Version July 2025
Antidepressants increased the risk of suicidal thinking and behaviors in pediatric and young adult patients in short-term studies. Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors. Citalopram is not approved for use in pediatric patients.
Dosage guidance:
Safety: Doses >40 mg/day are not recommended due to risk of QTc prolongation.
Dosing: Initiate at a low dose and with a slow titration to reduce the potential for behavioral activation/agitation that may occur with therapy initiation particularly in younger children (Ref).
Anxiety disorders (generalized, social, or separation anxiety, or panic disorder): Limited data available:
Note: In pediatric patients, selective serotonin reuptake inhibitor (SSRI) therapy is considered first-line pharmacologic treatment for moderate to severe anxiety disorders in combination with cognitive behavioral therapy (CBT); a preferred SSRI has not been defined; therapeutic selection should be based on pharmacokinetic and pharmacodynamic data, patient tolerability, cost, and unique risks/precautions with specific agents (eg, QT prolongation) (Ref).
Children ≥7 years to <12 years: Oral: Initial range: 2.5 to 10 mg once daily; titrate to target daily dose range: 10 to 20 mg/day. In trials, an initial dose of 10 mg/day titrated slowly every 1 to 2 weeks was reported; however, subsequent expert recommendations suggest in younger patients that lower initial doses (<10 mg) and slow titration be used to prevent dose-related behavioral activation/agitation that may occur early in treatment; some data based on trials treating OCD (a type of anxiety disorder) (Ref).
Children ≥12 years and Adolescents: Initial: 10 mg once daily; titrate at 1- to 2-week intervals up to a target daily dose of 20 to 40 mg/day (Ref).
Depression: Limited data available; efficacy results variable:
Note: In the management of depression in children and adolescents, if pharmacotherapy deemed necessary with/without psychotherapeutic interventions, an SSRI should be used first-line; citalopram is an alternative SSRI option for patients in which fluoxetine is not an option (Ref).
Children ≥7 years and Adolescents: Oral: Initial: 10 mg once daily; increase dose slowly by 10 mg/day every 1 to 2 weeks as clinically needed; reported effective dosage range: 20 to 40 mg/day (Ref).
Note: One randomized, placebo-controlled trial has shown citalopram to be effective for the treatment of depression in pediatric patients (Wagner 2004); other controlled pediatric trials have not shown benefit (Ref).
Obsessive-compulsive disorder (OCD): Limited data available:
Note: In the management of OCD in children and adolescents, if pharmacotherapy deemed necessary with/without psychotherapeutic interventions, an SSRI should be used first-line; a preferred agent has not been identified although fluoxetine and sertraline have FDA approval for OCD in pediatric patients (Ref).
Children ≥7 years: Oral: Initial: 2.5 to 10 mg once daily (Ref); in trials, doses were increased by 5 mg/day every 2 weeks as clinically needed; dosage range: 10 to 40 mg/day; children required higher mg/kg doses than adolescent patients (Ref).
Adolescents: Oral: 10 to 20 mg once daily (Ref); in trials, doses were increased by 10 mg/day every 2 weeks as clinically needed; dosage range: 10 to 40 mg/day (Ref).
Discontinuation of therapy: Consider planning antidepressant discontinuation for lower-stress times, recognizing non-illness-related factors could cause stress or anxiety and be misattributed to antidepressant discontinuation (Ref). Upon discontinuation of antidepressant therapy, gradually taper the dose to minimize the incidence of discontinuation syndromes (withdrawal) and allow for the detection of reemerging disease state symptoms (eg, relapse). Evidence supporting ideal taper rates after illness remission is limited. APA and NICE guidelines suggest tapering therapy over at least several weeks with consideration to the half-life of the antidepressant; antidepressants with a shorter half-life may need to be tapered more conservatively. After long-term (years) antidepressant treatment, WFSBP guidelines recommend tapering over 4 to 6 months, with close monitoring during and for 6 months after discontinuation. If intolerable discontinuation symptoms occur following a dose reduction, consider resuming the previously prescribed dose and/or decrease dose at a more gradual rate (Ref).
Switching antidepressants: Evidence for ideal antidepressant switching strategies in pediatric patients is sparse; strategies described in pediatric guidelines include a conservative approach (tapering and discontinuing the first SSRI before adding the second) and cross-titration (gradually discontinuing the first antidepressant while at the same time gradually increasing the new antidepressant). While consensus does not exist regarding which approach to utilize, it is important to note that the conservative approach runs the risk for exacerbation of symptoms or discontinuation syndrome; cross-titration may avoid these risks (Ref). Cross-titration (eg, over 1 to 4 weeks depending upon sensitivity to discontinuation symptoms and adverse effects) is standard for most switches but is contraindicated when switching to or from a monoamine oxidase inhibitor. While not as common of a strategy, a direct switch may be considered when switching to another agent in the same or similar class (eg, when switching between 2 SSRIs), when the antidepressant to be discontinued has been used for <1 week, or when the discontinuation is for adverse effects. When choosing the switch strategy, consider the risk of discontinuation symptoms, potential for drug interactions, other antidepressant properties (eg, half-life, adverse effects, pharmacodynamics), and the degree of symptom control desired (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Specific recommendations in pediatric patients are not available; based on experience in adult patients, in mild to moderate impairment, no adjustment needed, and in severe impairment, use with caution (has not been studied).
Specific recommendations in pediatric patients are not available; based on experience in adult patients, consider reduced daily doses due to increased serum concentrations and the risk of QT prolongation.
(For additional information see "Citalopram: Drug information")
Dosage guidance:
Safety: Doses >40 mg/day are generally not recommended due to risk of QT prolongation.
Dosing: Some experts suggest a lower starting dose of 10 mg daily and gradual titration in increments of ≤10 mg, particularly in patients with anxiety who are sensitive to antidepressant-associated overstimulation effects (eg, anxiety, insomnia) (Ref).
Aggressive or agitated behavior associated with dementia (off-label use): Oral: Initial: 10 mg once daily; increase to 20 mg once daily after ≥3 days. In adults ≤60 years, may further increase dose based on response and tolerability up to 30 mg/day (Ref); for adults >60 years, do not exceed the maximum dose of 20 mg/day.
Binge eating disorder (off-label use): Oral: Initial: 20 mg once daily. In adults ≤60 years of age, may gradually increase dose based on response and tolerability at intervals ≥1 week to 40 mg once daily. Although doses up to 60 mg/day have been studied, due to safety considerations the recommended maximum dose is 40 mg/day for adults ≤60 years of age and 20 mg/day for adults >60 years (Ref).
Generalized anxiety disorder (off-label use): Oral: Initial: 10 mg once daily; may gradually increase dose based on response and tolerability in 10 mg increments at intervals ≥1 week to a maximum dose of 40 mg/day for adults ≤60 years and 20 mg/day for adults >60 years of age (Ref). Doses may be increased every 3 to 4 days if warranted in inpatient settings. Some experts suggest maintaining the initial therapeutic dose for 4 to 6 weeks to assess for efficacy before increasing further (Ref).
Major depressive disorder (unipolar): Oral: Initial: 20 mg once daily. In adults ≤60 years of age, may gradually increase dose based on response and tolerability at intervals ≥1 week to a maximum recommended dose of 40 mg/day; for adults >60 years of age, the maximum recommended dose is 20 mg/day. Daily doses that exceeded these limits have been studied and may occasionally be warranted with additional monitoring but are generally not recommended due to safety considerations (Ref).
Obsessive-compulsive disorder (alternative agent) (off-label use):
Note: In order to effectively treat obsessive-compulsive disorder (OCD), selective serotonin reuptake inhibitors (SSRIs) are often used at doses exceeding the maximum dose for other indications. Some experts recommend against the use of citalopram in OCD due to risk of dose-related QTc prolongation (Ref).
Oral: Initial: 20 mg once daily. In adults ≤60 years of age, may gradually increase dose based on response and tolerability in 10 to 20 mg increments at intervals ≥1 week to a maximum dose of 40 mg/day; for adults >60 years of age, do not exceed the maximum dose of 20 mg/day (Ref). An adequate trial for assessment of effect in OCD is considered to be ≥6 weeks at maximum tolerated dose (Ref).
Panic disorder (off-label use): Oral: Initial: 10 mg once daily for 3 to 7 days, then 20 mg once daily. In adults ≤60 years, may gradually increase dose based on response and tolerability in 10 to 20 mg increments at intervals ≥1 week to a maximum of 40 mg/day; for adults >60 years of age, do not exceed the maximum dose of 20 mg/day. Daily doses that exceeded these limits have been studied but are not recommended due to safety considerations (Ref). Some experts maintain dose at 20 mg for 4 weeks before considering further dose increases. May require 6 weeks at maximally tolerated dose for adequate treatment trial (Ref).
Posttraumatic stress disorder (off-label use): Oral: Initial: 20 mg once daily. In adults ≤60 years of age, may gradually increase dose based on response and tolerability in 10 to 20 mg increments at intervals ≥1 week to a maximum dose of 40 mg once daily; for adults >60 years of age, do not exceed the maximum dose of 20 mg/day. Daily doses that exceeded these limits have been studied but are not recommended due to safety considerations (Ref).
