What can be added to citalopram (Celexa) for agitation in a patient who is already at the maximum dose of 40mg?

Managing Agitation in Patients on Maximum Dose Citalopram (40mg)

For patients who are already at the maximum dose of citalopram (40mg) and experiencing agitation, adding quetiapine is recommended as the first-line adjunctive treatment, starting at 25mg at bedtime and titrating as needed. 1

Medication Options for Agitation

First-line Options:

• Quetiapine:
  • Starting dose: 25mg orally at bedtime
  • Can be given every 12 hours if scheduled dosing required
  • Reduce dose in older patients and those with hepatic impairment
  • Benefits: Sedating, less likely to cause extrapyramidal side effects than other antipsychotics
  • Monitor for: Orthostatic hypotension, dizziness 2

Alternative Options:

1. Olanzapine:

   • Dosing: 2.5-5mg orally or subcutaneously
   • Reduce dose in older patients and those with hepatic impairment
   • Available as orally disintegrating tablet
   • Caution: Combining with benzodiazepines increases risk of oversedation and respiratory depression 2

2. Risperidone:

   • Dosing: 0.5mg orally, up to every 12 hours if needed
   • Reduce dose in older patients and those with renal/hepatic impairment
   • Monitor for extrapyramidal symptoms, especially at doses >6mg/24h 2

3. Aripiprazole:

   • Dosing: 5mg orally or IM once daily
   • Less likely to cause extrapyramidal symptoms
   • Reduce dose in older patients and poor CYP2D6 metabolizers
   • May cause headache, agitation, anxiety, insomnia 2

4. Mirtazapine:

   • Starting dose: 7.5-15mg at bedtime
   • Target dose: 15-30mg at bedtime
   • Particularly useful if insomnia is contributing to agitation
   • Addresses both depression and anxiety symptoms 1

Special Considerations

For Severe Agitation:

• If agitation is severe and immediate control is needed, consider:
  • Haloperidol: 0.5-1mg orally at night (max 5mg/day)
  • Chlorpromazine: 12.5-25mg orally or PR for immediate effect 2
  • Lorazepam: May be added for agitation refractory to high doses of neuroleptics, but avoid as initial treatment 2

For Elderly Patients:

• Use lower starting doses (e.g., quetiapine 25mg, olanzapine 2.5mg)
• Titrate more gradually
• Maximum target dose of quetiapine should be 200mg/day in divided doses 1
• Monitor closely for falls, cognitive effects, and orthostatic hypotension

Monitoring and Follow-up

• Initial follow-up within 1-2 weeks to assess side effects and response
• Monitor for:
  • QTc prolongation (particularly important as citalopram also affects QTc)
  • Cognitive function
  • Metabolic parameters (lipids, glucose)
  • Blood pressure and orthostatic changes
  • Extrapyramidal symptoms 1

Important Cautions

• Avoid benzodiazepines as first-line treatment due to risk of dependence, tolerance, and potential worsening of cognitive function 1
• Be aware that citalopram itself at 30mg or higher doses has been associated with QTc prolongation 3
• Consider non-pharmacological approaches alongside medication:
  • Structured routine
  • Consistent caregivers
  • Environmental modifications
  • Addressing underlying causes of agitation 1

Treatment Algorithm

1. Start with quetiapine 25mg at bedtime
2. If inadequate response after 1 week, increase to 25mg twice daily
3. Titrate up to effective dose (typically 50-200mg/day)
4. If quetiapine is ineffective or poorly tolerated, switch to olanzapine or risperidone
5. For refractory cases, consider consultation with psychiatry for more specialized management

Remember that all antipsychotics and benzodiazepines can potentially cause or worsen agitation and delirium, so use the lowest effective dose for the shortest period necessary 2.