Citalopram selectively inhibits the reuptake of serotonin in the presynaptic terminals of neurons. Because of minimal effect on GABA, adrenergic and dopaminergic pathways, citalopram side effects are minimal compared to TCAs and other drugs used to treat depression.

Citalopram is used to treat unipolar major depressive disorder. Other Off-Label uses of citalopram in adults include:

• Aggressive behavior associated with dementia

• Binge eating disorder

• Generalized anxiety disorder

• Obsessive-compulsive disorder

• Panic disorder

• Posttraumatic stress disorder

• Premature ejaculation

• Premenstrual dysphoric disorder

• Social anxiety disorder

• Vasomotor symptoms associated with menopause

Citalopram Dose in Adults

Note: Maximum daily dose should not exceed 40 mg per day because of the risk of QT prolongation. Patients with severe liver disease, concomitant medicines like omeprazole and cimetidine and older patients (aged 60 years and above) should not exceed 20 mg daily. The usual initial dose is 10 mg daily. The dose is titrated in increments of 10 mg to avoid citalopram side effects and overstimulation effects like anxiety and insomnia.

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Off-label use in Aggressive or agitated behavior associated with dementia:

•  10 mg once daily. Increase to 20 mg once daily after 3 days.

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Off-label use in Binge eating disorder:

•  20 mg once daily.
• The dose may gradually be increased based on response and tolerability at intervals of 1 week to 40 mg once daily.

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Off-label use in Generalized anxiety disorder:

• 10 mg once daily.
• The dose may gradually be increased based on the response and tolerability in 10 mg increments at intervals of one week to a maximum dose of 40 mg/day for adults less than 60 years and 20 mg/day for adults older than 60 years of age.

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Unipolar Major depressive disorder:

• 20 mg once daily.
• Adults less than 60 years of age may increase the dose gradually weekly intervals to a maximum dose of 40 mg/day
• Adults older than 60 years of age should not exceed the maximum dose of 20 mg/day.

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Off-label use in Obsessive-compulsive disorder:

• 20 mg once daily.
• Adults less than 60 years of age may increase the dose gradually weekly intervals to a maximum dose of 40 mg/day
• Adults older than 60 years of age should not exceed the maximum dose of 20 mg/day.

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Off-label use in Panic disorder:

• 10 mg once daily for 3 to 7 days, then 20 mg once daily.
• Adults less than 60 years of age may increase the dose gradually weekly intervals to a maximum dose of 40 mg/day
• Adults older than 60 years of age should not exceed the maximum dose of 20 mg/day.

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Off-label use in Posttraumatic stress disorder:

• 20 mg once daily.
• Adults less than 60 years of age may increase the dose gradually weekly intervals to a maximum dose of 40 mg/day
• Adults older than 60 years of age should not exceed the maximum dose of 20 mg/day.

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Off-label use in Premature ejaculation:

• 20 mg once daily.
• Adults less than 60 years of age may increase the dose gradually weekly intervals to a maximum dose of 40 mg/day. (some experts recommend increasing the dose at 3 - 4 weekly intervals)
• Adults older than 60 years of age should not exceed the maximum dose of 20 mg/day.

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Off-label use in Premenstrual dysphoric disorder:

• Continuous daily dosing regimen:

  • 10 mg once daily. Increase the dose to the usual effective dose of 20 mg once daily.
  • Some patients require doses up to 40 mg daily in the subsequent menstrual cycles for optimal response

• Intermittent regimens:

  • 10 mg once daily beginning 14 days before the anticipated onset of menstruation and continued to the onset of menses
  • The usual effective dose is 20 mg once daily. However, doses up to 30 mg may be used in some patients for optimal response.

• Symptom-onset dosing regimen:

  • 10 mg once daily from the day of symptom onset until a few days after the start of menses
  • The usual effective dose is 20 mg once daily. However, doses up to 30 mg may be used in some patients for optimal response.

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Off-label use in Social anxiety disorder:

• 10 to 20 mg once daily.
• Adults younger than 60 years of age may gradually increase the dose after 6 weeks based on response and tolerability in 10 to 20 mg increments at weekly intervals to a maximum dose of 40 mg/day.
• Adults older than 60 years of age should not exceed the maximum dose of 20 mg/day.

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Off-label use in alternative agent Vasomotor symptoms associated with menopause:

• 10 mg once daily. The dose may be increased after one week to 20 mg once daily.
• Adults less than 60 years of age may increase the dose gradually weekly intervals to a maximum dose of 40 mg/day
• Adults older than 60 years of age should not exceed the maximum dose of 20 mg/day.

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How to discontinue citalopram?

• Citalopram should be gradually tapered off when the treatment that has lasted for more than 3 weeks.
• The dose should be gradually tapered off over a period of 2 - 4 weeks to minimize withdrawal symptoms.
• Patients who develop withdrawal symptoms should resume the previous dose and then start tapering the drug more slowly over a period of 3 months or more.

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How to switch to other antidepressants:

• Different strategies are used:
  • Cross titration is the gradual discontinuation of one drug and an incremental increase of another antidepressant.
  • A direct switch is abruptly discontinuing the first antidepressant and then starting the new antidepressant at an equivalent dose or lower dose and increasing it gradually.

