Source: Medicines & Healthcare Products Regulatory Agency (GB) Revision Year: 2018 Publisher: Zentiva Pharma UK Limited, One Onslow Street, Guildford, Surrey, GU1 4YS, United Kingdom Trading as: Zentiva, One Onslow Street, Guildford, Surrey, GU1 4YS, UK
Treatment of depressive illness in the initial phase and as maintenance against potential relapse/recurrence. Citalopram is also indicated in the treatment of panic disorder with or without agoraphobia.
Citalopram should be administered as a single oral dose of 20 mg daily. Dependent on individual patient response, the dose may be increased to a maximum of 40 mg daily. In general, improvement in patients starts after one week, but may only become evident from the second week of therapy. As with all antidepressant medicinal products, dosage should be reviewed and adjusted, if necessary, within 3 to 4 weeks of initiation of therapy and thereafter as judged clinically appropriate. Although there may be an increased potential for undesirable effects at higher doses, if after some weeks on the recommended dose insufficient response is seen, some patients may benefit from having their dose increased up to a maximum of 40 mg a day (see section 5.1). Dosage adjustments should be made carefully on an individual patient basis, to maintain the patient at the lowest effective dose.
Patients with depression should be treated for a sufficient period of at least six months to ensure that they are free from symptoms.
A single oral dose of 10 mg is recommended for the first week before increasing the dose to 20 mg daily. Dependent on individual patient response, the dose may be increased to a maximum of 40 mg daily. Patients should be started on 10 mg/day and the dose gradually increased in 10 mg steps according to the patient’s response up to the recommended dose. A low initial starting dose is recommended to minimise the potential worsening of panic symptoms, which is generally recognised to occur early in the treatment of this disorder. Although there may be an increased potential for undesirable effects at higher doses, if after some weeks on the recommended dose insufficient response is seen some patients may benefit from having their dose increased gradually up to a maximum of 40 mg/day (see section 5.1). Dosage adjustments should be made carefully on an individual patient basis, to maintain the patients at the lowest effective dose.
Patients with panic disorder should be treated for a sufficient period to ensure that they are free from symptoms. This period may be several months or longer.
For older people the dose should be decreased to half of the recommended dose, e.g. 10-20 mg daily. The recommended maximum dose for older people is 20 mg daily.
Citalopram should not be used in the treatment of children and adolescents under the age of 18 years (see section 4.4).
An initial dose of 10mg daily for the first two weeks of treatment is recommended in patients with mild or moderate hepatic impairment. Depending on individual patient response, the dose may be increased to a maximum of 20 mg daily. Caution and extra careful dose titration is advised in patients with severely reduced hepatic function (see section 5.2).
An initial dose of 10mg daily during the first two weeks of treatment is recommended for patients who are known to be poor metabolisers with respect to CYP2C19. The dose may be increased to a maximum of 20 mg daily depending on individual patient response (see section 5.2).
Dosage adjustment is not necessary in cases of mild or moderate renal impairment. No information is available in cases of severe renal impairment (creatinine clearance <20 ml/min).
Abrupt discontinuation should be avoided. When stopping treatment with citalopram the dose should be gradually reduced over a period of at least one to two weeks in order to reduce the risk of withdrawal reactions (see sections 4.4 and 4.8). If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose, but at a more gradual rate.
Citalopram tablets are administered as a single daily dose. Citalopram tablets can be taken any time of the day without regard to food intake.
Comprehensive clinical data on citalopram are limited and many cases involve concomitant overdoses of other drugs/alcohol. Fatal cases of citalopram overdose have been reported with citalopram alone; however, the majority of fatal cases have involved overdose with concomitant medications.
Fatal dose is not known. Patients have survived ingestion of more than 2g citalopram. The effects may be potentiated by alcohol taken at the same time.
There is the potential for interaction with TCAs, MAOIs and other SSRIs.
Six fatalities have been reported to Winthrop. In one, overdose was suspected; high post mortem plasma levels were seen, although it is not technically possible to interpret these with confidence. In the remaining five a combination with other drugs had been taken. The clinical syndrome observed prior to death in three of these cases where citalopram was taken with moclobemide was interpreted as that of serotonin syndrome. No clinical details are available on the other two.
The following symptoms have been seen in reported overdoses of citalopram: convulsion, tachycardia, somnolence, QT interval prolongation, coma, vomiting, tremor, hypotension, cardiac arrest, nausea, serotonin syndrome, agitation, bradycardia, dizziness, bundle branch block, QRS prolongation, nodal rhythm, hypertension, mydriasis, torsade de pointes, stupor, sweating, cyanosis, hyperventilation, hyperpyrexia, rhabdomyolysis and atrial and ventricular arrhythmia. ECG changes including nodal rhythm, prolonged QT intervals and wide QRS complexes may occur. Fatalities have been reported.
Prolonged bradycardia with severe hypotension and syncope has also been reported. Rarely, features of the “serotonin syndrome” may occur in severe poisoning. This includes alteration of mental status, neuromuscular hyperactivity and autonomic instability. There may be hyperpyrexia and elevation of serum creatine kinase. Rhabdomyolysis is rare.
There is no known specific antidote to citalopram. Treatment should be symptomatic and supportive and include the maintenance of a clear airway and monitoring of ECG and vital signs until stable.
Activated charcoal, osmotically working laxative (such as sodium sulphate) and stomach evacuation should be considered. Consider oral activated charcoal in adults and children who have ingested more than 5 mg/kg body weight within 1 hour. Activated charcoal given ½ hour after ingestion of citalopram has been shown to reduce absorption by 50%. Gastric lavage should be carried out as soon as possible after oral ingestion. If consciousness is impaired the patient should be intubated. Control convulsions with intravenous diazepam if they are frequent or prolonged. ECG and vital signs should be monitored.
ECG monitoring is advisable in case of overdose in patients with congestive heart failure/bradyarrhythmias, in patients using concomitant medications that prolong the QT interval, or in patients with altered metabolism, e.g. liver impairment.
5 years.
None.
PVC/PVDC/aluminium blisters.
Pack size: 28 tablets.
Not applicable.
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