Indications
Ministry of Health of Russia
F32 Depressive episode
F33 Recurrent depressive disorder
F40.0 Agoraphobia
F41.0 Panic disorder [episodic paroxysmal anxiety]
F42 Obsessive-compulsive disorder
FDA recommendations
Depression
UK Medicines and Healthcare Products Regulatory Agency guidelines
Depression
Panic disorder with/without agoraphobia
Treatment regimen
Dosage and dose selection
- 20-40 mg/day
- Start with 20 mg/day, increase to 40 mg after a few weeks
- Take the daily dose at one time: morning or evening
- Treatment with a dose higher than 40 mg increases the risk of cardiac complications [1].
- If anxiety, insomnia, agitation, or akathisia occur at the beginning of treatment or after interruption of treatment, the possibility of bipolar disorder should be considered and switched to a mood stabilizer or an atypical antipsychotic
How quickly does it work?
Begins to act after 2-4 weeks
If there is no effect after 6-8 weeks, you need to increase the dose or switch to another drug
To prevent relapse, it can be taken for many years.
Expected Result
Complete remission.
After the symptoms of depression disappear, you should continue taking it for one year if this was the treatment of the first episode. If this is to treat a recurrent episode, treatment can be extended indefinitely.
Use in the treatment of anxiety is indefinite [1].
If it doesn't work
Change the dose, switch to another medicine or add an auxiliary drug;
Connect psychotherapy;
Review the diagnosis by identifying comorbid conditions;
In patients with undiagnosed bipolar affective disorder, the effectiveness of treatment may be low, in which case it is necessary to switch to a mood stabilizer [1].
How to stop taking it
There is no need to reduce it gradually, but to be sure to avoid withdrawal symptoms, you can reduce it gradually. Gradual reduction scheme: dose reduced by 50% - 3 days, again reduced by 50% - 3 days, complete cessation. If withdrawal symptoms appear, increase the dose, wait for withdrawal symptoms to subside, and continue decreasing [1].
Treatment combinations
- For insomnia: trazadone
- For fatigue, drowsiness, loss of concentration: modafinil [3].
- Combinations with other antidepressants may activate bipolar disorder and suicidal ideation
- For bipolar depression, psychotic depression, treatment-resistant depression, treatment-resistant anxiety disorder: mood stabilizers, atypical antipsychotics
- For anxiety disorder: gabapentin, tiagabine
Citalopram
Use in children and adolescents under 18 years of age
Antidepressants should not be prescribed to children and adolescents under 18 years of age. In clinical studies, children and adolescents taking antidepressants were more likely to experience suicidal behavior (suicide attempts and suicidal thoughts) and hostility (with a predominance of aggressive behavior, confrontational behavior, and irritation) than those in the placebo group.
When using drugs belonging to the SSRI therapeutic group, including citalopram, the following should be considered:
Paradoxical anxiety
Some patients with panic disorder may experience increased anxiety when starting antidepressant therapy. This paradoxical reaction usually resolves within the first two weeks after starting treatment. To reduce the likelihood of anxiogenic effects, low initial doses are recommended.
Hyponatremia
Rare cases of hyponatremia, apparently due to inadequate secretion of antidiuretic hormone (ADH), have been reported with the use of SSRIs. This reaction was generally reversible if treatment with the drug was discontinued. The risk was higher in older women.
Suicide/suicidal ideation or clinical worsening
Depression is associated with an increased risk of suicidal ideation, self-harm and suicide (suicidal events). This risk persists until stable remission develops.
Since improvement may not be observed during the first few weeks of treatment or even a longer period of time, patients should be closely monitored to ensure that such improvement is detected in a timely manner. Clinical experience shows that the risk of suicide increases in the early stages of recovery.
Other psychiatric disorders for which citalopram is prescribed may also be associated with an increased risk of suicidal events. In addition, these conditions may be a comorbidity in relation to a depressive episode. When treating patients with other mental disorders, the same precautions should be taken as when treating patients with a depressive episode.
Patients with a history of suicidal tendencies or patients with a significant level of suicidal thoughts before treatment are at greater risk for suicidal ideation or suicide attempts and should be closely monitored during treatment.
A meta-analysis of placebo-controlled clinical trials of antidepressants in adult patients with mental disorders showed that there is an increased risk of suicidal behavior in patients under 25 years of age when taking antidepressants compared with placebo.
Drug treatment of these patients, and in particular those at high risk for suicide, should be accompanied by careful monitoring, especially early in treatment and during dose changes. Patients (and caregivers) should be warned to monitor for any signs of clinical worsening, suicidal behavior or ideation, or unusual changes in behavior, and to seek immediate medical advice if these symptoms occur.
Akathisia/psychomotor restlessness
The use of drugs from the SSRI/SNRI group is associated with the development of akathisia, characterized by a feeling of subjectively unpleasant or unbearable motor restlessness, restlessness and the need to move. Often patients in this condition cannot sit or stand quietly. Most often this condition occurs during the first weeks of treatment. In patients with such symptoms, increasing the dose may cause a sharp deterioration of the condition.
Mania
Patients with bipolar affective disorder may develop a manic phase. If a manic state develops, citalopram should be discontinued.
Seizures
There is a risk of seizures when taking antidepressants. In any patient who experiences a seizure, citalopram should be discontinued. Citalopram should not be used in patients with unstable epilepsy; Controlled seizures require careful monitoring. If the frequency of seizures increases, citalopram should be discontinued.
Diabetes
In patients with diabetes mellitus, the use of SSRIs may change blood glucose concentrations. In this case, dose adjustment of insulin and/or oral hypoglycemic drugs may be required.