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Switching to or from an MAOI:

A time lapse of 14 days should be allowed between discontinuing an MAOI and initiation of citalopram.

Citalopram dose in Children

Note: The maximum daily dose should not exceed 40 mg per day because of the risk of QT prolongation. Patients with severe liver disease, concomitant medicines like omeprazole and cimetidine and older patients (aged 60 years and above) should not exceed 20 mg daily.

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Unipolar Depression (based on limited data):

• Children 7 to 11 years:

  • 10 mg/day given once daily. Increase the dose slowly by 5 mg/day every 2 weeks as clinically needed to a maximum of 40 mg/day

• Children and Adolescents older than 12 years of age:

  • 20 mg/day given once daily. Increase the dose slowly by 10 mg/day every 2 weeks as clinically needed to a maximum of 40 mg/day

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Obsessive-compulsive disorder (limited data available)

• Children 7 to 11 years:

  • 5 mg/day given once daily. Increase the dose slowly by 5 mg/day every 2 weeks as clinically needed to a maximum of 40 mg/day

• Children and Adolescents older than 12 years of age:

  • 10 mg/day given once daily. Increase the dose slowly by 10 mg/day every 2 weeks as clinically needed to a maximum of 40 mg/day.

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How to discontinue citalopram?

• Citalopram should be gradually tapered off when the treatment that has lasted for more than 3 weeks.
• The dose should be gradually tapered off over a period of 2 - 4 weeks to minimize withdrawal symptoms.
• Patients who develop withdrawal symptoms should resume the previous dose and then start tapering the drug more slowly over a period of 3 months or more.

How to switch to other antidepressants:

• Different strategies are used:
  • Cross titration is the gradual discontinuation of one drug and an incremental increase of another antidepressant.
  • A direct switch is abruptly discontinuing the first antidepressant and then starting the new antidepressant at an equivalent dose or lower dose and increasing it gradually.

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Switching to or from an MAOI:

A time-lapse of 14 days should be allowed between discontinuing an MAOI and initiation of citalopram.

Use with other MAO inhibitors (linezolid or IV methylene blue):

• Citalopram should not be started in patients receiving linezolid or IV methylene blue.
• If urgent treatment with linezolid or IV methylene blue is inevitable, discontinue citalopram promptly and administer linezolid or IV methylene blue.
• Monitor the patient for serotonin syndrome for 2 weeks or until 24 hours after the last dose of linezolid or IV methylene blue, whichever comes first.
• Citalopram may be resumed after 24 hours of the last dose of linezolid or IV methylene blue.

Pregnancy Risk Factor C

• Citalopram crosses over the placenta. Side effects of citalopram have been documented in both animal and human studies.
• Cardiovascular problems may be caused by citalopram's teratogenic effects.
• After citalopram or other SSRIs/ SNRIs are exposed in the third trimester, there have been no teratogenic effects on the newborn.

• Symptoms could be caused by discontinuation of toxicity or overuse of SSRIs/SNRIs
• A serious side effect of citalopram is persistent pulmonary hypertension in newborns due to SSRI exposure.
• The American Psychiatric Association states that patients who are at high risk for post-partum depression should weigh the benefits and risks of treatment.

Use of citalopram during breastfeeding

• Breast milk contains citalopram and active metabolites.
• According to the manufacturer, it is important to weigh the risks of citalopram in neonates and the benefits for breastfeeding as well as the benefits of continuing citalopram in breastfeeding mothers.
• Infants should be watched for excessive sleepiness, decreased appetite, and weight loss.
• Citalopram may, along with other SSRIs affect milk production and secretion.

Citalopram Dose in Kidney Disease:

The manufacturer has not recommended any dose adjustment in patients with renal disease.

Citalopram Dose in Liver Disease:

The maximum recommended dose in liver disease is 20 mg daily due to decreased clearance and the risk of citalopram side effects like QT prolongation

Common Citalopram Side Effects

• Central nervous system:

  • Drowsiness
  • Insomnia

• Dermatologic:

  • Diaphoresis

• Gastrointestinal:

  • Nausea
  • Xerostomia

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Less Common Citalopram Side Effects

• Cardiovascular:

  • Prolonged Q-T interval on ECG
  • Hypotension
  • Orthostatic hypotension
  • Tachycardia
  • Bradycardia

• Central nervous system:

  • Fatigue
  • Anxiety
  • Agitation
  • Yawning
  • Amnesia
  • Apathy
  • Confusion
  • Depression
  • Lack of concentration
  • Migraine
  • Paresthesia

• Dermatologic:

  • Skin rash
  • Pruritus

• Endocrine & metabolic:

  • Decreased libido
  • Amenorrhea
  • Weight gain
  • Weight loss

• Gastrointestinal:

  • Diarrhea
  • Dyspepsia
  • Anorexia
  • Vomiting
  • Abdominal pain
  • Dysgeusia
  • Flatulence
  • Increased appetite
  • Sialorrhea

• Genitourinary:

  • Ejaculatory disorder
  • Dysmenorrhea
  • Impotence

• Neuromuscular & skeletal:

  • Tremor
  • Arthralgia
  • Myalgia

• Ophthalmic:

  • Accommodation disturbance

• Renal:

