What is the recommended protocol for transitioning from citalopram (escitalopram) to Vraylar (cariprazine)?

Transitioning from Citalopram to Vraylar (Cariprazine)

The recommended protocol for transitioning from citalopram to Vraylar (cariprazine) involves a cross-tapering approach where you gradually taper citalopram while simultaneously introducing cariprazine at a low dose.

Cross-Tapering Schedule

Week 1-2:

• Continue current citalopram dose
• Start Vraylar (cariprazine) at 1.5 mg daily

Week 3-4:

• Reduce citalopram by 50% of original dose
• Increase Vraylar to 3 mg daily if tolerated

Week 5-6:

• Reduce citalopram to 25% of original dose
• Continue Vraylar at 3-4.5 mg daily as tolerated

Week 7-8:

• Discontinue citalopram completely
• Maintain Vraylar at effective dose (3-6 mg daily)

Rationale and Considerations

1. Pharmacological Differences:

   • Citalopram is an SSRI antidepressant
   • Vraylar (cariprazine) is an atypical antipsychotic with partial agonist activity at D2/D3 and 5-HT1A receptors

2. Monitoring Requirements:

   • Monitor for SSRI discontinuation symptoms during citalopram taper:

     • Dizziness, fatigue, headaches, nausea, sensory disturbances, irritability 1
     • Citalopram has a lower risk of discontinuation syndrome compared to paroxetine, fluvoxamine, and sertraline 2

   • Monitor for Vraylar side effects:

     • Extrapyramidal symptoms
     • Akathisia (most common side effect)
     • Metabolic changes

3. Special Considerations:

   • If patient experiences significant discontinuation symptoms, slow the taper of citalopram
   • QTc prolongation risk: Citalopram can prolong QTc interval at doses exceeding 40 mg/day 3, so ECG monitoring may be warranted during transition
   • Avoid abrupt discontinuation of citalopram as it can lead to withdrawal symptoms 1

Important Precautions

• Drug Interactions: Ensure no contraindicated medications are being used concurrently (especially MAOIs)
• Medical Conditions: Assess for conditions that might affect dosing of either medication (hepatic/renal impairment)
• Symptom Monitoring: Closely monitor for:
  • Worsening depression or anxiety
  • Emergence of suicidal ideation
  • Activation or agitation
  • Sleep disturbances

Follow-up Schedule

• Week 1: Phone or in-person follow-up after starting Vraylar
• Week 2-3: In-person assessment before first citalopram dose reduction
• Week 4-5: Follow-up before second citalopram dose reduction
• Week 7-8: Assessment after complete discontinuation of citalopram
• Week 12: Stability assessment on Vraylar monotherapy

This cross-tapering approach is similar to strategies used when switching between antipsychotics, which has been shown to be safe and well-tolerated 4. The gradual approach minimizes the risk of both discontinuation symptoms from citalopram and adverse effects from Vraylar while maintaining therapeutic coverage throughout the transition.