Premature ejaculation (off-label use): Oral: Initial: 20 mg once daily. In adults ≤60 years of age, may gradually increase dose based on response and tolerability at intervals of ≥1 week (some experts suggest 3- to 4-week titration intervals (Ref)) up to a maximum of 40 mg/day (Ref); for adults >60 years of age, do not exceed the maximum dose of 20 mg/day.
Premenstrual dysphoric disorder (PMDD) (off-label use):
Continuous daily dosing regimen: Oral: Initial: 10 mg once daily; over the first month increase to usual effective dose of 20 mg once daily; in subsequent menstrual cycles, further dose increases (eg, in 10 mg increments per menstrual cycle) up to 40 mg/day may be necessary in some patients for optimal response (Ref).
Intermittent regimens:
Luteal phase dosing regimen: Oral: Initial: 10 mg once daily during the luteal phase of menstrual cycle only (ie, beginning therapy 14 days before anticipated onset of menstruation and continued to the onset of menses); over the first month increase to usual effective dose of 20 mg once daily during the luteal phase; in a subsequent menstrual cycle, a further increase to 30 mg/day during the luteal phase may be necessary in some patients for optimal response (Ref).
Symptom-onset dosing regimen: Oral: Initial: 10 mg once daily from the day of symptom onset until a few days after the start of menses; over the first month increase to usual effective dose of 20 mg once daily; in a subsequent menstrual cycle a further increase to 30 mg/day may be necessary in some patients for optimal response (Ref).
Social anxiety disorder (off-label use): Oral: Initial: 10 to 20 mg once daily. In adults ≤60 years of age, after 4 to 6 weeks may gradually increase dose based on response and tolerability in 10 to 20 mg increments at intervals ≥1 week up to maximum of 40 mg/day; for adults >60 years of age, do not exceed the maximum dose of 20 mg/day. Daily doses that exceeded these limits have been studied but are not recommended due to safety considerations (Ref).
Vasomotor symptoms associated with menopause (alternative agent) (off-label use): Oral: Initial: 10 mg once daily; may increase dose to 20 mg once daily after 1 week. In adults ≤60 years of age, doses as high as 40 mg/day have been studied; however, doses >20 mg/day have demonstrated little additional benefit and greater adverse effects (Ref). Maximum: 40 mg/day. For adults >60 years of age, do not exceed the maximum dose of 20 mg/day.
CYP2C19 poor metabolizers: Maximum dose: 20 mg/day.
Discontinuation of therapy:When discontinuing antidepressant treatment that has lasted for ≥4 weeks, gradually taper the dose (eg, over 2 to 4 weeks) to minimize withdrawal symptoms and detect reemerging symptoms (Ref). For brief treatment (eg, 2 to 3 weeks) may taper over 1 to 2 weeks; <2 weeks treatment generally does not warrant tapering (Ref). Reasons for a slower taper (eg, over 4 weeks) include prior history of antidepressant withdrawal symptoms or high doses of antidepressants (Ref). If intolerable withdrawal symptoms occur, resume the previously prescribed dose and/or decrease dose at a more gradual rate (Ref). Select patients (eg, those with a history of discontinuation syndrome) on long-term treatment (>6 months) may benefit from tapering over >3 months (Ref). Evidence supporting ideal taper rates is limited (Ref).
Switching antidepressants: Evidence for ideal antidepressant switching strategies is limited; strategies include cross-titration (gradually discontinuing the first antidepressant while at the same time gradually increasing the new antidepressant) and direct switch (abruptly discontinuing the first antidepressant and then starting the new antidepressant at an equivalent dose or lower dose and increasing it gradually). Cross-titration (eg, over 1 to 4 weeks depending upon sensitivity to discontinuation symptoms and adverse effects) is standard for most switches, but is contraindicated when switching to or from an MAOI. A direct switch may be an appropriate approach when switching to another agent in the same or similar class (eg, when switching between two SSRIs), when the antidepressant to be discontinued has been used for <1 week, or when the discontinuation is for adverse effects. When choosing the switch strategy, consider the risk of discontinuation symptoms, potential for drug interactions, other antidepressant properties (eg, half-life, adverse effects, pharmacodynamics), and the degree of symptom control desired (Ref).
Switching to or from an MAOI:
Allow 14 days to elapse between discontinuing an MAOI and initiation of citalopram.
Allow 14 days to elapse between discontinuing citalopram and initiation of an MAOI.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.
Note: Limited pharmacokinetic data are available in patients with severe kidney impairment and on hemodialysis (Ref).
Altered kidney function:
CrCl ≥20 mL/minute: No dosage adjustment necessary.
CrCl <20 mL/minute: Initial: 10 mg once daily; gradually titrate based on tolerability and response with close monitoring for adverse effects (eg, QT prolongation) (Ref).
Hemodialysis, intermittent (thrice weekly): Neither citalopram nor its active metabolite, desmethylcitalopram, are significantly dialyzed (1% (Ref)):
Note: An increase in sudden cardiac death in hemodialysis patients prescribed selective serotonin reuptake inhibitors (SSRIs) with higher QT-prolonging potential (citalopram, escitalopram) compared to SSRIs with lower QT-prolonging potential was observed in a retrospective cohort study (Ref). Therefore, use of an SSRI with a lower QT-prolonging potential may be preferred.
Initial: 10 mg once daily; gradually titrate based on tolerability and response with close monitoring for adverse effects (eg, QT prolongation) (Ref).
Peritoneal dialysis: Unlikely to be significantly dialyzed (highly protein bound, large Vd) (Ref):
Note: An increase in sudden cardiac death in hemodialysis patients prescribed SSRIs with higher QT-prolonging potential (citalopram, escitalopram) compared to SSRIs with lower QT-prolonging potential was observed in a retrospective cohort study (Ref). A similar risk has not been observed in patients on peritoneal dialysis (has not been studied), but use of an SSRI with a lower QT-prolonging potential may be preferred.
Initial: 10 mg once daily; gradually titrate based on tolerability and response with close monitoring for adverse effects (eg, QT prolongation) (Ref).
The liver dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Matt Harris, PharmD, MHS, BCPS, FAST, FCCP; Jeong Park, PharmD, MS, BCTXP, FCCP, FAST; Arun Jesudian, MD; Sasan Sakiani, MD.
Note: In a small, single dose pharmacokinetic study in patients with cirrhosis (Child-Turcotte-Pugh class A to C) citalopram elimination was decreased and half-life was prolonged (two-fold) (Ref). Increased exposure may contribute to increased seizure risk and QTc prolongation, which is common in cirrhosis; consider alternative agents specifically in patients at high risk for QT prolongation (Ref).
Liver impairment prior to treatment initiation:
Initial or dose titration in patients with preexisting liver cirrhosis:
Child-Turcotte-Pugh class A to C: Oral: Initial: 10 mg once daily; if necessary, may increase to a maximum dose of 20 mg/day after ≥14 days; use with caution (Ref).
Liver impairment developing in patients already receiving citalopram:
Chronic disease progression (eg, outpatient):
Progression from baseline to Child-Turcotte-Pugh class A to C: Oral:
If current dose ≤20 mg/day: No dosage adjustment necessary; use with caution (Ref).
If current dose >20mg/day: Reduce dose to a maximum of 20 mg/day (Ref). Rate of reduction (eg, rapid versus gradual) should be individualized based on patient-specific factors (eg, indication, current dose); use with caution (Ref).
Acute hepatoxicity during treatment (eg, requiring hospitalization): Oral:
If current dose ≤20 mg/day: No dosage adjustment necessary; use with caution (Ref).
If current dose >20mg/day: Reduce dose to a maximum of 20 mg/day (Ref). Rate of reduction (eg, rapid versus gradual) should be individualized based on patient-specific factors (eg, indication, current dose); use with caution (Ref).
Antidepressants (when used as monotherapy) may precipitate a mixed/manic episode in patients with bipolar disorder. Treatment-emergent mania or hypomania in patients with unipolar major depressive disorder (MDD) have been reported, as many cases of bipolar disorder present in episodes of MDD (Ref). In addition, treatment-emergent mania or hypomania has been described in patients receiving antidepressants, including selective serotonin reuptake inhibitors (SSRIs), for the treatment of obsessive-compulsive disorder (OCD) without a history of bipolar disorder (with or without comorbid MDD) (Ref).
Mechanism: Non–dose-related; idiosyncratic. Unclear to what extent mood switches represent an uncovering of unrecognized bipolar disorder or a more direct pharmacologic effect independent of diagnosis (Ref).
Onset: Varied; a systematic review observed that the risk of switching increased significantly within the initial 2 years of antidepressant treatment in patients with unipolar MDD receiving an antidepressant as monotherapy, but not thereafter (up to 4.6 years) (Ref). In a systematic review of patients with OCD who experienced switching, the manic/hypomanic episodes were more common within 12 weeks of antidepressant treatment initiation; however, episodes occurred up to 9 months in these patients (Ref).
