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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 14 of 14. This is the beginning of the thread.
Posted by ed_uk2010 on December 12, 2011, at 15:00:47
Now that the maximum recommended dose of citalopram is 40mg, due to the possible risk of arrhythmias at higher doses, has anyone reduced their dose?
Similarly, the maximum dose of escitalopram (Lexapro, Cipralex) is 20mg.
Anyone amended their doses due to the new guidelines?
Posted by Phillipa on December 12, 2011, at 17:47:17
In reply to Maximum dose of citalopram (Celexa) now 40mg, posted by ed_uk2010 on December 12, 2011, at 15:00:47
Ed when did this happen? Glad I didn't raise dose of lexapro may can it. Why just these two sounds like the risk with TCA's? PJ
Posted by ed_uk2010 on December 13, 2011, at 15:18:17
In reply to Re: Maximum dose of citalopram (Celexa) now 40mg » ed_uk2010, posted by Phillipa on December 12, 2011, at 17:47:17
> Ed when did this happen?
A few months ago.
>Glad I didn't raise dose of lexapro may can it.
You're on a subtherapeutic dose of Lexapro, but I'm not sure why! It is usual to take only one SSRI.
>Why just these two sounds like the risk with TCAs?
There does not seem to be a high risk of arrhythmias with citalopram, but there is a small risk of QT interval prolongation at high doses.
Posted by jono_in_adelaide on December 13, 2011, at 16:39:01
In reply to Maximum dose of citalopram (Celexa) now 40mg, posted by ed_uk2010 on December 12, 2011, at 15:00:47
I guess anybody who needs high dose SSRI therapy should go with Zolfot, where doses of upto 200mg (~ equal to 80 mg citralopram) are aproved, and higher doses are used in practive
Posted by Phillipa on December 13, 2011, at 20:10:26
In reply to Re: Maximum dose of citalopram (Celexa) now 40mg, posted by ed_uk2010 on December 13, 2011, at 15:18:17
Ed I googled it after reading this and could find it anywhere? As for the two SSRI's this new pdoc said the same about two. This is something the old pdoc did she said try the lexapro with the luvox and see and I did and have been. But luvox for me seems to be best. But how could it do a thing after all these years and I wonder often if it's life circumstances and habit keeping me on meds. Your opinion appreciated. Thanks PJxx
Posted by Vincent_QC on December 14, 2011, at 7:52:13
In reply to Maximum dose of citalopram (Celexa) now 40mg, posted by ed_uk2010 on December 12, 2011, at 15:00:47
> Now that the maximum recommended dose of citalopram is 40mg, due to the possible risk of arrhythmias at higher doses, has anyone reduced their dose?
>
> Similarly, the maximum dose of escitalopram (Lexapro, Cipralex) is 20mg.
>
> Anyone amended their doses due to the new guidelines?
>I always hated the Celexa and Lexapro, they are the worse SSRI's for me and they both do nothing for my anxiety and lead to tachycardia most of the time and severe migraine... Safer SSRI's like the Paxil are best to treat anxiety disorders and safer also because they don't affect the heart QT interval between each heart beat, like olf TCA's or antipsychotic like Geodon...anyway this is the article about the FDA warning... that's well explain and now I understand why I always worse on those 2 meds...
**************************************************
FDA Drug Safety Communication: Abnormal heart rhythms associated with high doses of Celexa (citalopram hydrobromide.Safety Announcement
Additional Information for Patients
Additional Information for Healthcare Professionals
Data Summary
Safety Announcement
[8-24-2011] The U.S. Food and Drug Administration (FDA) is informing healthcare professionals and patients that the antidepressant Celexa (citalopram hydrobromide; also marketed as generics) should no longer be used at doses greater than 40 mg per day because it can cause abnormal changes in the electrical activity of the heart. Studies did not show a benefit in the treatment of depression at doses higher than 40 mg per day.
Facts about Celexa (citalopram hydrobromide)
Is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs).
Thought to work by increasing the amount of serotonin in the brain.1
Available as 10 mg, 20 mg, and 40 mg tablets. Also available as an oral solution (10 mg/5 mL).
Previously, the citalopram drug label stated that certain patients may require a dose of 60 mg per day.Changes in the electrical activity of the heart (prolongation of the QT interval of the electrocardiogram [ECG]) - see Data Summary below - can lead to an abnormal heart rhythm (including Torsade de Pointes), which can be fatal. Patients at particular risk for developing prolongation of the QT interval include those with underlying heart conditions and those who are predisposed to low levels of potassium and magnesium in the blood.
The citalopram drug label has been revised to include the new drug dosage and usage recommendations, as well as information about the potential for QT interval prolongation and Torsade de Pointes. (See Additional Information for Healthcare Professionals)
Additional Information for Patients
Do not stop taking citalopram or change your dose without talking to your healthcare professional. Stopping citalopram suddenly can cause unwanted side effects.
