Can you take Celexa (citalopram) and Vraylar (cariprazine) together?

Celexa and Vraylar: Safety of Combined Use

Yes, Celexa (citalopram) and Vraylar (cariprazine) can be taken together, but this combination requires careful monitoring for potential serotonin syndrome and other drug interactions.

Pharmacological Considerations

Mechanism of Action

• Celexa (citalopram): A selective serotonin reuptake inhibitor (SSRI) that works primarily by increasing serotonin levels in the brain
• Vraylar (cariprazine): A dopamine-serotonin partial agonist (atypical antipsychotic) with unique high affinity for dopamine D3 receptors 1

Potential Benefits of Combination

• This combination may be beneficial for patients with:
  • Bipolar depression with concurrent anxiety
  • Major depressive disorder with psychotic features
  • Treatment-resistant depression where Vraylar is used as an augmenting agent

Safety Considerations

Serotonin Syndrome Risk

• While this combination is generally acceptable, there is a potential risk of serotonin syndrome when combining serotonergic medications 2
• Symptoms of serotonin syndrome include:
  • Mental status changes (confusion, agitation, anxiety)
  • Neuromuscular hyperactivity (tremors, clonus, hyperreflexia)
  • Autonomic hyperactivity (hypertension, tachycardia, diaphoresis)
  • Advanced symptoms: fever, seizures, arrhythmias, unconsciousness 2

QT Prolongation

• Citalopram has been associated with QT prolongation at doses exceeding 40mg/day 2
• Monitor for cardiac symptoms, especially if the patient has pre-existing cardiac conditions

Dosing Considerations

• Start with lower doses of both medications and titrate slowly
• For citalopram:
  • Begin with 10-20mg daily
  • Maximum dose should not exceed 40mg daily (20mg in elderly or hepatic impairment) 3
• For cariprazine:
  • Begin with 1.5mg daily
  • Can be increased to 3mg daily if needed for bipolar depression 4

Monitoring Protocol

Initial Phase (First 4 Weeks)

1. Weekly monitoring for:
   • Signs of serotonin syndrome
   • Behavioral activation or agitation (especially in younger patients) 3
   • Mood changes, including potential manic/hypomanic symptoms 2
   • Sleep disturbances
   • Extrapyramidal symptoms (from cariprazine)

Maintenance Phase

1. Monthly monitoring for:
   • Therapeutic efficacy
   • Side effects
   • Weight changes
   • Blood pressure
2. Consider ECG monitoring if on higher doses of citalopram

Special Populations

Bipolar Disorder

• Use caution when prescribing citalopram to patients with bipolar disorder as SSRIs may trigger manic episodes 2
• Vraylar is FDA-approved for bipolar depression and mania, making it potentially beneficial in this population 5

Elderly Patients

• Use lower doses of both medications
• More frequent monitoring for side effects
• Higher risk of drug interactions due to polypharmacy

Management of Common Side Effects

Gastrointestinal Issues

• Take medications with food
• Temporary dose reduction if severe
• Slow titration schedule 3

Sleep Disturbances

• Consider morning dosing of citalopram if activating
• Evening dosing if sedating effects are noted 3

Sexual Dysfunction

• Monitor for sexual side effects from citalopram
• Consider dose adjustments if problematic 3

Contraindications

• Concurrent use with MAOIs is absolutely contraindicated due to high risk of serotonin syndrome 2
• Caution in patients with:
  • History of seizures
  • Significant cardiovascular disease
  • Severe hepatic impairment

Conclusion

While Celexa (citalopram) and Vraylar (cariprazine) can be used together, this combination requires careful monitoring, particularly for serotonin syndrome and cardiac effects. Start with lower doses, titrate slowly, and maintain regular follow-up to ensure safety and efficacy.