Is Celexa (citalopram) safe to use during pregnancy?

Citalopram (Celexa) Use During Pregnancy

Safety Profile and Recommendations

Citalopram should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus, as it carries FDA Pregnancy Category C classification and has shown adverse effects on embryo/fetal development in animal studies. 1

Risk Classification and Evidence

Citalopram has been classified as FDA Pregnancy Category C, indicating that:

• Animal reproduction studies have shown adverse effects on the fetus
• There are no adequate and well-controlled studies in pregnant women
• The drug should be used only if the potential benefit justifies the potential risk 1

Potential Risks

Congenital Malformations

• In animal studies, high doses of citalopram (approximately 18 times the maximum recommended human dose) resulted in decreased embryo/fetal growth and survival and increased incidence of cardiovascular and skeletal defects 1
• Human data shows some cases of malformations after maternal exposure to citalopram during early pregnancy, but the rate is generally in the range reported in unexposed women 2

Perinatal Complications

• Neonates exposed to citalopram late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding 1
• These complications can include:
  • Respiratory distress, cyanosis, apnea
  • Seizures, temperature instability
  • Feeding difficulties, vomiting, hypoglycemia
  • Hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability 1
• There is a relative risk of 4.2 for neonates exposed to citalopram close to term to be admitted to special-care nurseries compared to unexposed infants 2
• Infants exposed to SSRIs in pregnancy may have an increased risk for persistent pulmonary hypertension of the newborn (PPHN) 1

Breastfeeding Considerations

• Citalopram is excreted in human breast milk 1
• There have been two reports of infants experiencing excessive somnolence, decreased feeding, and weight loss associated with breastfeeding from citalopram-treated mothers 1
• The decision to continue or discontinue either nursing or citalopram therapy should consider both the risks of exposure for the infant and the benefits of treatment for the mother 1

Alternative Options

If antidepressant treatment is necessary during pregnancy, consider these alternatives:

• Sertraline is recommended as a first-line option for treating depression and anxiety during pregnancy due to its established safety profile and lower risk of adverse outcomes 3
• Citalopram and sertraline can both be used during pregnancy, though sertraline may have a more favorable risk profile 4, 5
• When selecting SSRIs for pregnant women, consider drugs with lower infant to maternal plasma concentration ratios 3

Clinical Management Approach

1. Risk-benefit assessment:

   • Weigh the risks of untreated maternal depression/anxiety against potential fetal risks
   • Consider that discontinuing antidepressant medication during pregnancy shows a significant increase in relapse of major depression 1

2. If citalopram is deemed necessary:

   • Use the lowest effective dose
   • Consider switching to sertraline if the patient is early in pregnancy and not yet stabilized on citalopram
   • Monitor closely for maternal symptoms and fetal development

3. Third trimester considerations:

   • Be aware of increased risk of neonatal adaptation syndrome
   • Consider gradual dose reduction before delivery if clinically appropriate
   • Arrange for neonatal monitoring after birth

4. Postpartum management:

   • Monitor infants for signs of drug toxicity or withdrawal during the first week of life
   • Consider alternatives if breastfeeding is planned

Important Caveats

• The decision to use citalopram during pregnancy should be made on a case-by-case basis after thorough discussion of risks and benefits 1
• Untreated depression during pregnancy carries its own risks to both mother and developing fetus
• If citalopram treatment is discontinued, it should be done gradually to minimize withdrawal symptoms 1
• Close monitoring of both mother and infant is essential if citalopram is used during pregnancy or breastfeeding