If you are currently taking a citalopram dose greater than 40 mg per day, talk to your healthcare professional about changing your dose.
Seek immediate care if you experience an irregular heartbeat, shortness of breath, dizziness, or fainting while taking citalopram.
If you are taking citalopram, your healthcare professional may occasionally order an electrocardiogram (ECG, EKG) to monitor your heart rate and rhythm. An ECG is a test that checks for problems with the electrical activity of your heart.Read the Medication Guide for citalopram carefully and discuss any questions you have with your healthcare professional.
Report any side effects you experience to the FDA MedWatch program using the information in the "Contact Us" box at the bottom of the page.
Additional Information for Healthcare Professionals
Citalopram causes dose-dependent QT interval prolongation. Citalopram should no longer be prescribed at doses greater than 40 mg per day.
Citalopram should not be used in patients with congenital long QT syndrome.
Patients with congestive heart failure, bradyarrhythmias, or predisposition to hypokalemia or hypomagnesemia because of concomitant illness or drugs, are at higher risk of developing Torsade de Pointes.
Hypokalemia and hypomagnesemia should be corrected before administering citalopram. Electrolytes should be monitored as clinically indicated. Consider more frequent electrocardiogram (ECG) monitoring in patients with congestive heart failure, bradyarrhythmias, or patients on concomitant medications that prolong the QT interval. 20 mg per day is the maximum recommended dose for patients with hepatic impairment, who are greater than 60 years of age, who are CYP 2C19 poor metabolizers, or who are taking concomitant cimetidine (Tagamet®), because these factors lead to increased blood levels of citalopram, increasing the risk of QT interval prolongation and Torsade de Pointes.
No dose adjustment is necessary for patients with mild or moderate renal impairment.Advise patients to contact a healthcare professional immediately if they experience signs and symptoms of an abnormal heart rate or rhythm while taking citalopram. Report adverse events involving citalopram to the FDA MedWatch program, using the information in the "Contact Us" box at the bottom of the page.
Data Summary
FDA has received post-marketing reports of QT interval prolongation and Torsade de Pointes associated with Celexa and its generic equivalents. In addition, FDA has evaluated the results of a thorough QT study assessing the effects of 20-mg and 60-mg doses of citalopram on the QT interval in adults. In this randomized, multi-center, double-blind, placebo-controlled, crossover study, 119 subjects received citalopram 20 mg per day (Day 9), citalopram 60 mg per day (Day 22), and placebo. The overall summary of findings is presented in Table 1
Table 1: Increase in the Corrected QT Interval for Citalopram (FDA Analysis)
Citalopram Dose Increase in QT Interval (ms) 90% Confidence Interval (ms)
20 mg/day 8.5 (6.2, 10.8)
60 mg/day 18.5 (16.0, 21.0)
40 mg/day 12.6* (10.9, 14.3)*
*Estimate based on the relationship between citalopram blood concentration and QT interval.
Compared to placebo, maximum mean prolongations in the individually corrected QT intervals were 8.5 and 18.5 milliseconds (ms) for 20 mg and 60 mg citalopram, respectively. For 40 mg citalopram, prolongation of the corrected QT interval was estimated to be 12.6 ms.
As a result of this thorough QT study, FDA has determined that citalopram causes dose-dependent QT interval prolongation and should no longer be used at doses above 40 mg per day. Important safety information about the potential for QT interval prolongation and Torsade de Pointes with drug dosage and usage recommendations are being added to the package inserts of Celexa and its generic equivalents.
References
National Center for Biotechnology Information. U.S. National Library of Medicine. PubMed Drug & Supplements Monograph Citalopram. Available at: http://www.nlm.nih.gov/medlineplus/druginfo/meds/a699001.html1. Accessed July 20, 2011.
Posted by Phillipa on December 14, 2011, at 20:18:24
In reply to Abnormal heart rhythms with high dose of Celexa » ed_uk2010, posted by Vincent_QC on December 14, 2011, at 7:52:13
Vincent at the new pdocs today asked him if he knew and he did said no more than 40mg now. So he up to date on the latest data. That's good to know and glad you posted the study results and changes in doses. Phillipa
Posted by linkadge on December 15, 2011, at 18:05:25
In reply to Re: Abnormal heart rhythms with high dose of Celexa » Vincent_QC, posted by Phillipa on December 14, 2011, at 20:18:24
I know the study was done with citalopram, but has there been any study with escitalopram? It is possible that some of the ion channel effects are due to the r-enantiomer.
If so, escitalopram may have a higher safety index.
Linakdge
Posted by Vincent_QC on December 15, 2011, at 18:19:58
In reply to Re: citalopram or escitalopram ??, posted by linkadge on December 15, 2011, at 18:05:25
Don't seem that the Lexapro is also dangerous for the heart at high dose... just find this on google:
Does the FDA's Celexa Warning Affect Lexapro?August 25, 2011, 05:00:00PM. By Heidi Turner
Washington, DC: The US Food and Drug Administration (FDA) recently made an announcement regarding the use of Celexa in some patients, but that warning did not include information about potential Lexapro side effects, even though Lexapro is closely related to Celexa. Lexapro, an SSRI used to treat anxiety and major depressive disorder, is part of a class of drugs that has been linked to newborn birth defects including persistent pulmonary hypertension.
