What are potential augmenter medications for a patient currently on citalopram (Celexa)?

From the Guidelines

Bupropion is the most recommended augmenter medication for patients currently on citalopram, as it has been shown to decrease depression severity more than buspirone augmentation 1. When considering augmenter medications for patients on citalopram, several options are available.

• Bupropion (Wellbutrin) can be added at 150-300mg daily to address residual depression symptoms or sexual side effects.
• Buspirone (BuSpar) at 15-60mg daily divided into doses can target comorbid anxiety, although it may not be as effective as bupropion in reducing depression severity 1. Other potential augmenter medications include atypical antipsychotics like aripiprazole (Abilify) or quetiapine (Seroquel), mirtazapine (Remeron), thyroid hormone supplementation with liothyronine (Cytomel), and lithium. However, the evidence for these medications is not as strong as for bupropion, and they may have different side effect profiles and mechanisms of action. The choice of augmenter medication should be based on the individual patient's needs and medical history, with careful monitoring for side effects and serotonin syndrome 1. It is essential to start at low doses and gradually increase as needed, while also considering the potential benefits and risks of each medication. In clinical practice, the goal is to improve symptoms and quality of life while minimizing adverse effects, and bupropion is a well-supported option for augmenting citalopram treatment 1.

From the FDA Drug Label

The concomitant use of citalopram tablets with MAOIs intended to treat psychiatric disorders is contraindicated. If concomitant treatment of citalopram tablets with a triptan is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases Lithium - Coadministration of citalopram tablets (40 mg/day for 10 days) and lithium (30 mmol/day for 5 days) had no significant effect on the pharmacokinetics of citalopram or lithium. CYP2C19 Inhibitors - Citalopram tablets 20 mg/day is the maximum recommended dose for patients taking concomitant CYP2C19 inhibitors because of the risk of QT prolongation

Augmenter medications for a patient currently on citalopram may include:

• Lithium: can be used concomitantly with citalopram, but caution should be exercised and plasma lithium levels should be monitored 2
• Triptans: can be used concomitantly with citalopram, but careful observation of the patient is advised, particularly during treatment initiation and dose increases 2
• Other medications: such as buspirone, amphetamines, and tryptophan may also be used as augmenters, but the FDA label does not provide specific information on their concomitant use with citalopram. Note that MAOIs are contraindicated for concomitant use with citalopram 2.

From the Research

Augmenter Medications for Citalopram

For a patient currently on citalopram (Celexa), several augmenter medications can be considered to enhance the therapeutic effect. These include:

• Second-generation antipsychotics (SGAs) such as aripiprazole 3, 4, 5
• Lithium salts 3, 6
• Thyroid hormones, specifically triiodothyronine (T3) 3, 6
• Dopamine agonists like pramipexole 3
• Other medications such as bupropion, mirtazapine, and venlafaxine can be used as part of a combination strategy 3

Efficacy of Augmenter Medications

The efficacy of these augmenter medications varies:

• Aripiprazole has been shown to be effective in several studies, with optimal dosages potentially being lower than the maximum licensed dose 4, 5
• Lithium salts have been found to be effective in some studies, particularly in patients with bipolar depression or suicidality 3, 6
• Thyroid hormones, specifically T3, have shown promising results in some studies, but more research is needed to confirm their efficacy 6
• Dopamine agonists like pramipexole have been found to be effective in some cases, but more research is needed to confirm their efficacy 3

Combination Strategies

Combination strategies involving multiple medications can also be effective:

• Combining citalopram with other antidepressants like bupropion, mirtazapine, or venlafaxine can be considered 3
• Adding aripiprazole or other SGAs to citalopram can enhance the therapeutic effect 3, 4, 5
• Using lithium salts or thyroid hormones in combination with citalopram can also be effective in some cases 3, 6