Citalopram Tapering Protocol
Citalopram should be tapered gradually over weeks to months rather than abruptly discontinued to minimize withdrawal symptoms and prevent complications such as hypertension and relapse of depression. 1, 2
Recommended Tapering Schedule
Initial approach: Reduce the dose by 10% of the original dose per month with monthly follow-up visits 3
For example, if starting at 40mg/day:
- Month 1: 36mg/day
- Month 2: 32mg/day
- Month 3: 29mg/day
- Continue this pattern until reaching the smallest available dose
For more sensitive patients: Consider an even slower taper of 5% reduction every 2-4 weeks, especially for:
- Elderly patients (>60 years)
- Those with history of anxiety disorders
- Patients who have been on citalopram for >1 year 3
Monitoring During Tapering
- Schedule follow-up visits at least every 2-4 weeks during the tapering process 3
- Monitor for withdrawal symptoms including:
- Physical symptoms: dizziness, nausea, headache, tremor, sweating, insomnia
- Psychological symptoms: anxiety, irritability, mood changes
- Cardiovascular: monitor blood pressure, as abrupt discontinuation has been associated with hypertension 4
Managing Withdrawal Symptoms
If significant withdrawal symptoms occur during tapering:
- Pause the taper at the current dose
- Wait 1-2 weeks for symptoms to stabilize
- Resume tapering at a slower rate (e.g., 5% reduction instead of 10%) 3
The following medications may help manage specific withdrawal symptoms:
- Trazodone or hydroxyzine for insomnia and anxiety
- NSAIDs/acetaminophen for headache or myalgia
- Loperamide for gastrointestinal symptoms 3
Special Considerations
- Maximum doses: Remember that doses above 40mg/day are not recommended due to QT prolongation risk 1
- Special populations: 20mg/day is the maximum recommended dose for:
- Patients >60 years of age
- Patients with hepatic impairment
- CYP2C19 poor metabolizers
- Patients taking cimetidine or other CYP2C19 inhibitors 1
- Final stages: Consider using liquid formulations or splitting tablets to achieve very small doses (potentially as low as 1/40th of therapeutic dose) before complete cessation 2, 5
- Hyperbolic tapering: Evidence suggests that reducing by smaller amounts as the dose gets lower (hyperbolic tapering) may be more effective than linear tapering 2, 5
Important Cautions
- Never discontinue citalopram abruptly as this can lead to withdrawal syndrome and potentially severe hypertension 4
- Be aware that withdrawal symptoms can be mistaken for depression recurrence, leading to unnecessary long-term medication 2
- Standard short tapers of 2-4 weeks show minimal benefits over abrupt discontinuation and are often not tolerated well by patients 2
- Consider adjunctive cognitive behavioral therapy during tapering, which can increase rates of successful discontinuation 6
By following these guidelines, the risk of withdrawal symptoms and relapse can be minimized during citalopram discontinuation.