Citalopram & Escitalopram maximum dose (MHRA Dec 2011)
New dose recommendations
•Citalopram max dose 40mg/day in adults and 20mg/day in the elderly
and people with reduced hepatic function.
•Escitalopram max dose in elderly 10mg/day, no other dose changes.
•Pre-treatment (or current patients where not already checked): correct
any electrolyte disturbances & undertake ECG for those with cardiac
disease.
•Escitalopram remains non-formulary (except for use by tertiary
OCD/BDD Services).
Adult above recommended dose
Reduce dose stepwise.
Monitor for 3 months
Other SSRIs:
Check ECG if
prescribing
above BNF
doses.
Remains stable
If es/citalopram dose currently above new recommendations:
Discuss with service user/patient. Consider continued need for
es/citalopram and alternative therapies. Consider switching if also
taking any other medicines likely to cause QTc prolongation.
(NB es/citalopram have few interactions and so has been a drug of choice
where interactions are likely).
Elderly or other risk factors above
recommended dose
Reduce dose stepwise. Monitor for 3 months
Relapses or deteriorates
Consider risk:benefit with service user.
Switch if possible
If under 18 refer to CAMHS (unlicensed use).
If all other options exhausted consider maintaining previously effective dose [document unlicensed
dose and rationale in notes; evidence of informed consent from service user with capacity].
Reduce and monitor any risk factors. Monitor with regular ECG (e.g. initially, 6-monthly and after
any medicine or dose changes) and tell service user to report any abnormal heart rate or rhythm.
If significant QT prolongation detected, must seek specialist advice and/or switch
Citalopram & escitalopram may cause a
dose-dependent QTc prolongation:
•Contraindicated with known QTc prolongation,
congenital long QT syndrome or taking other
QTc-prolonging medicines e.g. antipsychotics,
quinolones, macrolides & antiarrhythmics.
• Caution with higher risk of developing
Torsades de Pointes (e.g. in heart failure,
bradyarrythmia, hypokalaemia or
hypomagnesemia).
Known to need above new MHRA
recommended doses (elderly and reduced
hepatic function) e.g. for OCD, PTSD
Alternative medicines include:
Sertraline (optimum alternative as similar
indications, low interaction propensity, good
tolerability, generic, NICE approved)
Fluoxetine (beware of P450 interactions)
Mirtazapine (depression indication only)
Switch to different SSRI or
antidepressant
Other therapies considered
There is no comparative data available on QTc prolongation
for other antidepressants/doses.
There is no single switch method:
Depending on es/citalopram dose, urgency, tolerability and
other medicines then “drop, stop and switch” is safest.
Abrupt switching is not recommended.
If in doubt, consult medicines helpline (see below).
If switching be aware of serotonin syndrome and
es/citalopram discontinuation symptoms.
References see www.nelm.nhs.uk (search ‘escitalopram high dose’): Lundbeck communication and MHRA advice
Further advice: SWLStG Medicines Information on 020 3513 6829 or contact your Mental Health Team
8/3/13 (Thanks to Prof S Bazire)