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FDA Drug Safety Communication: Abnormal heart rhythms associated with high doses of Celexa (citalopram hydrobromide)
Safety Announcement
August 24, 2011

Safety Announcement
[8-24-2011] The U.S. Food and Drug Administration (FDA) is informing healthcare professionals and patients that the antidepressant Celexa (citalopram hydrobromide; also marketed as generics) should no longer be used at doses greater than 40 mg per day because it can cause abnormal changes in the electrical activity of the heart. Studies did not show a benefit in the treatment of depression at doses higher than 40 mg per day.

Facts about Celexa (citalopram hydrobromide)Is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs).
Thought to work by increasing the amount of serotonin in the brain.1
Available as 10 mg, 20 mg, and 40 mg tablets. Also available as an oral solution (10 mg/5 mL).

Previously, the citalopram drug label stated that certain patients may require a dose of 60 mg per day.

Changes in the electrical activity of the heart (prolongation of the QT interval of the electrocardiogram [ECG]) - see Data Summary below - can lead to an abnormal heart rhythm (including Torsade de Pointes), which can be fatal. Patients at particular risk for developing prolongation of the QT interval include those with underlying heart conditions and those who are predisposed to low levels of potassium and magnesium in the blood.

The citalopram drug label has been revised to include the new drug dosage and usage recommendations, as well as information about the potential for QT interval prolongation and Torsade de Pointes. (See Additional Information for Healthcare Professionals)

Additional Information for Patients
  • Do not stop taking citalopram or change your dose without talking to your healthcare professional. Stopping citalopram suddenly can cause unwanted side effects.
  • If you are currently taking a citalopram dose greater than 40 mg per day, talk to your healthcare professional about changing your dose.
  • Seek immediate care if you experience an irregular heartbeat, shortness of breath, dizziness, or fainting while taking citalopram.
  • If you are taking citalopram, your healthcare professional may occasionally order an electrocardiogram (ECG, EKG) to monitor your heart rate and rhythm. An ECG is a test that checks for problems with the electrical activity of your heart.
  • Read the Medication Guide for citalopram carefully and discuss any questions you have with your healthcare professional.

Additional Information for Healthcare Professionals
  • Citalopram causes dose-dependent QT interval prolongation. Citalopram should no longer be prescribed at doses greater than 40 mg per day.
  • Citalopram should not be used in patients with congenital long QT syndrome.
  • Patients with congestive heart failure, bradyarrhythmias, or predisposition to hypokalemia or hypomagnesemia because of concomitant illness or drugs, are at higher risk of developing Torsade de Pointes.
  • Hypokalemia and hypomagnesemia should be corrected before administering citalopram. Electrolytes should be monitored as clinically indicated.
  • Consider more frequent electrocardiogram (ECG) monitoring in patients with congestive heart failure, bradyarrhythmias, or patients on concomitant medications that prolong the QT interval.
  • 20 mg per day is the maximum recommended dose for patients with hepatic impairment, who are greater than 60 years of age, who are CYP 2C19 poor metabolizers, or who are taking concomitant cimetidine (Tagamet?), because these factors lead to increased blood levels of citalopram, increasing the risk of QT interval prolongation and Torsade de Pointes.
  • No dose adjustment is necessary for patients with mild or moderate renal impairment.
  • Advise patients to contact a healthcare professional immediately if they experience signs and symptoms of an abnormal heart rate or rhythm while taking citalopram.


Re: FDA: Celexa Warning

This advisory comes from the FDA in the U.S. and it is not clear if Health Canada will issue a similar advisory. We will endeavor to report any further developments.

The manufacturer states the following in the Canadian prescribing information to physicians:

Celexa should be administered as a single oral dose of 20 mg/day. .In patients who do not respond adequately,
an increase of dosage to 40 mg/day should be considered. Certain patients may require 60 mg/day. However, in
a dose-response study, the 60 mg/day dose did not demonstrate an advantage regarding effectiveness over the 40
mg/day dose.

Dose increases should usually occur in increments of 20 mg, at intervals of no less than one week.***

The advisory refers to dosages in excess of the usual recommended dose; if you happen to be taking more than 40 mg per day, do not stop the medication, but rather contact your doctor about changing your dose.

***Source: Canadian Product Monograph, Health Canada Drug Product Database
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