants, including citalopram, may activate mania/hypomania in some patients. Citalopram is not approved for treating bipolar depression.
Serotonin syndrome: Potentially life-threatening serotonin syndrome or neuroleptic malignant syndrome–like reactions may occur when citalopram is taken with other SSRIs or serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants, certain headache or migraine medications (triptans) or tryptophan, or drugs that impair the metabolism of serotonin, including MAOIs. Your doctor should be notified immediately if you develop one or more of the following: restlessness, hallucinations (seeing, hearing, feeling, or tasting something that is not actually there), loss of coordination, very rapid heartbeat, very high fever, muscle stiffness, increased or irregular blood pressure, diarrhea, nausea, vomiting, confusion, or coma.
Abnormal bleeding: There have been reports of abnormal bleeding in patients taking SSRIs or SNRIs. Patients taking SSRIs or SNRIs should be cautioned about the risks of using these drugs at the same time as nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil), aspirin, warfarin (Coumadin), or other blood thinners.
Hyponatremia: Hyponatremia (low blood sodium) can occur in patients taking SSRIs or SNRIs. Contact your doctor right away if you become severely ill and have any of the following symptoms: headache, feeling weak, confusion, problems concentrating, memory problems, or feeling unsteady. In more severe or acute cases, hallucinations, fainting, seizures, coma, respiratory arrest, or death may occur.
Discontinuing citalopram: Patients should be monitored closely when discontinuing treatment with citalopram, and doses should be reduced gradually whenever possible. If intolerable symptoms occur following a dose reduction or the stopping of treatment, resuming the previously prescribed dose may be considered. Side effects that have been reported with SSRI discontinuation include irritability, agitation, dizziness, anxiety, confusion, headache, lethargy, emotional lability, insomnia, and hypomania. Although these events generally resolve on their own, there have been some reports of serious discontinuation symptoms.
Pregnancy and nursing: Tell your doctor if you are pregnant, planning pregnancy, breastfeeding, or planning to breastfeed, as the potential benefits of citalopram must be weighed against the risks to the unborn child or infant.
Pediatrics: Citalopram is not approved for use in patients under the age of 18.
Geriatrics: There may be a greater sensitivity to citalopram in elderly patients. SSRIs, including citalopram, and SNRIs have been associated with clinically significant hyponatremia in elderly patients, who may be at greater risk of this adverse effect.
Seizures: Citalopram should be introduced with care in patients with a history of seizure disorders.
Common side effects: Common side effects associated with citalopram include dry mouth, increased sweating, cold symptoms, tremor, nausea, diarrhea, heartburn, fatigue, sleepiness, insomnia, numbness, and sexual dysfunction.
This is not a complete list of all known or potential adverse effects. Notify your prescriber or pharmacist of any symptoms that have started since you began taking this medication, changing its dose, or adding or changing other medication or diet. Take care when performing any task that requires your attention (such as driving or operating machinery) until you have experience with this drug and are confident that you can perform the task safely.
Interactions with other medications:
Citalopram should never be taken with pimozide (Orap) or with an MAOI, or within 14 days of starting or stopping an MAOI. MAOIs include phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan), rasagiline (Azilect), and selegiline (Eldepryl). Caution is advised when taking other SSRIs, SNRIs, or tricyclic antidepressants; the antibiotic linezolid (Zyvox); migraine and headache medications (triptans or tramadol); tryptophan; carbamazepine (Tegretol, Carbatrol, Equetro); St. John’s wort; lithium; or any other medication prescribed for a psychiatric condition. Caution is also advised when taking citalopram in combination with NSAIDs, such as ibuprofen (Advil), aspirin, or other drugs affecting blood coagulation, such as warfarin (Coumadin). Drinking alcohol while taking citalopram is not recommended.
This is not a complete list of all known or potential drug interactions. To help prevent problems, always make sure that your pharmacist and all prescribers know about all medications you are taking, including over-the-counter drugs; dietary herbal supplements; folk or home remedies; or unusual foods, drinks, or dietary habits.
Common dosages: Citalopram should be taken once daily, in the morning or evening, with or without food. The recommended starting dose is 20 mg once daily, which is generally increased to 40 mg per day. Dose increases should usually occur in increments of 20 mg per day at intervals of no less than one week. Although some patients may need a dose of 60 mg per day, the only study investigating citalopram dose response for effectiveness found no advantage of 60 mg over 40 mg. Therefore, doses above 40 mg per day are not ordinarily recommended.
The recommended dose for most elderly patients and patients with hepatic impairment is 20 mg per day, with a titration to 40 mg per day only for nonresponders.
Citalopram should be used with caution in patients with severe renal (kidney) impairment. No dose adjustments are needed for patients with mild or moderate renal impairment.
Identification: Citalopram is available in tablets of 10, 20, and 40 mg:
- 10-mg tablets: beige, oval, film-coated, imprinted on one side with “FP” and on the other side with “10 mg.”
- 20-mg tablets: pink, oval, scored on one side, film-coated, imprinted on the scored side with “F” on the left side and “P” on the right side, and on the nonscored side with “20 mg.”
- 40-mg tablets: white, oval, scored on one side, film-coated, imprinted on the scored side with “F” on the left side and “P” on the right side, and on the nonscored side with “40 mg.”
Citalopram is also available as a peppermint-flavored oral solution (240 mL).
Storage: This medication should be stored at controlled room temperature (77°F, with excursions permitted to 59°F to 86°F), in a tightly closed, child-, light-, and moisture-resistant container. If you have difficulty opening child-resistant containers, your pharmacist can provide you with a container that is easier to open. Keep the medication out of direct sunlight and avoid storing it in a warm and humid area, such as the bathroom or kitchen, to avoid deterioration. To prevent accidental poisoning, keep all medications out of the reach of children or adults with dementia. Do not take expired medication. Do not transfer medication from one container to another. Carefully discard discontinued medication where children or adults with dementia cannot find it.