Risk factors:
• Family history of bipolar disorder (Ref)
• Depressive episode with psychotic symptoms (Ref)
• Younger age at onset of depression (Ref)
• Antidepressant resistance (Ref)
• Females (Ref)
Selective serotonin reuptake inhibitors (SSRIs), including citalopram, may increase the risk of bleeding, particularly if used concomitantly with antiplatelets and/or anticoagulants. Multiple observational studies have found an association with SSRI use and a variety of bleeding complications, ranging from bruising, hematomas, petechiae, purpuric disease, and epistaxis to cerebrovascular accident, upper gastrointestinal hemorrhage, intracranial hemorrhage, postpartum hemorrhage (exposure during late gestation), vaginal hemorrhage, and perioperative bleeding, although conflicting evidence also exists (Ref).
Mechanism: Possibly via inhibition of serotonin-mediated platelet activation (inhibition of the serotonin reuptake transporter) and subsequent platelet dysfunction. Citalopram is considered to display moderate affinity for the serotonin reuptake receptor (Ref). SSRIs may also increase gastric acidity, which can increase the risk of GI bleeding (Ref).
Onset: Varied; bleeding risk is likely delayed for several weeks until SSRI-induced platelet serotonin depletion becomes clinically significant (Ref); although the onset of bleeding may be more unpredictable if patients are taking concomitant antiplatelets, anticoagulants, or nonsteroidal anti-inflammatory drugs (NSAIDs). For upper GI bleeding, some studies have found risk to be the highest in the first 28 to 30 days (Ref); whereas, another study reported a median time of onset of 25 weeks (Ref).
Risk factors:
• Concomitant use of anticoagulants and/or antiplatelets (Ref)
• Preexisting platelet dysfunction or coagulation disorders (eg, von Willebrand factor) (Ref)
• Concomitant use of NSAIDs increases the risk for upper GI bleeding (Ref)
Limited data from observational studies involving mostly older adults (≥50 years of age) suggest selective serotonin reuptake inhibitors (SSRIs) are associated with an increased risk of bone fractures (Ref). In addition, several trials and subsequent meta-analyses have found an increased risk of bone fracture with the use of SSRIs in stroke survivors (Ref).
Mechanism: Time-related; mechanism not fully elucidated; postulated to be through a direct effect by SSRIs on bone metabolism via interaction with 5-HT and osteoblast, osteocyte, and/or osteoclast activity (Ref). An increased tendency to falls may also contribute to the increased risk of fractures associated with SSRIs (Ref).
Onset: Delayed; risk appears to increase after initiation and may continue to increase with long-term use. A meta-analysis found risk of fracture increased from 2.9% over 1 year to 5.4% over 2 years; within 5 years, risk increased to 13.4% (Ref). Conversely, the increased risk of bone fracture in stroke survivors who received an SSRI (fluoxetine) was no longer statistically significant at 12 months post stroke (Ref).
Risk factors:
• Long-term use may be a risk factor (Ref)
Selective serotonin reuptake inhibitors (SSRIs) are associated with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and/or hyponatremia, including severe cases, predominantly in the elderly (Ref). Hyponatremia is reversible with discontinuation of therapy (Ref).
Mechanism: May cause SIADH via release of antidiuretic hormone (ADH) (Ref) or may cause nephrogenic SIADH by increasing the sensitivity of the kidney to ADH (Ref).
Onset: Intermediate; usually develops within the first few weeks of treatment with an SSRI (Ref).
Risk factors:
• Older age (Ref)
• Females (Ref)
• Concomitant use of diuretics (Ref)
• Low body weight (Ref)
• Lower baseline serum sodium concentration (Ref)
• Volume depletion (Ref)
• History of hyponatremia (potential risk factor) (Ref)
• Symptoms of psychosis (potential risk factor) (Ref)
Selective serotonin reuptake inhibitors (SSRIs) are associated with acute angle-closure glaucoma (AACG) in case reports and a case-control study. AACG may cause symptoms including eye pain, changes in vision, swelling, and redness, which can rapidly lead to permanent blindness if not treated (Ref). In addition, SSRIs may be associated with an increased risk of cataract development (Ref).
Mechanism: AACG: Unclear; hypothesized that SSRIs may increase the intraocular pressure via serotonergic effects on ciliary body muscle activation and pupil dilation (Ref).
Risk factors:
For AACG:
• Females (Ref)
• ≥50 years of age (slight increase) (Ref)
• Hyperopia (slight increase) (Ref)
• Personal or family history of AACG (Ref)
• Inuit or Asian descent (Ref)
Dose-dependent prolonged QT interval on ECG and torsades de pointes (TdP) have been reported, particularly in patients with coexisting risk factors for QT effects (Ref). Citalopram is associated with a greater effect on QTc prolongation (mean QTc increase 7.8 ms [10 to 20 mg citalopram] and 10.3 ms [20 to 40 mg citalopram]) compared to escitalopram; however, the clinical significance of citalopram’s effect on QT prolongation in patients without additional risk factors receiving usual therapeutic doses has been questioned (Ref).
Mechanism: Dose-related; citalopram is believed to cause QTc prolongation via direct blockade of the rapid potassium delayed rectifier current (IKr), encoded by the human ether-à-go-go-related gene (hERG) (Ref).
Risk factors:
In general, risk factors for drug-induced QT prolongation/TdP:
• Females (Ref)
• Age >65 years (Ref)
• Structural heart disease (eg, history of myocardial infarction or heart failure with a reduced ejection fraction) (Ref)
• History of drug-induced TdP (Ref)
• Genetic defects of cardiac ion channels (Ref)
• Congenital long QT syndrome (Ref)
• Baseline QTc interval prolongation (eg, >500 msec) or lengthening of the QTc by ≥60 msec (Ref)
• Electrolyte disturbances (eg, hypokalemia, hypocalcemia, or hypomagnesemia) (Ref)
• Bradycardia (Ref)
• Hepatic impairment (Ref)
• Kidney impairment (Ref)
• Coadministration of multiple medications (≥2) that prolong the QT interval or increase drug interactions that increase serum drug concentrations of QT-prolonging medications (Ref)
• Substance use (Ref)
Serotonin syndrome has been reported and typically occurs with coadministration of multiple serotonergic drugs but can occur following a single serotonergic agent at therapeutic doses (Ref). The diagnosis of serotonin syndrome is made based on the Hunter Serotonin Toxicity Criteria (Ref) and may result in a spectrum of symptoms, such as anxiety, agitation, confusion, delirium, hyperreflexia, muscle rigidity, myoclonus, tachycardia, tachypnea, and tremor. Severe cases may cause hyperthermia, significant autonomic instability (ie, rapid and severe changes in blood pressure and pulse), coma, and seizures (Ref).
Mechanism: Dose-related; overstimulation serotonin receptors by serotonergic agents (Ref).
Onset: Rapid; in the majority of cases (74%), onset occurred within 24 hours of treatment initiation, overdose, or change in dose (Ref).
Risk factors:
• Concomitant use of drugs that increase serotonin synthesis, block serotonin reuptake and/or impair serotonin metabolism (eg, monamine oxidase inhibitors [MAOIs]). Of note, concomitant use of some serotonergic agents, such as MAOIs, are contraindicated.
Selective serotonin reuptake inhibitors (SSRIs) are commonly associated with sexual disorder in both men and women. The following adverse reactions have been associated with SSRI use: Orgasm abnormal, anorgasmia, erectile dysfunction, and decreased libido (Ref). Priapism and decreased genital sensation have also been reported with SSRIs (Ref). The impact on sexual health may be lessened with drug holidays; in an open-label trial, patients taking an SSRI (other than fluoxetine) who were instructed to not take their medication on the weekends (n = 63) reported improved erection, ejaculation, satisfaction, and overall sexual health without significant worsening in their mental health status (Ref).
Mechanism: Dose-related (Ref); increases in serotonin may affect other hormones and neurotransmitters involved in sexual function; in particular, testosterone's effect on sexual arousal and dopamine's role in achieving orgasm (Ref).
Risk factors:
• Depression (sexual dysfunction is commonly associated with depression; SSRI-associated sexual dysfunction may be difficult to differentiate in treated patients) (Ref)
Antidepressants are associated with an increased risk of suicidal ideation and suicidal tendencies in pediatric and young adult patients (18 to 24 years of age) in short-term studies. In adults >24 years of age, short-term studies did not show an increased risk of suicidal thinking and behavior, and in older adults ≥65 years of age a decreased risk was observed. Although data have yielded inconsistent results regarding the association of antidepressants and risk of suicide, particularly among adults, collective evidence shows a trend of an elevated risk of suicidality in younger age groups (Ref). Of note, the risk of a suicide attempt is inherent in major depression and may persist until remission occurs.
Mechanism: Not established; one of several postulated mechanisms is antidepressants may energize suicidal patients to act on impulses; another suggests that antidepressants may produce a worsening of depressive symptoms leading to the emergence of suicidal thoughts and actions (Ref).
Onset: Varied; increased risk observed in short-term studies (ie, <4 months) in pediatric and young adults; it is unknown whether this risk extends to longer-term use (ie, >4 months).
Risk factors:
• Children and adolescents (Ref)
• Depression (risk of suicide is associated with major depression and may persist until remission occurs)
Withdrawal syndrome, consisting of both somatic symptoms (eg, dizziness, chills, light-headedness, vertigo, 'shock-like' sensations, paresthesia, fatigue, headache, nausea, tremor, diarrhea, visual disturbances) and psychological symptoms (eg, anxiety, agitation, confusion, insomnia, irritability, mania) have been reported, primarily following abrupt discontinuation. Withdrawal symptoms may also occur following gradual tapering (Ref).
