Citalopram and Decreased Appetite in Elderly Patients with Dose Changes
Citalopram can cause decreased appetite in elderly patients, and this side effect may emerge or worsen with dose changes, particularly when initiating therapy or increasing doses. 1
Evidence from FDA Drug Labeling
The FDA label for citalopram explicitly states that "decreased appetite and weight loss have been observed in association with the use of SSRIs" and recommends regular monitoring of weight in patients treated with citalopram. 1 This warning applies across age groups but is particularly relevant for elderly patients who may be more vulnerable to nutritional compromise.
Age-Related Considerations
Elderly patients (>60 years) have 23-30% higher citalopram blood levels and 30-50% longer half-lives compared to younger patients, making them more susceptible to side effects including appetite changes. 1 The FDA specifically limits the maximum dose to 20 mg/day for patients over 60 years due to these pharmacokinetic differences. 1
Clinical Evidence in Elderly Populations
A study examining age-related side effect profiles found that gastrointestinal side effects (including nausea, which often accompanies appetite loss) were actually less prevalent in elderly patients compared to younger populations, though this may reflect altered reporting rather than true absence of symptoms. 2
In a comparative trial of elderly depressed patients, citalopram produced significantly more nausea (12.8% vs 4.8% with amitriptyline), which can contribute to decreased appetite. 3
A repeated-dose study found that citalopram at 40 mg daily was associated with "loss of appetite" as a subjective complaint in healthy subjects after 9 days of treatment. 4
Dose-Change Specific Risks
When initiating citalopram or increasing doses, appetite suppression is most likely to occur during the first 1-3 weeks as plasma levels rise to steady state. 1, 4 The FDA label notes that elderly patients reach higher steady-state concentrations, meaning dose increases may produce more pronounced effects. 1
Guideline-Based Dosing for Elderly Patients
The American Family Physicians guidelines recommend starting citalopram at 10 mg per day in elderly patients, with a maximum of 40 mg per day (though FDA subsequently reduced this to 20 mg maximum for those >60 years). 5
Common side effects noted in guidelines include "nausea and sleep disturbances," both of which can indirectly affect appetite. 5
Clinical Management Algorithm
Monitor weight at baseline and regularly during dose titration, especially in the first month after any dose change. 1
When Appetite Loss Occurs:
- Assess severity and clinical impact - Determine if weight loss is occurring and whether nutritional status is compromised
- Consider dose reduction - The FDA label supports using the lowest effective dose, particularly in elderly patients 1
- Evaluate alternative agents - If appetite suppression is severe and problematic, consider switching to mirtazapine (7.5-30 mg at bedtime), which actively promotes appetite and weight gain in elderly patients 5, 6
Important Caveats
Do not confuse citalopram with escitalopram - While both are SSRIs, escitalopram has been specifically noted to have appetite-reducing properties that may make it less suitable for patients with pre-existing anorexia. 7
Depression itself causes appetite loss - Distinguish between medication side effects and inadequately treated depression, as both can manifest as decreased appetite. 5
Elderly patients may under-report symptoms - Active questioning about appetite, food intake, and weight changes is necessary rather than waiting for spontaneous complaints. 2