Can citalopram be used as an adjunct with duloxetine (Cymbalta) 120 milligrams daily?

From the Guidelines

It is not recommended to use citalopram as an adjunct with Cymbalta 120 mg daily due to the increased risk of serotonin syndrome and potential drug interactions. When considering the combination of these two medications, it is essential to weigh the potential benefits against the risks, prioritizing morbidity, mortality, and quality of life as the primary outcomes. According to the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders 1, concomitant administration of any of the SSRIs with any of the monoamine oxidase inhibitors (MAOIs) is contraindicated because of increased risk of serotonin syndrome. Although Cymbalta is not an MAOI, it does increase serotonin levels in the brain, and combining it with citalopram, an SSRI, may lead to potentially dangerous serotonin excess.

Some key points to consider when evaluating the safety of combining citalopram with Cymbalta include:

• The risk of serotonin syndrome, which can be life-threatening
• The potential for drug interactions, particularly with citalopram, which may interact with drugs that prolong the QT interval
• The importance of careful monitoring for adverse effects, starting with lower doses, and gradually titrating as tolerated
• The need for close medical supervision when combining antidepressants

As noted in the guideline 1, citalopram may cause QT prolongation associated with Torsade de Pointes, ventricular tachycardia, and sudden death at daily doses exceeding 40 mg/d, and should be avoided in patients with long QT syndrome. Additionally, the guideline recommends that medical education, training, and experience are necessary to safely and effectively prescribe antidepressant medications. If additional antidepressant treatment is needed, it would be safer to consult with a psychiatrist about alternative strategies such as switching medications completely rather than combining these two. Some patients may require combinations of antidepressants, but this should only be done under close medical supervision with careful monitoring for adverse effects, starting with lower doses, and gradually titrating as tolerated 1.

From the FDA Drug Label

Drugs That Interfere With Hemostasis (NSAIDs, Aspirin, Warfarin, etc.) - Serotonin release by platelets plays an important role in hemostasis. Epidemiological studies of the case-control and cohort design that have demonstrated an association between use of psychotropic drugs that interfere with serotonin reuptake and the occurrence of upper gastrointestinal bleeding have also shown that concurrent use of an NSAID or aspirin may potentiate the risk of bleeding Altered anticoagulant effects, including increased bleeding, have been reported when SSRIs and SNRIs are coadministered with warfarin.

CYP2C19 Inhibitors - Citalopram tablets 20 mg/day is the maximum recommended dose for patients taking concomitant CYP2C19 inhibitors because of the risk of QT prolongation (see WARNINGS, DOSAGE AND ADMINISTRATION, AND CLINICAL PHARMACOLOGY)

The use of citalopram with SNRIs such as cymbalta (duloxetine) may increase the risk of serotonin syndrome and bleeding. However, the provided drug label does not explicitly address the use of citalopram as an adjunct to cymbalta 120 mg daily.

• Key consideration: The combination of citalopram and cymbalta may pose a risk of increased serotonin levels, potentially leading to serotonin syndrome.
• Clinical decision: Due to the lack of explicit information in the drug label, it is recommended to exercise caution when considering the use of citalopram as an adjunct to cymbalta 120 mg daily.
• Recommendation: Consult with a healthcare professional to discuss the potential risks and benefits of this combination and to determine the best course of treatment 2.

From the Research

Citalopram as an Adjunct to Cymbalta

• There is no direct evidence in the provided studies to support the use of citalopram as an adjunct to Cymbalta (duloxetine) 120 mg daily.
• However, studies have shown that citalopram can be used as an adjunctive treatment to other medications, such as atypical antipsychotics 3 and estrogen therapy 4.
• The efficacy and safety of citalopram as an adjunct to Cymbalta would depend on various factors, including the patient's medical history, current medications, and the specific condition being treated.
• It is essential to note that combining citalopram with other serotonergic agents, such as Cymbalta, may increase the risk of serotonin syndrome, as reported in a case study involving quetiapine and citalopram 5.
• A comprehensive review of citalopram's clinical efficacy and safety profile is available 6, but it does not specifically address its use as an adjunct to Cymbalta.
• A systematic review of citalopram versus other antidepressants found that citalopram was more efficacious than some antidepressants, but less efficacious than others, such as escitalopram 7.