  • Polyuria

• Respiratory:

  • Rhinitis
  • Upper respiratory tract infection
  • Sinusitis
  • Cough

• Miscellaneous:

  • Fever

Contraindication To Citalopram Include

• Hypersensitivity or Allergy to Citalopram or any other component of the formulation
• MAO inhibitors should be used within 14 days after stopping citalopram.
• Patients who receive intravenous methyleneblue or linezolid
• Pimozide may be taken with other medications
• Congenital QT prolongation, congenital long QT syndrome or known QT interval prolongation

Warnings and Precautions

•   Suicidal thoughts and behavior [US Boxed Warning]
  • Children, adolescents, and young adults aged 18-24 with major depressive disorder (MDD), and other mental disorders are at greater risk of suicide.
  • Monitor patients closely for signs of clinical worsening or suicidality. This is especially important during the first 2 to 3 months of therapy.
  • Family members should be informed to monitor the patient closely for any changes in behavior and report back.
•   Bleeding risk:
  • Citalopram can impair platelet aggregation, which could lead to an increase in bleeding events, especially if taken with aspirin or NSAIDs, warfarin or other anticoagulants.
  • Bleeding due to SSRI/SNRI use can range from minor bruising to epistaxis to potentially life-threatening.
•   Depression in the CNS:
  • Citalopram is not likely to cause cognitive or motor impairments, but it should still be used cautiously by those who operate hazardous machinery or drive.
•   Fractures
  • Undiagnosed bone pain, swelling, tenderness, or bruising should be reported to your doctor.
• Ocular effects
  • Zitropram can cause mild pupillary dilation, which may lead to worsening of symptoms in patients with angle-closure Glaucoma.
• Extension of QT
  • Citalopram has been linked to a dose-dependent QTc extension, torsade des pointes and ventricular tachycardia.
• It is not recommended to consume more than 40 mg/day.
  • Patients with liver disease and elderly patients should not receive doses exceeding 20 mg daily.
•   Citalopram is not recommended for use in Patients with
  • Congenital QT syndrome with long QT.
  • Bradycardia
  • Recent MI
  • Heart failure that has been decompensated
  • Hypokalemia
  • Hypomagnesemia or
  • respiratory distress
  • Cyanosis
  • Apnea
  • Seizures
  • Temperature instability
  • Feeding difficulty
  • Vomiting
  • Hypoglycemia
  • Hypotonia or hypertonia
  • Hyperreflexia
  • Jitteriness
  • Irritability
  • Constant crying
  • Tremors
  • Patients who are taking concomitant drugs that prolong the QT interval may be affected.
  • Patients with QTc readings of over 500 msec should stop taking therapy. 
  • Patients at higher risk of electrolyte disturbances, especially potassium and magnesium, need to be monitored before and during therapy.
• Serotonin syndrome
  • SSRIs such as citalopram have been linked to life-threatening serotonin disorder, especially when combined with serotonergic agents such as triptans, TCAs and buspirone.
•   Sexual dysfunction
  • Citropram can cause or exacerbate sexual dysfunction.
• SIADH and Hyponatremia
  • SIADH was developed in part by SSRIs such as citalopram or SNRIs.
  • Hyponatremia can cause seizures in some patients, especially if they are taking diuretics or other medications that cause hyponatremia.
•   Heart Failure:
  • Citalopram can exacerbate myocardial dysfunction. Patients at high risk should avoid it.
•   Hepatic impairment
  • Patients with liver disease should not consume more than 20mg per day due to the possibility of arrhythmias and prolonged QT intervals.
• Hypomania & Mania:
  • Citalopram has not been approved by the FDA for treatment of bipolar disorder.
  • It is important to screen patients for hypomania and mania symptoms and treat accordingly.
  • Monotherapy with Citalopram may worsen the symptoms
•   Renal impairment
  • Patients with kidney disease should not be given dose adjustments.
•   Seizure disorders
  • Patients with seizure disorders or conditions that can predispose them to seizures, such as brain damage or addiction, should not take Citalopram.

Citalopram: Drug Interaction

Note: Drug Interaction Categories:

• Risk Factor C: Monitor When Using Combination
• Risk Factor D: Consider Treatment Modification
• Risk Factor X: Avoid Concomitant Use