Mechanism: Withdrawal; due to reduced availability of serotonin in the CNS with decreasing levels of the selective serotonin reuptake inhibitor (SSRI). Other neurotransmission systems, including increased glutamine and dopamine, may also be affected, as well as the hypothalamic-pituitary-adrenal axis (Ref).
Onset: Intermediate; expected onset is 1 to 10 days (following either abrupt or tapered discontinuation) (Ref).
Risk factors:
• Abrupt discontinuation (rather than dose taper) or tapering the antidepressant too quickly (Ref)
• Drugs with a half-life <24 hours (eg, paroxetine, venlafaxine) (Ref)
• Higher doses (Ref)
• Longer duration of treatment (eg, ≥4 weeks) (Ref)
• Prior history of antidepressant withdrawal symptoms (Ref)
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
>10%:
Dermatologic: Diaphoresis (11%)
Gastrointestinal: Nausea (21%), xerostomia (20%)
Nervous system: Drowsiness (18%; literature suggests incidence occurs less frequently in children and adolescents compared to adults (Ref)), insomnia (15%)
1% to 10%:
Cardiovascular: Bradycardia (1%), hypotension (≥1%), orthostatic hypotension (≥1%), prolonged QT interval on ECG (2%) (table 1), tachycardia (≥1%)
|
Drug (Citalopram) |
Placebo |
Number of Patients (Citalopram) |
Number of Patients (Placebo) |
|---|---|---|---|
|
2% |
1% |
802 |
241 |
Dermatologic: Pruritus (≥1%), skin rash (≥1%)
Endocrine & metabolic: Amenorrhea (≥1%), decreased libido (1% to 4%) (table 2), weight gain (≥1%), weight loss (≥1%)
|
Drug (Citalopram) |
Placebo |
Population |
Number of Patients (Citalopram) |
Number of Patients (Placebo) |
|---|---|---|---|---|
|
1% |
N/A |
Females |
638 |
N/A |
|
4% |
<1% |
Males |
425 |
194 |
|
2% |
<1% |
Males and females |
1,063 |
446 |
Gastrointestinal: Abdominal pain (3%), anorexia (4%), diarrhea (8%), dysgeusia (≥1%), dyspepsia (5%), flatulence (≥1%), increased appetite (≥1%), sialorrhea (≥1%), vomiting (4%; literature suggests incidence is higher in adolescents compared to adults and is two- to threefold higher in children compared to adults (Ref))
Genitourinary: Dysmenorrhea (3%), ejaculatory disorder (6%), erectile dysfunction (3%) (table 3) (table 4), polyuria (≥1%)
|
Drug (Citalopram) |
Placebo |
Number of Patients (Citalopram) |
Number of Patients (Placebo) |
|---|---|---|---|
|
6% |
1% |
1,063 |
446 |
|
Drug (Citalopram) |
Placebo |
Number of Patients (Citalopram) |
Number of Patients (Placebo) |
|---|---|---|---|
|
3% |
<1% |
425 |
194 |
Nervous system: Agitation (3%), amnesia (≥1%), anxiety (4%), apathy (≥1%), confusion (≥1%), depression (≥1%), fatigue (5%), lack of concentration (≥1%), migraine (≥1%), paresthesia (≥1%), tremor (8%), yawning (2%)
Neuromuscular & skeletal: Arthralgia (2%), myalgia (2%)
Ophthalmic: Accommodation disturbance (≥1%)
Respiratory: Cough (≥1%), rhinitis (5%), sinusitis (3%), upper respiratory tract infection (5%)
Miscellaneous: Fever (2%)
<1%:
Cardiovascular: Acute myocardial infarction, angina pectoris, atrial fibrillation, bundle branch block, extrasystoles, flushing, heart failure, hypertension, ischemic heart disease, peripheral edema, phlebitis, pulmonary embolism, syncope
Dermatologic: Acne vulgaris, alopecia, cellulitis, dermatitis, eczema, hypertrichosis, hypohidrosis, psoriasis, skin discoloration, skin photosensitivity, urticaria, xeroderma
Endocrine & metabolic: Altered serum glucose, dehydration, galactorrhea not associated with childbirth, goiter, gynecomastia, hot flash, hypoglycemia, hypokalemia, hyponatremia (literature suggests incidence of hyponatremia among SSRIs ranges from <1% to as high as 32% (Ref)) (Ref), hypothyroidism, increased libido, increased thirst, obesity
Gastrointestinal: Bruxism, cholecystitis, cholelithiasis, colitis, diverticulitis of the gastrointestinal tract, duodenal ulcer, dysphagia, eructation, esophagitis, gastric ulcer, gastritis, gastroenteritis, gastroesophageal reflux disease, gingival hemorrhage, gingivitis, glossitis, hemorrhoids, hiccups, melanosis, pruritus ani, stomatitis
Genitourinary: Breast hypertrophy, dysuria, hematuria, mastalgia, oliguria, urinary incontinence, urinary retention, vaginal hemorrhage
Hematologic & oncologic: Anemia, disorder of hemostatic components of blood, hypochromic anemia, leukocytosis, leukopenia, lymphadenopathy, lymphocytopenia, lymphocytosis, purpuric disease
Hepatic: Hepatitis, hyperbilirubinemia, increased liver enzymes, increased serum alkaline phosphatase, jaundice
Hypersensitivity: Facial edema
Nervous system: Abnormal gait, aggressive behavior, ataxia, catatonia, cerebrovascular accident, delusion, depersonalization, drug dependence, emotional lability, euphoria, extrapyramidal reaction, hallucination, hyperesthesia, hypertonia, hypoesthesia, involuntary muscle movements, myasthenia, neuralgia, nightmares, panic attack, paranoid ideation, psychosis, rigors, seizure, serotonin syndrome, stupor, transient ischemic attacks, vertigo
Neuromuscular & skeletal: Arthritis, bursitis, dystonia, hyperkinetic muscle activity, hypokinesia, lower limb cramp, osteoporosis, skeletal pain
Ophthalmic: Abnormal lacrimation, blepharoptosis, cataract, conjunctivitis, diplopia, dry eye syndrome, eye pain, keratitis, mydriasis, photophobia
Otic: Tinnitus
Renal: Nephrolithiasis, pyelonephritis, renal pain
Respiratory: Asthma, bronchitis, bronchospasm, dyspnea, epistaxis, flu-like symptoms, laryngitis, pneumonia, pneumonitis
Postmarketing:
Cardiovascular: Chest pain, Raynaud disease (Ref), thrombosis, torsades de pointes (Ref), ventricular arrhythmia
Dermatologic: Ecchymoses, erythema multiforme, toxic epidermal necrolysis
Endocrine & metabolic: Hyperprolactinemia, SIADH (Ref)
Gastrointestinal: Gastrointestinal hemorrhage (Ref), pancreatitis
Genitourinary: Abnormal organism (Ref), anorgasmia (Ref), priapism (including clitoral priapism) (Ref), sexual difficulty (decreased genital sensation) (Ref), sexual disorder (including persistent post SSRI) (Ref)
Hematologic & oncologic: Hemolytic anemia, hypoprothrombinemia, thrombocytopenia (Ref)
Hepatic: Hepatic necrosis
Hypersensitivity: Anaphylaxis, angioedema, hypersensitivity reaction
Nervous system: Akathisia, anosmia (including hyposmia), choreoathetosis, delirium, hyperactive behavior (including restlessness occurring in children at a two- to threefold higher incidence compared to adolescents (Ref)), mania (Ref), myoclonus, neuroleptic malignant syndrome (Ref), suicidal ideation (Ref), suicidal tendencies (Ref), withdrawal syndrome (Ref)
Neuromuscular & skeletal: Dyskinesia (Ref), rhabdomyolysis
Ophthalmic: Acute angle-closure glaucoma (Ref), nystagmus disorder
Renal: Acute kidney injury
Hypersensitivity (including angioedema, anaphylaxis) to citalopram or any component of the formulation; use of monoamine oxidase inhibitors (MAOIs) intended to treat psychiatric disorders (concurrently or within 14 days of discontinuing either citalopram or the MAOI); initiation of citalopram in a patient receiving IV methylene blue; concomitant use with pimozide.
Note: Although citalopram is contraindicated per manufacturer labeling when used in combination with linezolid, new evidence suggests that the combination is unlikely to cause serotonin syndrome (0.06% to 3% risk), and therefore these agents can be administered concomitantly when necessary. Monitor patients on this combination; average duration of serotonin toxicity is ~4 days; however, risks may be greater with longer durations of concurrent therapy. Educate patients on the signs and symptoms of serotonin syndrome (Bai 2022; Butterfield 2012; Karkow 2017; Kufel 2023; Narita 2007; Taylor 2006).
Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Canadian labeling: Additional contraindications (not in US labeling): Known QT interval prolongation or congenital long QT syndrome
Concerns related to adverse effects:
• CNS depression: Has a low potential to impair cognitive or motor performance; caution operating hazardous machinery or driving.