The FDA's announcement concerned Celexa, known generically as citalopram. Celexa is another SSRI and has reportedly been linked to an increased risk of potentially deadly changes to a patient's heart rhythm. The FDA recommends in its Drug Safety Communication (08/24/11) that Celexa not be used at doses greater than 40 mg per day, "because it can cause abnormal changes in the electrical activity of the heart." Furthermore, the FDA notes, studies have not shown a benefit to using doses higher than 40 mg per day. Celexa had previously been available to some patients at 60 mg per day.
Patients with congestive heart failure, congenital long QT syndrome, bradyarrhythmias, or predisposition to hypokalemia or hypomagnesemia are not recommended to use Celexa. Patients who are currently taking more than 40 mg daily doses of Celexa are advised to speak to their doctor about changing the dose.
The FDA made its announcement after studies found that patients who took 60 mg per day of citalopram had a higher risk of changes to the heart's electrical activity than patients who took a much lower dose or took a placebo. The label for Celexa is being changed to reflect the new information.
Lexapro, known generically as escilatopram, is similar to Celexa in chemical design. The FDA's announcement, however, did not mention Lexapro or whether the drug might have similar side effects to Celexa, indicating that current data does not suggest a link between Lexapro and the same heart problems.
Both Lexapro and Celexa are in a class of drugs known as selective serotonin reuptake inhibitors (SSRI) and both are manufactured by Forest Laboratories. Some SSRI medications were linked in a study to an increased risk of autism spectrum disorder. The study, published in the Archives of General Psychiatry (07/04/11) suggested that when women took an SSRI medication during the 12 months prior to delivery, they had double the risk of having a baby diagnosed with autism spectrum disorder compared with mothers who did not take an SSRI. When the SSRI was taken during the first trimester of pregnancy, the risk quadrupled.
That study did not specifically mention Lexapro but did include other drugs in the SSRI class.> I know the study was done with citalopram, but has there been any study with escitalopram? It is possible that some of the ion channel effects are due to the r-enantiomer.
>
> If so, escitalopram may have a higher safety index.
>
> Linakdge
Posted by ed_uk2010 on December 16, 2011, at 15:10:27
In reply to Re: citalopram or escitalopram ??, posted by linkadge on December 15, 2011, at 18:05:25
>It is possible that some of the ion channel effects are due to the r-enantiomer.
Cardiac effects have been reported with escitalopram too, but neither drug causes cardiac problems frequently.
Posted by Vincent_Qc on December 16, 2011, at 17:30:20
In reply to Re: citalopram or escitalopram ?? » linkadge, posted by ed_uk2010 on December 16, 2011, at 15:10:27
> >It is possible that some of the ion channel effects are due to the r-enantiomer.
>
> Cardiac effects have been reported with escitalopram too, but neither drug causes cardiac problems frequently.
>
>A question for you ed , do you know a med to help with the severe constipation ? Not a laxative but a real med like the motilium or another one who work has an agonist as the 5Ht4 receptor with no cardiovascular effect ? Thanks, Vincent
Posted by Phillipa on December 16, 2011, at 20:59:57
In reply to Re: citalopram or escitalopram ?? » ed_uk2010, posted by Vincent_Qc on December 16, 2011, at 17:30:20
Didn't hear from you? Phillipa
Posted by Vincent_Qc on December 17, 2011, at 13:39:23
In reply to Re: citalopram or escitalopram ?? » linkadge, posted by ed_uk2010 on December 16, 2011, at 15:10:27
> >It is possible that some of the ion channel effects are due to the r-enantiomer.
>
> Cardiac effects have been reported with escitalopram too, but neither drug causes cardiac problems frequently.
>
>A question for you ed , do you know a med to help with the severe constipation ? Not a laxative but a real med like the motilium or another one who work has an agonist as the 5Ht4 receptor with no cardiovascular effect ? Thanks, Vincent
Posted by ed_uk2010 on December 18, 2011, at 7:00:36
In reply to Re: citalopram or escitalopram ?? » ed_uk2010, posted by Vincent_Qc on December 17, 2011, at 13:39:23
>A question for you ed , do you know a med to help with the severe constipation ? Not a laxative but a real med like the motilium or another one who work has an agonist as the 5Ht4 receptor with no cardiovascular effect ? Thanks, Vincent
A med we have in Europe is prucalopride, but it is rarely used. It is a 5-HT4 agonist with improved cardiovascular safety compared with related drugs. At the moment, it is only approved for use in women, because most of the patients in clinical trials were women. There is no evidence that prucalopride is superior to laxatives.
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