Citalopram (Celexa) Titration Schedule
The recommended titration schedule for citalopram (Celexa) is to start at 20 mg once daily with an increase to a maximum dose of 40 mg/day at an interval of no less than one week. 1
Initial Dosing and Titration
- Citalopram should be administered once daily, in the morning or evening, with or without food 1
- Start with 20 mg once daily as the initial dose 1
- If needed, increase to 40 mg/day after at least one week on the initial dose 1
- Doses above 40 mg/day are not recommended due to the risk of QT prolongation 1, 2
Special Populations
- For patients over 60 years of age, the maximum recommended dose is 20 mg/day 1
- For patients with hepatic impairment, the maximum recommended dose is 20 mg/day 1
- For CYP2C19 poor metabolizers or patients taking CYP2C19 inhibitors (such as cimetidine), the maximum recommended dose is 20 mg/day 1
- No dosage adjustment is necessary for patients with mild or moderate renal impairment, but citalopram should be used with caution in patients with severe renal impairment 1
Monitoring During Titration
- During the initial titration phase, weekly contact (which can be by telephone) is recommended 3
- The titration phase typically requires 2-4 weeks to complete 3
- Assess for side effects systematically by asking specific questions about known side effects such as insomnia, anorexia, headaches, and weight loss 3
- Monitor for QT prolongation, especially when using doses at the upper limit of 40 mg/day 2
Maintenance Treatment
- After stabilization, follow-up appointments should be made at least monthly until symptoms have been fully stabilized 3
- Antidepressant efficacy has been shown to be maintained for periods of up to 24 weeks following 6-8 weeks of initial treatment 1
Discontinuation
- When discontinuing treatment, a gradual reduction in dose rather than abrupt cessation is recommended 1
- If intolerable symptoms occur during dose reduction, consider resuming the previously prescribed dose and then continue decreasing the dose at a more gradual rate 1
Common Pitfalls and Caveats
- Avoid exceeding the maximum dose of 40 mg/day, as higher doses increase the risk of QT prolongation without providing additional efficacy benefits 1, 2
- For elderly patients, starting at a lower dose (10 mg) and titrating more slowly may be beneficial, as this population is more sensitive to side effects 4, 5
- The dose-response relationship shows that even 10 mg daily can provide antidepressive effects after 6 weeks of therapy, though with lower effect sizes than 40 mg daily 6
- Side effects at 20 mg daily may be more pronounced initially than at 10 mg daily, which should be considered when evaluating overall benefit 6
- For patients experiencing significant side effects at 20 mg, consider maintaining this dose rather than increasing, as more is not necessarily better if side effects are problematic 1
Following this titration schedule will help maximize the therapeutic benefits of citalopram while minimizing potential adverse effects.