Disease-related concerns:
• Bariatric surgery: Presurgical assessment of the indication for use, symptoms, and goals of therapy should be documented to enable postsurgical assessment. Data from one patient in a small pharmacokinetic study showed an approximate decrease in citalopram exposure of 50% early postsurgery (eg, <30 days); overall selective serotonin reuptake inhibitors (SSRIs) had wide interpatient variability (Hamad 2012). Monitor for continued efficacy after bariatric surgery and consider switching to an alternate medication if symptoms worsen.
• Hepatic impairment: Use with caution in patients with hepatic impairment; clearance is decreased and half-life and plasma concentrations are increased.
• Renal impairment: Use with caution in patients with severe renal impairment.
• Seizure disorders: Use with caution in patients with a previous seizure disorder or condition predisposing to seizures such as brain damage or alcohol use disorder.
Special populations:
• CYP2C19 poor metabolizers: Citalopram exposure and maximum concentrations are increased in CYP2C19 poor metabolizers; a dose reduction may be required.
• Older adult: Pharmacokinetics are altered in patients >60 years of age.
• Pediatric: Citalopram is not FDA-approved for use in children; however, if used, monitor weight and growth regularly during therapy due to the potential for decreased appetite and weight loss with SSRI use.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Capsule, Oral, as hydrobromide:
Generic: 30 mg
Solution, Oral, as hydrobromide:
Generic: 10 mg/5 mL (10 mL [DSC], 240 mL, 473 mL); 20 mg/10 mL (10 mL)
Tablet, Oral, as hydrobromide:
CeleXA: 10 mg
CeleXA: 20 mg, 40 mg [scored]
Generic: 10 mg, 20 mg, 40 mg
Yes
Capsules (Citalopram Hydrobromide Oral)
30 mg (per each): $6.48
Solution (Citalopram Hydrobromide Oral)
10 mg/5 mL (per mL): $0.49 - $0.98
Tablets (CeleXA Oral)
10 mg (per each): $10.89
20 mg (per each): $11.35
40 mg (per each): $11.85
Tablets (Citalopram Hydrobromide Oral)
10 mg (per each): $2.43 - $2.58
20 mg (per each): $2.53 - $2.69
40 mg (per each): $2.64 - $2.78
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Tablet, Oral, as hydrobromide:
CeleXA: 20 mg, 40 mg
CTP 30: 30 mg
Generic: 10 mg, 20 mg, 30 mg, 40 mg
Oral: May be administered without regard to meals.
Oral: May be administered without regard to food.
Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F).
An FDA-approved patient medication guide, which is available with the product information and as follows, must be dispensed with this medication:
Citalopram capsules: https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/215428s002lbl.pdf#page=24
Citalopram tablets: https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/020822s054lbl.pdf#page=22
Treatment of depression (FDA approved in adults); has also been used to treat obsessive-compulsive disorder (OCD).
CeleXA may be confused with CeleBREX, Cerebyx, Ranexa, ZyPREXA
Citalopram may be confused with escitalopram
Beers Criteria: Selective Serotonin Reuptake Inhibitors (SSRIs) are identified in the Beers Criteria as potentially inappropriate medications to be used with caution in patients 65 years and older because of the potential to cause or exacerbate syndrome of inappropriate antidiuretic hormone secretion (SIADH) or hyponatremia; monitor sodium concentration closely when initiating or adjusting the dose in older adults (Beers Criteria [AGS 2023]).
Citalopram is identified in the Screening Tool of Older Person's Prescriptions (STOPP) criteria as a potentially inappropriate medication in older adults (≥65 years of age) with a history of recurrent falls due to an increased risk of falls. In addition, some disease states of concern include QTc prolongation, hyponatremia, and recent or current bleeding (O’Mahony 2023).
Substrate of CYP2C19 (Major with inhibitors), CYP2C19 (Minor with inducers), CYP2D6 (Minor), CYP3A4 (Major with inducers), CYP3A4 (Minor with inhibitors); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential; Inhibits CYP2D6 (Weak);
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program
Abciximab: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor
Abrocitinib: Agents with Antiplatelet Effects may increase antiplatelet effects of Abrocitinib. Risk X: Avoid
Acalabrutinib: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor
Agents with Blood Glucose Lowering Effects: Selective Serotonin Reuptake Inhibitor may increase hypoglycemic effects of Agents with Blood Glucose Lowering Effects. Risk C: Monitor
Alcohol (Ethyl): May increase adverse/toxic effects of Selective Serotonin Reuptake Inhibitor. Specifically, the risk of psychomotor impairment may be enhanced. Management: Patients receiving selective serotonin reuptake inhibitors should be advised to avoid alcohol. Monitor for increased psychomotor impairment in patients who consume alcohol during treatment with selective serotonin reuptake inhibitors. Risk D: Consider Therapy Modification
Almotriptan: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Alosetron: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Amisulpride (Oral): May increase QTc-prolonging effects of QT-prolonging Agents (Moderate Risk). Risk C: Monitor
Amphetamines: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability). Initiate amphetamines at lower doses, monitor frequently, and adjust doses as needed. Risk C: Monitor
Anagrelide: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor
Anticoagulants (Miscellaneous Agents): Antidepressants with Antiplatelet Effects may increase anticoagulant effects of Anticoagulants (Miscellaneous Agents). Risk C: Monitor
Antiemetics (5HT3 Antagonists): May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Antiplatelet Agents (P2Y12 Inhibitors): Agents with Antiplatelet Effects may increase antiplatelet effects of Antiplatelet Agents (P2Y12 Inhibitors). Risk C: Monitor
Antipsychotic Agents: Serotonergic Agents (High Risk) may increase adverse/toxic effects of Antipsychotic Agents. Specifically, serotonergic agents may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotic Agents may increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Risk C: Monitor
Aspirin: Selective Serotonin Reuptake Inhibitor may increase antiplatelet effects of Aspirin. Risk C: Monitor
Brexanolone: Selective Serotonin Reuptake Inhibitor may increase CNS depressant effects of Brexanolone. Risk C: Monitor
Bromopride: May increase adverse/toxic effects of Selective Serotonin Reuptake Inhibitor. Risk X: Avoid
BuPROPion: May increase adverse/toxic effects of Citalopram. BuPROPion may increase serum concentration of Citalopram. Management: Initiate citalopram at the lower end of the normal dose range in patients receiving bupropion and consider limiting the maximum citalopram adult dose to 20 mg/day during concomitant bupropion treatment. Monitor for citalopram toxicities. Risk D: Consider Therapy Modification
BusPIRone: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Caplacizumab: Agents with Antiplatelet Effects may increase adverse/toxic effects of Caplacizumab. Specifically, the risk of bleeding may be increased. Risk C: Monitor
Cimetidine: May increase serum concentration of Citalopram. Management: Limit citalopram dose to a maximum of 20 mg/day if used with cimetidine. Patients using this combination should be monitored closely for evidence of citalopram toxicity (eg, serotonin syndrome, QT prolongation). Risk D: Consider Therapy Modification
CloZAPine: May increase QTc-prolonging effects of Citalopram. CloZAPine may increase serotonergic effects of Citalopram. This could result in serotonin syndrome. Management: Monitor for QTc interval prolongation, ventricular arrhythmias, serotonin syndrome, and neuroleptic malignant syndrome when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
Collagenase (Systemic): Agents with Antiplatelet Effects may increase adverse/toxic effects of Collagenase (Systemic). Specifically, the risk of injection site bruising and or bleeding may be increased. Risk C: Monitor
Cyclobenzaprine: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
CYP2C19 Inhibitors (Moderate): May increase serum concentration of Citalopram. Management: Limit citalopram dose to a maximum of 20 mg/day if used with a moderate CYP2C19 inhibitor. Patients using this combination should be monitored closely for evidence of citalopram toxicity (eg, serotonin syndrome, QT prolongation). Risk D: Consider Therapy Modification
CYP3A4 Inducers (Strong): May decrease serum concentration of Citalopram. Risk C: Monitor
Cyproheptadine: May decrease therapeutic effects of Selective Serotonin Reuptake Inhibitor. Risk C: Monitor
Dabrafenib: May increase QTc-prolonging effects of QT-prolonging Antidepressants (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias, including torsades de pointes when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
Dapoxetine: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Do not use serotonergic agents (high risk) with dapoxetine or within 7 days of serotonergic agent discontinuation. Do not use dapoxetine within 14 days of monoamine oxidase inhibitor use. Dapoxetine labeling lists this combination as contraindicated. Risk X: Avoid
Dasatinib: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor
Deoxycholic Acid: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor
Desmopressin: Hyponatremia-Associated Agents may increase hyponatremic effects of Desmopressin. Risk C: Monitor
Dexmethylphenidate-Methylphenidate: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Dextromethorphan: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Direct Oral Anticoagulants (DOACs): Antidepressants with Antiplatelet Effects may increase anticoagulant effects of Direct Oral Anticoagulants (DOACs). Risk C: Monitor
Domperidone: QT-prolonging Agents (Moderate Risk) may increase QTc-prolonging effects of Domperidone. Risk X: Avoid
DULoxetine: Selective Serotonin Reuptake Inhibitor may increase serotonergic effects of DULoxetine. This could result in serotonin syndrome. Selective Serotonin Reuptake Inhibitor may increase antiplatelet effects of DULoxetine. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, mental status changes) when these agents are combined. In addition, monitor for signs and symptoms of bleeding. Risk C: Monitor
