From the Guidelines
Taking citalopram with arrhythmias is not recommended due to the risk of QT interval prolongation and potentially life-threatening arrhythmias, such as Torsades de Pointes. According to the most recent and highest quality study 1, citalopram may cause QT prolongation associated with Torsade de Pointes, ventricular tachycardia, and sudden death at daily doses exceeding 40 mg/d.
Key Considerations
- Citalopram is generally not recommended for people with certain heart rhythm disorders, particularly those with congenital long QT syndrome, recent heart attacks, or uncontrolled heart failure 1.
- The FDA has issued specific dosing limitations for citalopram: no more than 20mg daily for patients over 60 years old or those with liver problems, and a maximum of 40mg daily for others 1.
- If you have arrhythmias and need depression treatment, your doctor might recommend alternative antidepressants with less cardiac impact, such as sertraline or fluoxetine.
Monitoring and Precautions
- Before starting citalopram, inform your healthcare provider about any heart conditions, and they may order an ECG to establish a baseline 1.
- During treatment, report any symptoms like palpitations, dizziness, or fainting immediately, as these could indicate heart rhythm problems.
- Medical education, training, and experience are necessary to safely and effectively prescribe antidepressant medications, and a conservative medication trial may be necessary to optimize the benefit-to-harm ratio 1.
From the FDA Drug Label
Citalopram causes dose-dependent QTc prolongation, an ECG abnormality that has been associated with Torsade de Pointes (TdP), ventricular tachycardia, and sudden death, all of which have been observed in postmarketing reports for citalopram It is recommended that citalopram should not be used in patients with congenital long QT syndrome, bradycardia, hypokalemia or hypomagnesemia, recent acute myocardial infarction, or uncompensated heart failure Citalopram should also not be used in patients who are taking other drugs that prolong the QTc interval. If patients taking citalopram experience symptoms that could indicate the occurrence of cardiac arrhythmias, e.g., dizziness, palpitations, or syncope, the prescriber should initiate further evaluation, including cardiac monitoring.
Citalopram and Arrhythmias:
- Citalopram can cause QTc prolongation, which may lead to arrhythmias such as Torsade de Pointes, ventricular tachycardia, and sudden death.
- Patients with a history of arrhythmias, such as those with congenital long QT syndrome, bradycardia, or uncompensated heart failure, should not take citalopram.
- Patients taking citalopram who experience symptoms of arrhythmias, such as dizziness, palpitations, or syncope, should be evaluated further, including cardiac monitoring 2.
- It is recommended to avoid using citalopram in patients with arrhythmias or those taking other drugs that prolong the QTc interval 2.
From the Research
Citalopram and Arrhythmias
- Citalopram is a Selective Serotonin Reuptake Inhibitor (SSRI) used to treat depression and anxiety, but it has been associated with a risk of arrhythmias, particularly in older patients 3.
- A study published in EBioMedicine found that therapeutic concentrations of citalopram and escitalopram, but not their metabolites, showed pro-arrhythmic changes in the human cardiac action potential, increasing the risk of arrhythmias in patients, especially those over 65 years old 3.
- Another study published in Clinical Therapeutics found that citalopram and escitalopram were not associated with an elevated risk of arrhythmia compared to other SSRIs or non-SSRI antidepressants, but were associated with an increase in mortality risk 4.
Risk Factors for Arrhythmias
- Age-dependent reduction of drug clearance can increase the proportion of patients above the threshold for arrhythmia risk, with 20% of patients over 65 years predicted to reach potentially pro-arrhythmic concentrations following intake of 10 mg escitalopram 3.
- Patients with genetic disposition for acquired long-QT syndrome, those using additional pro-arrhythmic drugs, or those with predisposition for arrhythmias should be monitored with therapeutic drug monitoring (TDM) to avoid exposure to potentially cardiotoxic concentrations 3.
- Serum concentrations of citalopram and escitalopram should be kept below 100 nM to reduce arrhythmia risk 3.
Comparison with Other SSRIs
- A study published in Clinical and Translational Science found that initiation of citalopram and escitalopram was not associated with an increased risk of serious arrhythmia, but lower point estimates were observed after the safety warning 5.
- An umbrella review published in the International Journal of Psychiatry in Clinical Practice found that escitalopram was more effective than other defined SSRIs in terms of response rate, remission rate, and withdrawal rate, but did not specifically address the risk of arrhythmias 6.