From the Guidelines
Citalopram should not exceed a maximum dosage of 40 mg per day for most adults, as doses above this have been associated with QT prolongation and increased risk of Torsade de Pointes, ventricular tachycardia, and sudden death 1.
Key Considerations
- For older adults (over 60 years), patients with hepatic impairment, or those taking medications that inhibit CYP2C19 enzymes, the maximum dose should be limited to 20 mg daily due to increased risk of QT interval prolongation 1.
- Treatment typically begins at 20 mg once daily, which can be increased to 40 mg daily after at least one week if needed for symptom control.
- Citalopram should be taken at the same time each day, with or without food.
- The medication works by increasing serotonin levels in the brain by blocking its reuptake, which helps improve symptoms of depression and anxiety.
Important Safety Information
- Therapeutic effects may take 2-4 weeks to become noticeable, and the medication should not be stopped abruptly as this can cause withdrawal symptoms 1.
- Any dose adjustments should be made under medical supervision.
- Concomitant administration of any of the SSRIs with any of the monoamine oxidase inhibitors (MAOIs) is contraindicated because of increased risk of serotonin syndrome 1.
Clinical Guidance
- A conservative medication trial for mild to moderate anxiety presentations may entail increasing the dose as tolerated (if adherence is confirmed) within the therapeutic dosage range in the smallest available increments at approximately 1- to 2-week intervals when prescribing shorter half-life SSRIs (eg, sertraline, citalopram) to approximately 3- to 4-week intervals when prescribing longer half-life SSRIs (eg, fluoxetine) until the benefit-to-harm ratio is optimized and remission is achieved 1.
- Faster up-titration may be indicated as tolerated for more severe anxiety presentations; however, it is not clear that dose of medication is related to magnitude of response, and higher doses or blood concentrations can be associated with more adverse effects 1.
From the FDA Drug Label
The efficacy of citalopram tablets as a treatment for depression was established in two placebo-controlled studies (of 4 to 6 weeks in duration) in adult outpatients (ages 18-66) meeting DSM-III or DSM-III-R criteria for major depression Study 1, a 6-week trial in which patients received fixed citalopram tablets doses of 10, 20, 40 and 60 mg/day, showed that citalopram tablets at doses of 40 and 60 mg/day was effective as measured by the Hamilton Depression Rating Scale (HAMD) total score, the HAMD depressed mood item (Item 1), the Montgomery Asberg Depression Rating Scale, and the Clinical Global Impression (CGI) Severity scale
The maximum dosage of citalopram (Celexa) is 60 mg/day for patients less than 60 years of age, as indicated by the efficacy of doses of 40 and 60 mg/day in clinical studies 2. However, for patients greater than 60 years of age, the maximum recommended dose is 20 mg/day, due to the risk of QT prolongation. Similarly, for hepatically impaired patients and CYP2C19 poor metabolizers, the maximum recommended dose is also 20 mg/day.
From the Research
Maximum Dosage of Citalopram
The maximum recommended dosage of citalopram (Celexa) varies based on age and other factors.
- For patients 60 years and older, the maximum recommended dosage is 20 mg per day 3, 4.
- For patients under 60 years, the maximum recommended dosage is 40 mg per day 3, 5.
Clinical Studies and Recommendations
Clinical studies have shown that higher doses of citalopram are associated with abnormal heart rhythms, particularly QT interval prolongation 3, 4.
- However, some studies suggest that the risk of QT interval prolongation may not be as high as previously thought, and that the benefits of higher doses of citalopram may outweigh the risks for some patients 3, 6.
Dosage Reduction and Clinical Outcomes
Reducing the dosage of citalopram to the recommended limit has been associated with increased hospitalizations and mortality in some patient populations 6.
- A study of veterans found that reducing the dosage of citalopram to 40 mg per day or less was associated with a higher rate of hospitalization and mortality, particularly for depression and all-cause death 6.