Eletriptan: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Encorafenib: Citalopram may increase QTc-prolonging effects of Encorafenib. Encorafenib may decrease serum concentration of Citalopram. Management: Monitor for QTc interval prolongation, ventricular arrhythmias, and reduced citalopram concentrations and efficacy when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
Epinephrine (Racemic): Selective Serotonin Reuptake Inhibitor may increase adverse/toxic effects of Epinephrine (Racemic). Risk X: Avoid
Ergot Derivatives: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Escitalopram: May increase QTc-prolonging effects of Citalopram. Escitalopram may increase serotonergic effects of Citalopram. This could result in serotonin syndrome. Citalopram may increase antiplatelet effects of Escitalopram. Risk X: Avoid
Esomeprazole: May increase serum concentration of Citalopram. Management: Limit citalopram dose to a maximum of 20 mg/day if used with esomeprazole. Patients using this combination should be monitored closely for evidence of citalopram toxicity (eg, serotonin syndrome, QT prolongation, etc.). Risk D: Consider Therapy Modification
Fenfluramine: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Risk C: Monitor
Fexinidazole: May increase QTc-prolonging effects of Citalopram. Fexinidazole may increase serum concentration of Citalopram. Management: Limit citalopram dose to a maximum of 20 mg/day if used with fexinidazole, which is a moderate CYP2C19 inhibitor. Monitor for citalopram toxicity (eg, serotonin syndrome), QTc prolongation, and arrhythmias (including torsades de pointes). Risk D: Consider Therapy Modification
Fluconazole: May increase QTc-prolonging effects of Citalopram. Fluconazole may increase serum concentration of Citalopram. Management: Limit citalopram dose to a maximum of 20 mg/day if used with fluconazole, which is a strong CYP2C19 inhibitor. Patients using this combination should be monitored closely for citalopram toxicities, including serotonin syndrome and QT prolongation. Risk D: Consider Therapy Modification
Fluorouracil Products: May increase QTc-prolonging effects of QT-prolonging Antidepressants (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias, including torsades de pointes when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
FLUoxetine: Citalopram may increase serotonergic effects of FLUoxetine. This could result in serotonin syndrome. Citalopram may increase antiplatelet effects of FLUoxetine. FLUoxetine may increase serum concentration of Citalopram. Management: Limit citalopram dose to a maximum of 20 mg/day. Monitor for signs and symptoms of bleeding, QTc interval prolongation, or serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor) if combined. Risk D: Consider Therapy Modification
FluvoxaMINE: Citalopram may increase serotonergic effects of FluvoxaMINE. This could result in serotonin syndrome. Citalopram may increase antiplatelet effects of FluvoxaMINE. FluvoxaMINE may increase serum concentration of Citalopram. Management: Limit citalopram dose to a maximum of 20 mg/day. Monitor for signs and symptoms of bleeding, QTc prolongation, or serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor) if combined. Risk D: Consider Therapy Modification
Fondaparinux: Antidepressants with Antiplatelet Effects may increase anticoagulant effects of Fondaparinux. Risk C: Monitor
Gepirone: May increase QTc-prolonging effects of QT-prolonging Antidepressants (Moderate Risk). Gepirone may increase serotonergic effects of QT-prolonging Antidepressants (Moderate Risk). This could result in serotonin syndrome. Risk C: Monitor
Gilteritinib: May decrease therapeutic effects of Citalopram. Citalopram may increase QTc-prolonging effects of Gilteritinib. Management: Avoid use of this combination if possible. If use is necessary, monitor for reduced response to citalopram and for QTc prolongation and arrhythmias. Patients with other risk factors may be at greater risk for these serious toxicities. Risk D: Consider Therapy Modification
Glycoprotein IIb/IIIa Inhibitors: Agents with Antiplatelet Effects may increase antiplatelet effects of Glycoprotein IIb/IIIa Inhibitors. Risk C: Monitor
Haloperidol: QT-prolonging Antidepressants (Moderate Risk) may increase QTc-prolonging effects of Haloperidol. Haloperidol may increase serotonergic effects of QT-prolonging Antidepressants (Moderate Risk). This could result in serotonin syndrome. Management: Monitor for QTc interval prolongation, ventricular arrhythmias, and serotonin syndrome/serotonin toxicity (SS/ST) or NMS when these agents are combined. Patients with additional risk factors for QTc prolongation or SS/ST may be at even higher risk. Risk C: Monitor
Heparin: Antidepressants with Antiplatelet Effects may increase anticoagulant effects of Heparin. Risk C: Monitor
Heparins (Low Molecular Weight): Antidepressants with Antiplatelet Effects may increase anticoagulant effects of Heparins (Low Molecular Weight). Risk C: Monitor
Herbal Products with Anticoagulant/Antiplatelet Effects: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor
Hydroxychloroquine: May increase QTc-prolonging effects of Citalopram. Citalopram may increase hypoglycemic effects of Hydroxychloroquine. Risk C: Monitor
Ibritumomab Tiuxetan: Agents with Antiplatelet Effects may increase antiplatelet effects of Ibritumomab Tiuxetan. Risk C: Monitor
Ibrutinib: Agents with Antiplatelet Effects may increase adverse/toxic effects of Ibrutinib. Specifically, the risk of bleeding and hemorrhage may be increased. Risk C: Monitor
Inotersen: Agents with Antiplatelet Effects may increase adverse/toxic effects of Inotersen. Specifically, the risk of bleeding may be increased. Risk C: Monitor
Ioflupane I 123: Coadministration of Selective Serotonin Reuptake Inhibitor and Ioflupane I 123 may alter diagnostic results. Risk C: Monitor
Lasmiditan: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Levoketoconazole: QT-prolonging Agents (Moderate Risk) may increase QTc-prolonging effects of Levoketoconazole. Risk X: Avoid
Levomethadone: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Limaprost: May increase adverse/toxic effects of Agents with Antiplatelet Effects. Specifically, the risk of bleeding may be increased. Risk C: Monitor
Linezolid: May increase serotonergic effects of Selective Serotonin Reuptake Inhibitor. This could result in serotonin syndrome. Risk X: Avoid
Lofexidine: May increase QTc-prolonging effects of Citalopram. Citalopram may increase QTc-prolonging effects of Lofexidine. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
Metaxalone: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Methylene Blue: Selective Serotonin Reuptake Inhibitor may increase serotonergic effects of Methylene Blue. This could result in serotonin syndrome. Risk X: Avoid
Metoclopramide: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Consider monitoring for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Miscellaneous Antiplatelets: Agents with Antiplatelet Effects may increase antiplatelet effects of Miscellaneous Antiplatelets. Risk C: Monitor
Mivacurium: Selective Serotonin Reuptake Inhibitor may increase serum concentration of Mivacurium. Risk C: Monitor
Monoamine Oxidase Inhibitors (Antidepressant): Selective Serotonin Reuptake Inhibitor may increase serotonergic effects of Monoamine Oxidase Inhibitors (Antidepressant). This could result in serotonin syndrome. Risk X: Avoid
Nefazodone: May increase serotonergic effects of Selective Serotonin Reuptake Inhibitor. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective): Selective Serotonin Reuptake Inhibitor may increase antiplatelet effects of Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective). Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective) may decrease therapeutic effects of Selective Serotonin Reuptake Inhibitor. Risk C: Monitor
Nonsteroidal Anti-Inflammatory Agents (Nonselective): Selective Serotonin Reuptake Inhibitor may increase antiplatelet effects of Nonsteroidal Anti-Inflammatory Agents (Nonselective). Nonsteroidal Anti-Inflammatory Agents (Nonselective) may decrease therapeutic effects of Selective Serotonin Reuptake Inhibitor. Management: Consider alternatives to NSAIDs. Monitor for evidence of bleeding and diminished antidepressant effects. It is unclear whether COX-2-selective NSAIDs reduce risk. Risk D: Consider Therapy Modification
Nonsteroidal Anti-Inflammatory Agents (Topical): May increase antiplatelet effects of Selective Serotonin Reuptake Inhibitor. Risk C: Monitor
Obinutuzumab: Agents with Antiplatelet Effects may increase adverse/toxic effects of Obinutuzumab. Specifically, the risk of bleeding may be increased. Management: Consider avoiding coadministration of obinutuzumab and agents with antiplatelet effects, especially during the first cycle of obinutuzumab therapy. Risk D: Consider Therapy Modification
Omeprazole: May increase serum concentration of Citalopram. Management: Limit citalopram dose to a maximum of 20 mg/day if used with omeprazole. Monitor for evidence of citalopram toxicity (eg, serotonin syndrome, QT prolongation) in patients receiving this combination. Risk D: Consider Therapy Modification
Ondansetron: May increase QTc-prolonging effects of QT-prolonging Antidepressants (Moderate Risk). Ondansetron may increase serotonergic effects of QT-prolonging Antidepressants (Moderate Risk). This could result in serotonin syndrome. Management: Monitor for QTc interval prolongation, ventricular arrhythmias, and serotonin syndrome when these agents are combined. Patients with additional risk factors for QTc prolongation or serotonin syndrome may be at even higher risk. Risk C: Monitor
Opioid Agonists (metabolized by CYP3A4 and CYP2D6): May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Opioid Agonists (metabolized by CYP3A4): May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Opioid Agonists: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Opipramol: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Oxitriptan: Serotonergic Agents (High Risk) may increase serotonergic effects of Oxitriptan. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
