Citalopram Overview

Citalopram is an antidepressant medication belonging to the selective serotonin reuptake inhibitor (SSRI) class. It is primarily prescribed to treat major depressive disorder. As an SSRI, it works by increasing serotonin levels in the brain, which are thought to have a good influence on mood, emotion, and sleep.

Indications for Use

Citalopram is mainly indicated for the treatment of depression in adults. It is prescribed to relieve symptoms such as persistent sadness, loss of interest in daily activities, and feelings of guilt or worthlessness. In some cases, it is also utilized off-label to address anxiety disorders, panic disorders, and obsessive-compulsive disorder under medical supervision.

Pharmacokinetics and Metabolism

Citalopram is absorbed efficiently when administered orally, with peak plasma concentrations occurring approximately 2-4 hours after ingestion. It is extensively metabolized in the liver and primarily excreted through urine. The half-life of citalopram generally ranges from 24 to 36 hours, allowing for once-daily dosing. It is metabolized by cytochrome P450 enzymes, especially CYP2C19, CYP3A4, and CYP2D6.

Dosage and Administration

The usual starting dose for adults with depression is 20 mg daily, taken once daily in the morning or evening. Based on individual patient response and tolerability, the dose may be increased gradually, up to a maximum of 40 mg per day. It is important to follow a physician’s dosing instructions and not to exceed prescribed amounts to avoid potential adverse events.

Potential Side Effects

Common side effects of citalopram include nausea, dry mouth, insomnia, increased sweating, and drowsiness. Some individuals may experience dizziness, fatigue, and changes in appetite. Infrequent but serious side effects include significant mood changes, tremors, and visual disturbances. Continuous monitoring is advised to manage these symptoms effectively.

Contraindications and Precautions

Citalopram is contraindicated in patients with a known hypersensitivity to the drug or its excipients. It should not be used concurrently with monoamine oxidase inhibitors (MAOIs) or within 14 days of discontinuing MAOI treatment. Caution is advised when prescribing to individuals with a history of seizures, liver dysfunction, or bipolar disorder due to the risk of exacerbating these conditions.

Drug Interactions

Serious and potentially life-threatening interactions may occur if citalopram is taken with other serotonergic drugs, leading to serotonin syndrome. Caution is required when combining with other medications that prolong QT interval or those metabolized via liver enzymes affected by citalopram. Concurrent use with alcohol or other CNS depressants can enhance sedative effects.

Pregnancy and Lactation

During pregnancy, citalopram should only be used if the potential benefit justifies the potential risk to the fetus. It is known to cross the placental barrier and may pose risks such as persistent pulmonary hypertension of the newborn (PPHN). Although present in breast milk, the decision to continue breast-feeding or treatment should consider the drug’s importance to the mother.

Considerations for the Elderly

In elderly patients, dose adjustments are often necessary due to alterations in drug metabolism and clearance. The starting dose is typically lower, around 10 mg daily, with careful titration based on clinical response and side effect profile. Caution is necessary to avoid complications such as hyponatremia and increased sensitivity to the drug’s effects.

Treatment Discontinuation

Abrupt discontinuation of citalopram can result in withdrawal symptoms such as dizziness, sensory disturbances, sleep disturbances, and irritability. Tapering off the drug gradually, under physician guidance, helps mitigate these symptoms. This process involves reducing the dose incrementally over a period specified by a healthcare provider.

Monitoring and Assessment

Regular monitoring of patients prescribed citalopram includes assessment of mood symptoms, evaluation of side effects, and adherence to prescribed doses. Bloodwork may be periodically required to assess liver function and electrolyte levels, particularly in those at risk of developing hyponatremia or hepatic impairment due to age or pre-existing conditions.

Pediatric Considerations

Though citalopram is generally not recommended for pediatric populations due to an increased risk of suicidal thoughts and behaviors, exceptions occur when the benefits outweigh potential risks. Should treatment be necessary, a specialist in child psychiatry should supervise with additional safeguards in place for monitoring mental health outcomes closely.

Patient Counseling Points

Patients should be informed about the potential onset of side effects and the importance of adherence to prescribed dosages. They should seek medical advice before taking any new medication, including over-the-counter drugs and supplements. Discussions should emphasize the gradual nature of mood improvement, recognizing that symptoms may take several weeks to fully ameliorate.