Notice: Drug Interaction Categories  

Risk Factor C (Monitor therapy).
Antiplatelet Agents (e.g. P2Y12 inhibitors NSAIDs, SSRIs etc.)	May increase the antiplatelet effects of other Agents with Antiplatelet Properties.
Anticoagulants	Anticoagulant agents may have antiplatelet properties that can enhance their effectiveness.
Antiemetics (5HT3 Antagonists).	This may increase the serotonergic effects of Serotonin Activators. This could lead to serotonin syndrome.
Antipsychotic Agents	Antipsychotic Agents may have a greater adverse/toxic effect if they are regulated with serotonin modulators. Serotonin modulators can increase dopamine blockade and, therefore, may increase the risk of developing neuroleptic malignant syndrome. Serotonin modulators may have a serotonergic effect that is enhanced by antipsychotic agents. This could lead to serotonin syndrome.
Apixaban	Apixaban's toxic/adverse effects may be exacerbated by agents with Antiplatelet Properties. The risk of bleeding could be increased. Management: Take the time to carefully consider both the risks and the benefits of this combination, and keep an eye on it.
ARIPiprazole	CYP2D6 inhibitors (Weak), may increase serum levels of ARIPiprazole. Monitoring for increased aripiprazole-pharmacologic effects is important. Aripiprazole dosage adjustments may be necessary depending on the indication and/or concomitant therapy. For more information, consult the full interaction monograph.
Aspirin	Aspirin may have an antiplatelet effect that is enhanced by selective serotonin reuptake inhibitors.
Blood Glucose-Limiting Agents	Some Serotonin Reuptake inhibitors may increase the hypoglycemic effects of Blood Glucose Lowing Agents.
Bosentan	Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
Brexanolone	Selective Serotonin Reuptake inhibitors may increase the CNS depressant effects of Brexanolone.
CarBAMazepine	Could lower the serum Citalopram concentration.
Cephalothin	Antiplatelet agents may increase the toxic/adverse effects of Cephalothin. In particular, bleeding risk may be increased.
Cimetidine	May increase serum Citalopram concentration.
CNS Depressants	This may increase the toxic/adverse effect of Selective Serotonin Reuptake inhibitors. Particularly, psychomotor impairment could be increased.
Collagenase Systemic	Antiplatelet agents may increase the toxic/adverse effect of Collagenase Systemic. In particular, there may be an increase in the risk of bleeding and/or bruising at the injection site.
Moderate CYP2C19 Inducers	Could lower the serum concentration of CYP2C19 substrates (High Risk with Inducers).
Moderate CYP3A4 Inducers	Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
Cyproheptadine	This may reduce the therapeutic effects of Selective Serotonin Reuptake Incitators.
Dabigatran Etexilate	Antiplatelet properties may increase the anticoagulant effects of Dabigatran Etexilate. Agents with Antiplatelet Properties can increase serum levels of Dabigatran Etexilate. Clopidogrel is exempt from this mechanism. Management: Be aware of the risks and benefits and keep an eye on this combination. Canadian labeling suggests that you avoid prasugrel and ticagrelor.
Deferasirox	Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
Deoxycholic Acid	Antiplatelet agents may increase the toxic/adverse effects of Deoxycholic Acid. In particular, bleeding and bruising may increase in the treatment area.
Desmopressin	Desmopressin may have an adverse/toxic effect on select Serotonin Reuptake inhibitors.
Doxepin-Contained Products	Citalopram could increase the QTc-prolonging effects of DoxepinContaining Products. Citalopram could increase the serotonergic effects of DoxepinContaining Product. This could lead to serotonin syndrome. Management: If these agents are combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients at higher risk for QTc prolongation might have additional risk factors.
Edoxaban	Antiplatelet agents may increase the toxic/adverse effects of Edoxaban. In particular, bleeding risk may be increased.
Erdafitinib	Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
Esomeprazole	May increase serum Citalopram concentration.
Fat Emulsion (Fish oil-based)	Agents with Antiplatelet Property may have an adverse/toxic effect.
Glucosamine	Agents with Antiplatelet Properties may increase the antiplatelet effects.
Haloperidol	QT-prolonging Antidepressants may increase the QTc prolonging effect of Haloperidol (Moderate risk). When using these agents together, monitor for QTc interval prolongation or ventricular arrhythmias. Patients at higher risk for QTc prolongation might have additional risk factors.
Ibritumomab Tiuxetan	Antiplatelet agents may increase the toxic/adverse effects of Ibritumomab Tiuxetan. Both agents can cause impaired platelet function, which could lead to increased bleeding risk.
Ibrutinib	Agents with Antiplatelet Property may have an adverse/toxic effect.
Inotersen	Agents with Antiplatelet Properties may increase the antiplatelet effects.
Ioflupane I, 123	Ioflupane I123 may be reduced by selective serotonin reuptake inhibitors.
Limaprost	Agents with Antiplatelet Properties may increase the antiplatelet effects.
Lofexidine	QT-prolonging Antidepressants with Moderate Risk may increase the QTc prolonging effect Lofexidine. Lofexidine could increase the QTc prolonging effect QT-prolonging Antidepressants with moderate risk. When these agents are used together, monitor for QTc interval prolongation or ventricular arrhythmias. Patients at higher risk for QTc prolongation might have additional risk factors.
Metaxalone	This may increase the serotonergic effects of Serotonin Activators. This could lead to serotonin syndrome.
Methylphenidate	Can increase the toxic/adverse effects of Serotonin Modulators. In particular, there may be an increase in the risk of serotonin syndrome and serotonin toxicities.