OxyCODONE: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Pentamidine (Systemic): May increase QTc-prolonging effects of QT-prolonging Antidepressants (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
Pentosan Polysulfate Sodium: Agents with Antiplatelet Effects may increase adverse/toxic effects of Pentosan Polysulfate Sodium. Specifically, the risk of hemorrhage may be increased. Risk C: Monitor
Perhexiline: Citalopram may increase serum concentration of Perhexiline. Risk C: Monitor
Pimozide: May increase QTc-prolonging effects of QT-prolonging Agents (Moderate Risk). Risk X: Avoid
Piperaquine: QT-prolonging Agents (Moderate Risk) may increase QTc-prolonging effects of Piperaquine. Risk X: Avoid
Pirtobrutinib: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor
Psilocybin: Antidepressants may decrease therapeutic effects of Psilocybin. Risk C: Monitor
QT-prolonging Agents (Highest Risk): May increase QTc-prolonging effects of Citalopram. Risk X: Avoid
QT-prolonging Antidepressants (Moderate Risk): Citalopram may increase QTc-prolonging effects of QT-prolonging Antidepressants (Moderate Risk). Citalopram may increase serotonergic effects of QT-prolonging Antidepressants (Moderate Risk). This could result in serotonin syndrome. Citalopram may increase serum concentration of QT-prolonging Antidepressants (Moderate Risk). Management: Monitor for QTc interval prolongation, ventricular arrhythmias, and serotonin syndrome when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
QT-prolonging Antipsychotics (Moderate Risk): May increase QTc-prolonging effects of QT-prolonging Antidepressants (Moderate Risk). QT-prolonging Antipsychotics (Moderate Risk) may increase serotonergic effects of QT-prolonging Antidepressants (Moderate Risk). This could result in serotonin syndrome. Management: Monitor for QTc interval prolongation, ventricular arrhythmias, and serotonin syndrome/serotonin toxicity (SS/ST) or NMS when these agents are combined. Patients with additional risk factors for QTc prolongation or SS/ST may be at even higher risk. Risk C: Monitor
QT-prolonging Class IC Antiarrhythmics (Moderate Risk): May increase QTc-prolonging effects of QT-prolonging Antidepressants (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
QT-Prolonging Inhalational Anesthetics (Moderate Risk): May increase QTc-prolonging effects of QT-prolonging Antidepressants (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias, including torsades de pointes when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
QT-prolonging Kinase Inhibitors (Moderate Risk): QT-prolonging Antidepressants (Moderate Risk) may increase QTc-prolonging effects of QT-prolonging Kinase Inhibitors (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
QT-prolonging Miscellaneous Agents (Moderate Risk): QT-prolonging Antidepressants (Moderate Risk) may increase QTc-prolonging effects of QT-prolonging Miscellaneous Agents (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk): Citalopram may increase QTc-prolonging effects of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of Citalopram. Risk C: Monitor
QT-prolonging Quinolone Antibiotics (Moderate Risk): May increase QTc-prolonging effects of QT-prolonging Antidepressants (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
QT-prolonging Strong CYP3A4 Inhibitors (Moderate Risk): Citalopram may increase QTc-prolonging effects of QT-prolonging Strong CYP3A4 Inhibitors (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor
Ramosetron: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Rasagiline: Selective Serotonin Reuptake Inhibitor may increase serotonergic effects of Rasagiline. This could result in serotonin syndrome. Risk X: Avoid
Safinamide: May increase serotonergic effects of Selective Serotonin Reuptake Inhibitor. This could result in serotonin syndrome. Risk X: Avoid
Selective Serotonin Reuptake Inhibitor: Citalopram may increase serotonergic effects of Selective Serotonin Reuptake Inhibitor. This could result in serotonin syndrome. Citalopram may increase antiplatelet effects of Selective Serotonin Reuptake Inhibitor. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, mental status changes) when these agents are combined. In addition, monitor for signs and symptoms of bleeding. Risk C: Monitor
Selegiline: Selective Serotonin Reuptake Inhibitor may increase serotonergic effects of Selegiline. This could result in serotonin syndrome. Risk X: Avoid
Selumetinib: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor
Serotonergic Agents (High Risk, Miscellaneous): May increase serotonergic effects of Selective Serotonin Reuptake Inhibitor. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Serotonergic Non-Opioid CNS Depressants: Selective Serotonin Reuptake Inhibitor may increase serotonergic effects of Serotonergic Non-Opioid CNS Depressants. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Serotonergic Opioids (High Risk): May increase serotonergic effects of Selective Serotonin Reuptake Inhibitor. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) if these agents are combined. Risk C: Monitor
Serotonin 5-HT1D Receptor Agonists (Triptans): May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Serotonin/Norepinephrine Reuptake Inhibitor: Selective Serotonin Reuptake Inhibitor may increase serotonergic effects of Serotonin/Norepinephrine Reuptake Inhibitor. This could result in serotonin syndrome. Selective Serotonin Reuptake Inhibitor may increase antiplatelet effects of Serotonin/Norepinephrine Reuptake Inhibitor. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, mental status changes) when these agents are combined. In addition, monitor for signs and symptoms of bleeding. Risk C: Monitor
Sertindole: May increase QTc-prolonging effects of QT-prolonging Agents (Moderate Risk). Risk X: Avoid
St John's Wort: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. St John's Wort may decrease serum concentration of Serotonergic Agents (High Risk). Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Syrian Rue: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Thiazide and Thiazide-Like Diuretics: Selective Serotonin Reuptake Inhibitor may increase hyponatremic effects of Thiazide and Thiazide-Like Diuretics. Risk C: Monitor
Thioridazine: QT-prolonging Agents (Moderate Risk) may increase QTc-prolonging effects of Thioridazine. Risk X: Avoid
Thrombolytic Agents: Agents with Antiplatelet Effects may increase adverse/toxic effects of Thrombolytic Agents. Specifically, the risk of bleeding may be increased. Risk C: Monitor
Thyroid Products: Selective Serotonin Reuptake Inhibitor may decrease therapeutic effects of Thyroid Products. Thyroid product dose requirements may be increased. Risk C: Monitor
Tilidine: May increase serotonergic effects of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor
Tipranavir: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor
TraMADol: May increase adverse/toxic effects of Selective Serotonin Reuptake Inhibitor. Specifically, the risk for serotonin syndrome/serotonin toxicity and seizures may be increased. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) and seizures when these agents are combined. Risk C: Monitor
Tricyclic Antidepressants: May increase serotonergic effects of Citalopram. Tricyclic Antidepressants may increase serum concentration of Citalopram. Citalopram may increase serum concentration of Tricyclic Antidepressants. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) and increased TCA and citalopram concentrations/effects. Risk C: Monitor
Vasopressin: Drugs Suspected of Causing SIADH may increase therapeutic effects of Vasopressin. Specifically, the pressor and antidiuretic effects of vasopressin may be increased. Risk C: Monitor
Venlafaxine: Selective Serotonin Reuptake Inhibitor may increase antiplatelet effects of Venlafaxine. Selective Serotonin Reuptake Inhibitor may increase serotonergic effects of Venlafaxine. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, mental status changes) when these agents are combined. In addition, monitor for signs and symptoms of bleeding. Risk C: Monitor
Vitamin E (Systemic): May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor
Vitamin K Antagonists: Antidepressants with Antiplatelet Effects may increase anticoagulant effects of Vitamin K Antagonists. Risk C: Monitor
Volanesorsen: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor
Vonoprazan: May increase serum concentration of Citalopram. Risk C: Monitor
Voriconazole: Citalopram may increase QTc-prolonging effects of Voriconazole. Voriconazole may increase serum concentration of Citalopram. Management: Limit citalopram dose to a maximum of 20 mg/day if used with voriconazole, which is a moderate CYP2C19 inhibitor. Monitor for citalopram toxicity (eg, serotonin syndrome), QTc prolongation, and arrhythmias (including torsades de pointes). Risk D: Consider Therapy Modification
Zanubrutinib: May increase antiplatelet effects of Agents with Antiplatelet Effects. Risk C: Monitor
Ziprasidone: May increase QTc-prolonging effects of Citalopram. Ziprasidone may increase serotonergic effects of Citalopram. This could result in serotonin syndrome. Risk X: Avoid
May be taken without regard to food.
Evaluate pregnancy status prior to initiating treatment in patients who could become pregnant. Treatment should not be withheld, but pharmacologic management may vary based on reproductive status, severity of illness, and history of antidepressant response (ACOG 2023; WFSBP [Dodd 2018]). When treating depression, anxiety, obsessive-compulsive disorder, or post-traumatic stress disorder, selective serotonin reuptake inhibitors (SSRIs) are preferred for use prior to conception in patients who are treatment naive or who do not have a history of effective treatment. Patients effectively treated may continue their current medication when planning a pregnancy unless contraindications exist (BAP [McAllister-Williams 2017]). Management of mental health conditions in patients who could become pregnant should be based on a shared decision-making process that considers the possibility of pregnancy during treatment (ACOG 2023; BAP [McAllister-Williams 2017]; CANMAT [MacQueen 2016]).
