Protocol for Increasing Citalopram Dose
When increasing citalopram dosage, start with 20 mg once daily and increase to a maximum of 40 mg/day with at least one week interval between dose adjustments. 1
Initial Dosing and Titration
- Citalopram should be administered once daily, either in the morning or evening, with or without food 1
- Start with an initial dose of 20 mg once daily 1
- Allow at least one week at each dose before considering an increase 1
- Increase to a maximum dose of 40 mg/day if needed 1
- Doses above 40 mg/day are not recommended due to the risk of QT prolongation 1
Special Population Considerations
- For patients over 60 years of age, the maximum recommended dose is 20 mg/day 1
- Patients with hepatic impairment should not exceed 20 mg/day 1
- CYP2C19 poor metabolizers should be limited to 20 mg/day 1
- Patients taking CYP2C19 inhibitors (e.g., cimetidine) should not exceed 20 mg/day 1
- Use caution in patients with severe renal impairment 1
Monitoring During Dose Increases
- Monitor for initial adverse effects which may include anxiety or agitation, especially early in treatment 2
- Watch for common side effects including nausea, dry mouth, somnolence, insomnia, and increased sweating 3
- Be alert for signs of QT prolongation, particularly at higher doses 2
- Assess for serotonin syndrome when combining with other serotonergic medications 2
Discontinuation Protocol
- When discontinuing citalopram, gradually reduce the dose rather than abrupt cessation 1
- If intolerable discontinuation symptoms occur, resume the previously prescribed dose and decrease more gradually 1
- Discontinuation symptoms may include dizziness, fatigue, headaches, nausea, insomnia, sensory disturbances, anxiety, and irritability 2
Efficacy Considerations
- While 20 mg/day is the minimum effective dose for most patients, some with severe depression may benefit from higher doses up to 40 mg/day 4
- Allow 4-6 weeks at the therapeutic dose to fully assess efficacy 2
- If inadequate response occurs at 40 mg/day, consider switching to another antidepressant rather than exceeding the maximum recommended dose 5
Common Pitfalls to Avoid
- Never exceed 40 mg/day due to risk of QT prolongation, even if the patient shows partial response 1
- Avoid combining with MAOIs - allow at least 14 days between discontinuing an MAOI and starting citalopram 1
- Be cautious when combining with other serotonergic medications due to risk of serotonin syndrome 2
- Don't increase the dose too rapidly; always allow at least one week between dose adjustments 1
- Don't discontinue abruptly as this may lead to withdrawal symptoms, especially with longer-term treatment 2