MetyroSINE	This may increase the toxic/adverse effect of Selective Serotonin Reuptake Incitors.
Multivitamins/Fluoride (with AD)	Agents with Antiplatelet Properties may increase the antiplatelet effects.
Multivitamins/Minerals with ADEK Folate Iron	Agents with Antiplatelet Properties may increase the antiplatelet effects.
Multivitamins/Minerals (with or without AE, no Iron)	Agents with Antiplatelet Properties may increase the antiplatelet effects.
Nonsteroidal Anti-Inflammatory Agents COX-2 Selective	Nonsteroidal Anti-Inflammatory Drugs (COX-2 Selective) may have an antiplatelet effect that is enhanced by Selective Serotonin Resuptake Inhibitors. Nonsteroidal Anti Inflammatory Agents (COX-2 selective) can decrease the therapeutic effects of Selective Serotonin Resuptake Inhibitors.
Obinutuzumab	Antiplatelet agents may increase the toxic/adverse effects of Obinutuzumab. In particular, there may be an increase in the risk of bleeding-related complications.
Omega-3 Fatty Acids	Agents with Antiplatelet Properties may increase the antiplatelet effects.
Ondansetron	QTc-prolonging effects of QT-prolonging antidepressants may be increased (moderate risk). When these agents are used together, monitor for QTc interval prolongation or ventricular arrhythmias. Patients at higher risk for QTc prolongation might have additional risk factors.
Opioid Agonists	This may increase the serotonergic effects of Serotonin Activators. This could lead to serotonin syndrome.
Pentamidine Systemic	QTc-prolonging effects of QT-prolonging antidepressants may be increased (moderate risk). When these agents are used together, monitor for QTc interval prolongation or ventricular arrhythmias. Patients at higher risk for QTc prolongation might have additional risk factors.
Pentosan Monosulfate Sodium	May increase the toxic/adverse effect of Antiplatelet Agents. Concurrent use of these agents may increase the risk of bleeding.
Pentoxifylline	Agents with Antiplatelet Properties may increase the antiplatelet effects.
Perhexiline	Perhexiline serum concentration may be increased by CYP2D6 inhibitors (Weak).
Analogues of Prostacyclin	Agents with Antiplatelet Properties may increase the antiplatelet effects.
QT-prolonging antipsychotics (Moderate risk)	QTc-prolonging effects of QTprolonging antidepressants may be increased (moderate risk). When these agents are used together, monitor for QTc interval prolongation or ventricular arrhythmias. Patients at higher risk for QTc prolongation might have additional risk factors. Pimozide is an exception.
QT-prolonging Class IC Antiarrhythmics for QT-prolonging (Moderate risk)	QTc-prolonging effects of QT-prolonging antidepressants may be increased (moderate risk). When these agents are used together, monitor for QTc interval prolongation or ventricular arrhythmias. Patients at higher risk for QTc prolongation might have additional risk factors.
QT-prolonging Kinase inhibitors (Moderate risk)	QT-prolonging antidepressants (Moderate risk) can increase the QTc prolonging effect QT-prolonging kinase inhibitors (Moderate risk). When these agents are used together, monitor for QTc interval prolongation or ventricular arrhythmias. Patients at higher risk for QTc prolongation might have additional risk factors. Gilteritinib is an exception.
QT-prolonging Miscellaneous Drugs (Moderate risk)	QT-prolonging Antidepressants may increase the QTc prolonging effect QT-prolonging miscellaneous agents (Moderate risk). When these agents are used together, monitor for QTc interval prolongation or ventricular arrhythmias. Patients at higher risk for QTc prolongation might have additional risk factors. Lofexidine and Domperidone are exceptions.
QT-prolonging Moderate CYP3A4 Drug Inhibitors (Moderate risk)	Citalopram could increase the QTcprolonging effects of QT-prolonging Moderate CYP3A4 inhibitors (Moderate risk). The serum concentrations of Citalopram may be increased by QT-prolonging Moderate CYP3A4 inhibitors (Moderate risk). Fluconazole is an exception.
Quinolone Antibiotics for QT-prolonging (Moderate risk)	QTc-prolonging effects of QT-prolonging antidepressants may be increased (moderate risk). When these agents are used together, monitor for QTc interval prolongation or ventricular arrhythmias. Patients at higher risk for QTc prolongation might have additional risk factors.
QT-prolonging Strong CYP3A4 Antiinhibitors (Moderate risk)	Citalopram could increase the QTcprolonging effects of QT-prolonging Strength CYP3A4 Drug Inhibitors (Moderate risk). The serum concentration of Citalopram may be increased by QT-prolonging strong CYP3A4 inhibitors (Moderate risk). Voriconazole is an exception.
RifAMPin	Could lower the serum Citalopram concentration.
Rivaroxaban	Rivaroxaban may be enhanced by agents with Antiplatelet Properties. Management: Be aware of the risks and benefits and keep an eye on this combination. Canadian labeling suggests that you avoid prasugrel and ticagrelor.
Salicylates	Antiplatelet agents may increase the toxic/adverse effects of Salicylates. This could lead to an increase in bleeding risk.
Sarilumab	Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
Serotonin Modulators	This may increase the toxic/adverse effects of other Serotonin Activators. Serotonin syndrome can develop. Tedizolid; Nicergoline are exceptions.
Siltuximab	Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
Tedizolid	This may increase the serotonergic effects of Serotonin Activators. This could lead to serotonin syndrome.
Thiazide and Thiazide -Like Diuretics	Selective Serotonin-Reuptake Inhibitors can increase the hyponatremic effects of Thiazide or Thiazidelike Diuretics.
Thrombolytic Agents	Agents with Antiplatelet Properties can enhance the anticoagulant effects of Thrombolytic Agents.