Citalopram is also used off label for the treatment of premenstrual dysphoric disorder. Symptom-onset dosing, which is initiated on the day of symptom onset and continued until after the start of menses, may be beneficial in patients attempting to conceive (Lanza di Scalea 2019, Ravindran 2007).
Amenorrhea has been reported following use of citalopram. SSRI use may cause hyperprolactinemia and rarely changes in thyroid function, both of which can be associated with menstrual irregularities. Depression is also associated with menstrual changes (Padda 2021).
Some studies suggest SSRIs may impair semen parameters, including the motility of spermatozoa; use of other treatments may be preferred in male patients planning a pregnancy (ISSM [Althof 2014]; Sylvester 2019). SSRIs are associated with an increased risk of sexual dysfunction (Tarchi 2023). Citalopram may delay ejaculation and is used off label for the treatment of premature ejaculation (ISSM [Althof 2014]; Sathianathen 2021).
Citalopram and its metabolites cross the human placenta (Paulzen 2017).
As a class, selective serotonin reuptake inhibitors (SSRIs) have been evaluated extensively in pregnant patients. Studies focusing on newborn outcomes following first trimester exposure often have inconsistent results. Overall, an increased risk of major congenital malformations has not been observed with citalopram when considering differences in study design and confounders; data evaluating the risk of specific defects are inconclusive (ACOG 2023; Anderson 2020; BAP [McAllister-Williams 2017]; Biffi 2020; Fitton 2020; Gao 2018; Lebin 2022).
Adverse effects in the newborn following SSRI exposure in the third trimester include neonatal adaptation syndrome and persistent pulmonary hypertension of the newborn. Neonatal adaptation syndrome can occur shortly after birth and typically resolves within 2 weeks. Mechanisms of neonatal adaptation syndrome are not well understood but may be due to either SSRI toxicity or withdrawal. Reducing the dose or discontinuing the SSRI prior to delivery to reduce the risk of neonatal adaptation syndrome is not recommended (ACOG 2023). Symptoms can include apnea, constant crying, cyanosis, feeding difficulty, hyperreflexia, hypo- or hypertonia, hypoglycemia, irritability, jitteriness, respiratory distress, seizures, temperature instability, tremor, and vomiting. Prolonged hospitalization, respiratory support, or tube feedings may be required.
Persistent pulmonary hypertension of the newborn is a rare complication of SSRI use during pregnancy with symptoms of respiratory distress within the first hours of life and an increased risk of neonatal mortality (ACOG 2023). Monitoring of infants exposed to SSRIs late in pregnancy is recommended (Masarwa 2019; Ng 2019). Data related to the long-term effects of in utero SSRI exposure on infant neurodevelopment and behavior are limited (CANMAT [MacQueen 2016]; Lebin 2022).
SSRIs may increase the risk of bleeding. Exposure late in pregnancy is associated with less than a 2-fold increase in postpartum hemorrhage. The clinical significance of this is uncertain (BAP [McAllister-Williams 2017]; Lebin 2022). Due to pregnancy-induced physiologic changes, some pharmacokinetic properties of citalopram may be altered. In addition, changes in maternal CYP2D6 and CYP2C19 activity also influence citalopram and metabolite concentrations. Close clinical monitoring as pregnancy progresses and therapeutic drug monitoring to detect patterns of changing plasma concentrations is recommended to assist dose adjustment when needed (Paulzen 2017; Schoretsanitis 2020).
Untreated and undertreated mental health conditions are associated with adverse pregnancy outcomes. Untreated or undertreated depression is associated with preterm birth, low birth weight (LBW), preeclampsia, postpartum depression, and impaired infant attachment (associated with long-term developmental effects). Anxiety disorders during pregnancy are associated with LBW, preterm birth, and adverse behavioral outcomes in the offspring. Discontinuing effective medications during pregnancy increases the risk of symptom relapse. Management should be made as part of a shared decision-making process (ACOG 2023). Patients effectively treated for depression, anxiety, obsessive-compulsive disorder, or post-traumatic stress disorder prepregnancy may use the same medication during pregnancy unless contraindications exist (ACOG 2023; CANMAT [MacQueen 2016]; BAP [McAllister-Williams 2017]). Treatment should not be withheld or discontinued based only on pregnancy status (ACOG 2023).
SSRIs are preferred for use in pregnant patients who are treatment naive or who do not have a history of effective treatment with another medication (ACOG 2023). An SSRI other than citalopram may be preferred (ACOG 2023); however, use may be considered for pregnant patients with no prior medication history (CANMAT [MacQueen 2016]). SSRI dosing should be initiated with half the lowest recommended dose and titrated gradually over 4 to 10 days. Dose adjustments may be required as pregnancy progresses to keep symptoms in remission (ACOG 2023).
When medications are used, the lowest effective dose of a single agent is recommended. Optimize dosing prior to changing a medication or adding additional agents whenever possible. Monthly monitoring for symptom improvement with a validated screening tool during pregnancy is recommended. Manage side effects as needed (ACOG 2023).
Data collection to monitor pregnancy and infant outcomes following exposure to antidepressant medications is ongoing. Pregnant patients ≤45 years of age with a history of psychiatric illness are encouraged to enroll in the National Pregnancy Registry for Antidepressants (1-866-961-2388 or https://womensmentalhealth.org/research/pregnancyregistry/antidepressants).
ECG (patients at increased risk for QT-prolonging effects due to certain conditions); electrolytes (potassium and magnesium concentrations [prior to initiation and periodically during therapy in patients at increased risk for electrolyte abnormalities]); liver and renal function tests (baseline; as clinically indicated); serum sodium in at-risk populations (as clinically indicated); CBC (as clinically indicated); closely monitor patients for depression, clinical worsening, suicidality, psychosis, or unusual changes in behavior (eg, anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia, hypomania, mania), particularly during the initial 1 to 2 months of therapy or during periods of dosage adjustments (increases or decreases); signs/symptoms of serotonin syndrome such as mental status changes (eg, agitation, hallucinations, delirium, coma), autonomic instability (eg, tachycardia, labile BP, diaphoresis), neuromuscular changes (eg, tremor, rigidity, myoclonus), GI symptoms (eg, nausea, vomiting, diarrhea), and/or seizures.
A racemic bicyclic phthalane derivative, citalopram selectively inhibits serotonin reuptake in the presynaptic neurons and has minimal effects on norepinephrine or dopamine. Uptake inhibition of serotonin is primarily due to the S-enantiomer of citalopram. Displays little to no affinity for serotonin, dopamine, adrenergic, histamine, GABA, or muscarinic receptor subtypes.
Onset of action:
Anxiety disorders (generalized anxiety, obsessive-compulsive, panic, and posttraumatic stress disorder): Initial effects may be observed within 2 weeks of treatment, with continued improvements through 4 to 6 weeks (Issari 2016; Varigonda 2016; WFSBP [Bandelow 2023a]); some experts suggest up to 12 weeks of treatment may be necessary for response, particularly in patients with obsessive-compulsive disorder and posttraumatic stress disorder (BAP [Baldwin 2014]; Katzman 2014; WFSBP [Bandelow 2023a]; WFSBP [Bandelow 2023b]).
Depression: Initial effects may be observed within 1 to 2 weeks of treatment, with continued improvements through 4 to 6 weeks (Papakostas 2006; Posternak 2005; Szegedi 2009; Taylor 2006).
Premenstrual dysphoric disorder: Initial effects may be observed within the first few days of treatment, with response at the first menstrual cycle of treatment (ISPMD [Nevatte 2013]).
Duration: 1 to 2 days.
Distribution: Vd: 12 L/kg.
Protein binding, plasma: ~80%.
Metabolism: Extensively hepatic, via CYP3A4 and 2C19 (major pathways), and 2D6 (minor pathway); metabolized to demethylcitalopram (DCT), didemethylcitalopram (DDCT), citalopram-N-oxide, and a deaminated propionic acid derivative, which are at least eight times less potent than citalopram.
Bioavailability: 80%; tablets and oral solution are bioequivalent.
Half-life elimination: 24 to 48 hours (average: 35 hours); doubled with hepatic impairment and increased by 30% (following multiple doses) to 50% (following single dose) in elderly patients (≥60 years).
Time to peak, serum: 1 to 6 hours, average within 4 hours.
Excretion: Urine (Citalopram 10% and DCT 5%).
Altered kidney function: Oral clearance decreased 17% in mild to moderate renal impairment. Limited information is available in patients with severe impairment (Joffe 1998; Spigset 2000).
Hepatic function impairment: Oral clearance decreased 37%, half-life doubled, and plasma concentrations increased in reduced hepatic function.
Older adult: Multiple dose: AUC increased 23% and half-life increased 30%. Single dose: AUC increased 30% and half-life increased 50%.
Sex: AUC in women was 1.5 to 2 times that in men in 3 studies; no difference was observed in 5 other studies.
CYP2C19 poor metabolizers: Steady state Cmax and AUC increased by 68% and 107%, respectively.