Serotonin syndrome
In rare cases, the development of serotonin syndrome has been reported when taking SSRIs. The development of this condition may be indicated by a combination of symptoms such as agitation, myoclonus and hyperthermia. If such phenomena occur, citalopram should be immediately discontinued and symptomatic treatment should be started.
Serotonergic drugs
Citalopram should not be used in combination with drugs that have serotonergic effects, such as sumatriptan or other triptans, tramadol, oxytriptan and tryptophan.
Bleeding
There are reports of the development of skin hemorrhages, such as ecchymosis, gynecological, gastrointestinal bleeding and other hemorrhagic complications of the skin or mucous membranes while taking SSRIs. Caution should be exercised when using SSRIs concomitantly with drugs that affect platelet function or drugs that may increase the risk of bleeding, as well as when treating patients with a history of bleeding disorders.
Electroconvulsive therapy (ECT)
Because clinical experience with the concomitant use of SSRIs and electroconvulsive therapy (ECT) is limited, caution should be used when citalopram and ECT are used concomitantly.
Reversible selective MAO A inhibitors
Concomitant use of citalopram and MAO A inhibitors is not recommended due to the risk of developing serotonin syndrome.
St. John's wort
Citalopram and preparations containing St. John's wort (Hypericum perforatum) should not be used simultaneously, because this may increase the risk of adverse reactions.
Psychosis
Treatment of psychotic patients with a depressive episode may increase the manifestation of psychotic symptoms.
Withdrawal symptoms when stopping SSRI therapy
Withdrawal symptoms occur quite often, especially when therapy is abruptly stopped.
The likelihood of withdrawal symptoms may depend on a number of factors, including the duration of treatment, the dose of the drug, and the rate at which it is tapered.
The most commonly reported symptoms were: dizziness, sensory disturbances (including paresthesia), sleep disturbances (including insomnia and vivid dreams), agitation or anxiety, nausea and/or vomiting, tremor, confusion, sweating, headache, diarrhea, rapidity palpitations, emotional lability, irritability and visual disturbances. These symptoms are usually mild or moderate in severity, but in some patients they can be severe. Typically, such manifestations develop during the first days after discontinuation of the drug, however, there are isolated reports of the development of such conditions in patients who accidentally missed taking the next dose.
In most cases, these complications resolve within 2 weeks, although in some patients symptoms may persist for 2-3 months or longer. Therefore, before ending the course of taking citalopram, it is recommended to gradually reduce the dose of the drug over a period of several weeks to several months, depending on the patient’s condition.
QT prolongation
Citalopram has been found to cause dose-dependent prolongation of the QT interval. Cases of QT prolongation and ventricular arrhythmias, including torsade de pointes
, predominantly in female patients, with hypokalemia or pre-existing QT prolongation or other cardiac disease.
The drug is recommended to be used with caution in patients with significant bradycardia, in patients who have recently suffered a myocardial infarction, or with decompensated heart failure. Electrolyte disturbances, such as hypokalemia and hypomagnesemia, increase the risk of malignant arrhythmias and should therefore be corrected before initiating citalopram therapy.
In patients with compensated heart disease, an ECG study should be performed before starting treatment.
If any signs of cardiac arrhythmias occur during treatment with citalopram, the latter should be discontinued and an ECG study performed.
Special patient groups
Patients with kidney problems
Use caution if the patient has severe kidney disease [1].
Patients with liver disease
Do not increase the dose above 20 mg [1].
Patients with heart disease
Exceeding the dose of 40 mg is dangerous [1].
Elderly patients
In patients over 60, the dose should not be raised above 20 mg;
Citalopram is one of the best-tolerated antidepressants in elderly patients [1].
Children and teenagers
- It is necessary to regularly and personally check the patient's condition, especially in the first weeks of treatment.
- Use with caution due to the risk of undiagnosed bipolar disorder and suicidality.
- Inform adults about the risks.
Pregnant
- There have been no adequate studies in pregnant women [1].
- Not recommended for pregnant women, especially in the first trimester
- All risks should be weighed and compared
- Bleeding can be expected during childbirth
Breast-feeding
- The medicine passes into breast milk.
- If the infant shows signs of irritation or sedation, discontinue feeding or citalopram
- However, treatment after childbirth may be necessary, so the risks should be weighed.
Use of the drug Citalopram
At the beginning of treatment, adults are prescribed 20 mg orally 1 time per day, regardless of meals. Depending on the response to treatment and the severity of the disease, the dose can be increased to 60 mg/day. For elderly patients, the recommended daily dose is 20 mg; if necessary, it can be increased to 40 mg/day. For liver failure, the minimum daily dose is prescribed. In case of mild or moderate renal failure, it is not necessary to limit the dose.
Side effects and other risks
Mechanism of side effects
Side effects are caused by an increase in serotonin. Most side effects occur immediately after starting treatment and go away over time.
Side effects
- Gastroenterological (reduced appetite, nausea, diarrhea, constipation)
- Insomnia, sedation, agitation, tremor
- Sweating
- Urinary dysfunction
- Dry mouth
- Dangerous side effects: seizures, mania, suicidal ideation
- Weight gain: very rare
- Sedation: yes, but infrequently
- Sexual dysfunction: yes
What to do about side effects
- Wait;
- For insomnia, take the drug in the morning;
- For sedation, take at night;
- Switch to another antidepressant [1].
Long term use
Safely
addictive
No.
Overdose
Very rare cases of fatal overdoses.
Vomiting, sedation, cardiac arrhythmia, dizziness, tremor