Thyroid Products	Thyroid products may have a reduced therapeutic effect if they are inhaled with select serotonin reuptake inhibitors. The dosage requirements for thyroid products may be increased.
Tipranavir	Agents with Antiplatelet Properties may increase the antiplatelet effects.
Tocilizumab	Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
TraMADol	The adverse/toxic effects of TraMADol may be exacerbated by Serotonin Modulators. Seizures may increase. TraMADol could increase the serotonergic effects of Serotonin Activators. This could lead to serotonin syndrome.
Vitamin E (Systemic).	Agents with Antiplatelet Properties may increase the antiplatelet effects.
Vitamin K antagonists (eg warfarin)	Vitamin K Antagonists may have an anticoagulant effect that is enhanced by selective serotonin reuptake inhibitors.
Risk Factor D (Consider therapy modifications)
Alcohol (Ethyl).	This may increase the toxic/adverse effect of Selective Serotonin Reuptake inhibitors. In particular, psychomotor impairment could be increased. Treatment: Patients on selective serotonin receptor inhibitors should avoid alcohol. Patients who have taken selective serotonin receptor inhibitors should be monitored for signs of psychomotor impairment.
BuPROPion	Citalopram may have an adverse/toxic effect that can be increased by this combination. This combination may increase the risk of seizures and serotonin syndrome. BuPROPion can increase Citalopram's serum concentration. Management: Start citalopram treatment at the lower dose of bupropion-treated patients. Also, consider reducing the daily maximum dose of citalopram to 20 mg for concomitant bupropion therapy.
BusPIRone	This may increase the serotonergic effects of Selective Serotonin Reuptake inhibitors. This could lead to serotonin syndrome. The metabolism of BusPIRone may be affected by selective serotonin reuptake inhibitors. You should take care when combining a selective serotonin receptor inhibitor with buspirone. If combined treatment is indicated clinically, be sure to monitor for signs of serotonin toxic/serotonin syndrome.
Strong CYP2C19 Inducers	May increase metabolism of CYP2C19 substrates (High Risk with Inducers). Management: You may consider a different drug to replace one of the interacting drugs. Some combinations might be contraindicated. Refer to the manufacturer's label.
Moderate CYP2C19 inhibitors	Increased serum Citalopram concentrations may occur. Use moderate CYP2C19 inhibitors to limit citalopram dosage. This combination should be closely monitored for signs of citalopram toxicities (e.g. serotonin syndrome, QT prolongation etc. .
Strong CYP3A4 Inducers	May increase metabolism of CYP3A4 substrates (High Risk with Inducers). Management: You may consider a different drug to replace one of the interacting drugs. Some combinations might be contraindicated. Refer to the manufacturer's label.
Dabrafenib	High risk of Inducers causing a decrease in serum CYP3A4 substrates. Management: If possible, seek alternatives to the CYP3A4 substrate. Concomitant therapy should be avoided if possible. Monitor the clinical effects of the substrate carefully (especially therapeutic effects).
Dabrafenib	High risk of Inducers causing a decrease in serum CYP2C19 Substrates. Management: If possible, seek alternatives to the CYP2C19 substrat. Concomitant therapy should be avoided if possible. Monitor the clinical effects of the substrate carefully (especially therapeutic effects).
Dextromethorphan	Selective Serotonin Recovery Inhibitors can enhance Dextromethorphan's serotonergic effects. Selective Serotonin Recovery Inhibitors can increase Dextromethorphan serum levels. When possible, avoid the simultaneous use of dextromethorphan, SSRIs, especially fluoxetine, and paroxetine. This interaction can last for weeks after discontinuation of paroxetine or fluoxetine.
Domperidone	QT-prolonging agents (moderate risk) could increase the QTc-prolonging effects of Domperidone. Management: Look for alternatives to this combination. Monitor for QTc interval prolongation or ventricular arrhythmias if the drug combination is combined. Patients at higher risk for QTc prolongation might have additional risk factors.
Enzalutamide	High risk of Inducers causing a decrease in serum concentrations of CYP3A4 substrates. Management: Avoid concurrent use of enzalutamide and CYP3A4 substrates with a narrow therapeutic index. You should exercise caution when using enzalutamide or any other CYP3A4 sub-substance.
Enzalutamide	High risk of Inducers causing a decrease in serum concentrations of CYP2C19 substrates For drugs that are activated by CYP2C19, the concentrations of active metabolites could be higher. Management: Avoid concurrent use of enzalutamide and CYP2C19 substrats with a low therapeutic index. You should exercise caution when using enzalutamide or any other CYP2C19 substrat.
Fluconazole	May increase the QTc-prolonging effects of Citalopram. Fluconazole can increase Citalopram's serum concentration. Management: Citalopram should be taken only 20 mg per day if combined with fluconazole. Fluconazole is a strong CYP2C19 antagonist.
Gilteritinib	Citalopram could increase the QTc-prolonging effects of Gilteritinib. Gilteritinib could decrease the therapeutic effects of Citalopram. If possible, avoid this combination. Monitor for decreased response to citalopram, QTc prolongation or arrhythmias. These serious toxicities may be more common in patients with other risk factors.
Anticoagulant/Antiplatelet Herbs: (eg, Alfalfa and Anise, Bilberry).	Agents with Antiplatelet Property may have an adverse/toxic effect. Possible bleeding. Management: Avoid using combination medications whenever possible. Monitor for bleeding signs if you use this combination. Stop using herbal products that contain anticoagulant or Antiplatelet actions two weeks before any surgical, dental or invasive procedure.
