Is citalopram (Selective Serotonin Reuptake Inhibitor) an absolute contraindication in patients with alcohol use disorder?

Citalopram is Not an Absolute Contraindication in Alcohol Use Disorder

Citalopram is not an absolute contraindication in patients with alcohol use disorder, but it may lead to poorer drinking outcomes and should generally be avoided as a first-line treatment for these patients.

Evidence Assessment

The available evidence does not support classifying citalopram as absolutely contraindicated in alcohol use disorder. However, there are important clinical considerations:

Efficacy and Safety Concerns

• A randomized, double-blind, placebo-controlled trial showed that citalopram provided no advantage over placebo for alcohol dependence treatment and actually produced poorer outcomes in some measures, including higher numbers of heavy drinking days 1

• Patients in the citalopram group demonstrated smaller changes in frequency and amount of alcohol consumption at 12 weeks compared to placebo 1

• The study concluded that "the use of SSRIs among depressed and nondepressed alcohol-dependent individuals early in recovery, prior to the onset of abstinence, may be contraindicated" 1

Pharmacological Considerations

• The FDA label for citalopram does not list alcohol use disorder as an absolute contraindication 2

• However, the label does advise: "patients should be told that, although citalopram has not been shown in experiments with normal subjects to increase the mental and motor skill impairments caused by alcohol, the concomitant use of citalopram and alcohol in depressed patients is not advised" 2

• CYP2C19 genetic polymorphism can affect citalopram metabolism, which may be particularly relevant in patients with alcohol use disorder who may have compromised liver function 3

Recommended Pharmacotherapy for Alcohol Use Disorder

According to clinical guidelines, the following medications are preferred for alcohol use disorder:

1. First-line options:

   • Acamprosate - The presence of liver disease does not change the indications or conditions of acamprosate use 4
   • Naltrexone - Although contraindicated in severe hepatic insufficiency according to product characteristics, this contraindication is not supported by solid data 4
   • Baclofen - The presence of liver disease does not generally affect prescribing at recommended doses (up to 80 mg/day) 4

2. WHO recommendations:

   • "Acamprosate, disulfiram, or naltrexone should be offered as part of treatment to reduce relapse in alcohol dependent patients" 4

Clinical Decision Algorithm

When considering pharmacotherapy for a patient with alcohol use disorder:

1. Assess liver function:

   • For patients without significant liver impairment: Consider naltrexone, acamprosate, or disulfiram
   • For patients with liver disease: Consider acamprosate or baclofen (with dose adjustment in severe liver disease) 4

2. If depression is present:

   • First establish abstinence or reduced consumption using evidence-based medications for alcohol use disorder
   • Consider antidepressants only after addressing the alcohol use disorder or if depression persists after a period of abstinence
   • Avoid citalopram as a first-line treatment due to evidence of poorer drinking outcomes 1

3. Monitor for interactions:

   • If citalopram must be used (e.g., for treatment-resistant depression), monitor closely for:
     • Changes in drinking patterns
     • Potential hepatotoxicity
     • Serotonin syndrome risk with other medications

Conclusion

While not absolutely contraindicated, citalopram should generally be avoided as a first-line treatment in patients with alcohol use disorder due to evidence suggesting poorer drinking outcomes. Acamprosate, naltrexone, or baclofen are preferred pharmacological options according to current guidelines 4.