Linezolid	This may increase the serotonergic effects of Selective Serotonin Reuptake inhibitors. This could lead to serotonin syndrome. Management: If possible, consider other combinations. Linezolid can be initiated if clinically acceptable.
Linezolid	This may increase the serotonergic effects of Serotonin Activators. This could lead to serotonin syndrome. Management: Serotonin syndrome/serotonin toxicemia can occur if serotonin modulators are stopped 2 weeks before linezolid is administered. Stop using serotonin modators immediately if you need to initiate linezolid immediately.
Lithium	This could increase the serotonergic effects of Selective Serotonin Reuptake Ihibitors. This could increase the risk for serotonin toxicity/serotonin disorder. You should exercise caution when combining these treatments. If combined treatment is clinically recommended, be sure to monitor for signs of serotonin toxicities/serotonin syndrome.
Lorlatinib	High risk of Inducers causing a decrease in serum concentrations of CYP3A4 substrates. Management: Do not use lorlatinib concurrently with any CYP3A4 Substrates. Even a slight decrease in serum concentrations could cause therapeutic failure or serious clinical consequences.
Metoclopramide	This may increase the toxic/adverse effect of Selective Serotonin Reuptake inhibitors. When possible, seek alternatives to this combination. Patients receiving metoclopramide and selective serotonin receptor inhibitors should be monitored for extrapyramidal symptoms, neuroleptic malignant Syndrome, or serotonin syndrome.
Mitotane	High risk of Inducers causing a decrease in serum concentrations of CYP3A4 substrates. Treatment: Patients receiving mitotane may require significant adjustments in the dosage of CYP3A4 Substrates.
Nonsteroidal Anti-Inflammatory Drugs (Nonselective).	Nonsteroidal Anti-Inflammatory Drugs (Nonselective) may have an antiplatelet effect that is enhanced by Selective Serotonin Resuptake Inhibitors. Nonsteroidal Anti Inflammatory Agents (Nonselective), which are nonsteroidal anti-inflammatory agents, may decrease the therapeutic effects of Selective Serotonin Reuptake Inhibitors. Management: If necessary, consider using other analgesics and/or adding a gastroprotective agent. Patients should be closely monitored for bleeding signs and symptoms, as well as evidence of decreased effectiveness of SSRIs when used concurrently.
Omeprazole	Citalopram may increase serum concentrations. Use omeprazole with Citralopram to limit Citalopram dosage to 20 mg/day.
Pitolisant	High risk of Inducers causing a decrease in serum concentrations of CYP3A4 substrates Management: Avoid combining pitolisant and a CYP3A4 substrat with a low therapeutic index. Pitolisant should not be combined with other CYP3A4 sub-substances.
Inhibitor/Antagonist for Serotonin Reuptake	Serotonin Reuptake inhibitors may increase the serotonergic effects of Serotonin Reuptake Ihibitor/Antagonists. This could lead to serotonin syndrome. Management: Look for alternatives and start with conservative doses. These combinations can cause serotonin toxicities.
St John's Wort	High risk of Inducers causing a decrease in serum CYP3A4 Substrates. Management: You may consider a different drug to replace one of the interacting drugs. Some combinations might be contraindicated. Refer to the manufacturer's label.
Tricyclic Antidepressants	Citalopram may have an adverse/toxic effect. Tricyclic Antidepressants can increase Citalopram's serum concentration. Citalopram could increase serum levels of Tricyclic Depressants. Management: If possible, consider alternatives to this combination. When citalopram is used with a tricyclic antidepressant (TCA), monitor for adverse effects, including serotonin syndrome or QT-interval prolongation. Doxepin Systemic; Doxepin Topical are exceptions.
Voriconazole	Citalopram could increase the QTc-prolonging effects of Voriconazole. The serum Citalopram concentration may be increased by Voriconazole. Management: Citalopram should be taken only 20 mg per day if combined with voriconazole. Voriconazole is a mild CYP2C19 antagonist.
Risk Factor X (Avoid the combination)
Bromopride	This may increase the toxic/adverse effect of Selective Serotonin Reuptake Incitors.
Dapoxetine	Can increase the toxic/adverse effects of Serotonin Activators.
Dosulepin	Dosulepin may be increased by selective serotonin reuptake inhibitors
Escitalopram	Citalopram may increase the QTc-prolonging effects. Citalopram's serotonergic effects may be enhanced by Escitalopram. This could lead to serotonin syndrome.
Methylene blue	Selective Serotonin Uptake Inhibitors can enhance the serotonergic effects of Methylene Blue. This could lead to serotonin syndrome.
Methylene Blue	This may increase the serotonergic effects of Serotonin Activators. This could lead to serotonin syndrome.
Monoamine Oxidase inhibitors	This may increase the serotoninrgic effect of Selective Serotonin Reuptake inhibitors. This could lead to serotonin syndrome. Although methylene blue is expected to interact with linezolid via this mechanism, management guidelines differ from those for other monoamine-oxidase inhibitors. For more information, refer to the monographs for those agents. Linezolid, Methylene Blue, Tedizolid are exceptions.
Pimozide	QTc-prolonging agents may have a moderate risk of increasing their QTc-prolonging effects (Moderate Risk).
QT-prolonging agents (Highest risk)	May increase the QTc-prolonging effects of Citalopram.
Tryptophan	This may increase the serotoninrgic effect of Selective Serotonin Reuptake inhibitors. This could lead to serotonin syndrome.
Urokinase	Agents with Antiplatelet Property may increase the anticoagulant effects of Urokinase.

Monitor the patient for the following parameters:

• ECG, especially for patients at high risk of QT-prolongation
• Before starting therapy, electrolytes (potassium & magnesium) are required.
• Signs and symptoms of arrhythmias such as dizziness, palpitations, or syncope
• Tests of liver function
• CBC
• Serotonin syndrome symptoms and signs
• Mental state for depression, suicidal ideation, anxiety and social functioning. Mania, panic attacks.
• Akathisia

How to take Citalopram?

Citalopram may be administered without regard to meals.

Mechanism Of Action Of Citalopram:

• Citalopram selectively inhibits serotonin reuptake in presynaptic neuronal neurons.
• It has minimal effects on norepinephrine or dopamine.
• Citalopram side effect are minimal due to its receptor selectivity. 
• It is not affected by dopamine, GABA, GABA or subtypes of muscarinic receptors.

The beginning of actionThe average treatment time for patients with depression is between 1 and 4 weeks. Individual responses may vary and the full therapeutic response might not be evident until 8 to 12 weeks after treatment has been initiated.

The time taken to complete an actionIt can take up to 2 days. It is bound to proteins at 80 % and

extensivelyMetabolizedBy the liver via the enzymes CYP3A4 or 2C19

Bioavailability is80 % Both oral and tablet solutions have the same bioavailability.

Eliminating half-life is possible24-48 hours, and double for patients with liver disease or elderly patients.

When plasma concentration reaches its peak is1 to 6 hours (average in 4 hours).

The majority of excretion occurs viaUrine

International brands of Citalopram:

• Ansiben
• Ansiodex
• Arpolax
• Celapram
• Celica
• Cimal
• Ciprager
• Cipram
• Cipramax
• Cipramil
• Ciprotan
• Ciram
• Citaalogen
• Cital
• Citalo
• Citalogen
• Citalon
• Citalvir
• Citao
• Citapram
• Citazone
• Citopam
• Citox
• Citrol
• Denyl
• Depaway
• Feliz
• Humorap
• Kitapram
• Lecital
• Linisan
• Lopram
• Lowdep
• Oropram
• Pram
• Prepram
• Prisdal
• Psiconor
• Sepram
• Seropram
• Starcitin
• Talam
• Talosin
• Xylorane
• Zentius
• Zinetron

Citalopram  Brands in Pakistan:

Citalopram (HBr) [Syrup 10 mg/5ml]
CITOPRAM SYRUP	VISION PHARMACUETICALS

 

Citalopram (HBr) [Tabs 10 mg]
AVAIL	XENON PHARMACEUTICALS (PVT) LTD.
CHEER UP	WILSHIRE LABORATORIES (PVT) LTD.
CITACIP	GOODMAN LABORATORIES
CITOPRAM TABLET	GLOBAL PHARMACEUTICALS
DEPINOR	ARIES PHARMACEUTICALS (PVT) LTD
ESTAR	PHARMEVO (PVT) LTD.
EVEPRAM	EVEREST PHARMACEUTICALS
GIGGLE	KURATIVE PAK (PVT) LTD
GLIT-PAM	GLITZ PHARMA
LOPRAM	HANSEL PHARMACUEUTICAL PVT (LTD)
NAZIPRAM	NENZA PHARMACEUTICALS (PVT) LIMITED
ZIPRAM	ZANCTOK PHARMACEUTICALS
ZIPRAM	ZANCTOK PHARMACEUTICALS

 

Citalopram (HBr) [Tabs 10 mg]
AVAIL	XENON PHARMACEUTICALS (PVT) LTD.
CHEER UP	WILSHIRE LABORATORIES (PVT) LTD.
CITACIP	GOODMAN LABORATORIES
CITOPRAM TABLET	GLOBAL PHARMACEUTICALS
DEPINOR	ARIES PHARMACEUTICALS (PVT) LTD
ESTAR	PHARMEVO (PVT) LTD.
EVEPRAM	EVEREST PHARMACEUTICALS
GIGGLE	KURATIVE PAK (PVT) LTD
GLIT-PAM	GLITZ PHARMA
LOPRAM	HANSEL PHARMACUEUTICAL PVT (LTD)
NAZIPRAM	NENZA PHARMACEUTICALS (PVT) LIMITED
ZIPRAM	ZANCTOK PHARMACEUTICALS

 

Citalopram [Tabs 40 mg]
CHEER	WILSHIRE LABORATORIES (PVT) LTD.
CITOPRAM TABLET	GLOBAL PHARMACEUTICALS
ZIPRAM	ZANCTOK PHARMACEUTICALS