Chester Clinic

 

Citalopram hydrobromide tablets

Citalopram Hydrobromide Tablets
Suicidality and Antidepressant Drugs
Antidepressants increased the risk compared to placebo of suicidal thinking and behavior
(suicidality) in children, adolescents, and young adults in short-term studies of major
depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of
Citalopram HBr or any other antidepressant in a child, adolescent, or young adult must
balance this risk with the clinical need. Short-term studies did not show an increase in the
risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there
was a reduction in risk with antidepressants compared to placebo in adults aged 65 and
older. Depression and certain other psychiatric disorders are themselves associated with
increases in the risk of suicide. Patients of all ages who are started on antidepressant
therapy should be monitored appropriately and observed closely for clinical worsening,
suicidality, or unusual changes in behavior. Families and caregivers should be advised of
the need for close observation and communication with the prescriber. Citalopram HBr is
not approved for use in pediatric patients. (See WARNINGS: Clinical Worsening and
Suicide Risk, PRECAUTIONS: Information for Patients, and PRECAUTIONS: Pediatric
DESCRIPTION
Citalopram HBr is an orally administered selective serotonin reuptake inhibitor (SSRI) with a
chemical structure unrelated to that of other SSRIs or of tricyclic, tetracyclic, or other available
antidepressant agents. Citalopram HBr is a racemic bicyclic phthalane derivative designated (±)-
1-(3-dimethylaminopropyl)-1-(4-fluorophenyl)-1,3-dihydroisobenzofuran-5-carbonitrile, HBr
with the following structural formula:
The molecular formula is C20H22BrFN2O and its molecular weight is 405.35.
Citalopram HBr occurs as a fine, white to off-white powder. Citalopram HBr is sparingly soluble
in water and soluble in ethanol.
Citalopram HBr is available as tablets.
Citalopram HBr 10 mg tablets are film-coated, oval tablets with strengths equivalent to 10 mg
citalopram base. Citalopram HBr 20 mg and 40 mg tablets are film-coated, oval, scored tablets
with strengths equivalent to 20 mg or 40 mg citalopram base. The tablets also contain the
following inactive ingredients: copolyvidone, corn starch, crosscarmellose sodium, glycerin,
lactose monohydrate, magnesium stearate, hypromellose, microcrystalline cellulose,
polyethylene glycol, and titanium dioxide. Iron oxides are used as coloring agents in the beige
(10 mg) and pink (20 mg) tablets.
CLINICAL PHARMACOLOGY
Pharmacodynamics
The mechanism of action of Citalopram HBr as an antidepressant is presumed to be linked to
potentiation of serotonergic activity in the central nervous system (CNS) resulting from its
inhibition of CNS neuronal reuptake of serotonin (5-HT). In vitro and in vivo studies in animals
suggest that citalopram is a highly selective serotonin reuptake inhibitor (SSRI) with minimal
effects on norepinephrine (NE) and dopamine (DA) neuronal reuptake. Tolerance to the
inhibition of 5-HT uptake is not induced by long-term (14-day) treatment of rats with citalopram.
Citalopram is a racemic mixture (50/50), and the inhibition of 5-HT reuptake by citalopram is
primarily due to the (S)-enantiomer.
Citalopram has no or very low affinity for 5-HT1A, 5-HT2A, dopamine D1 and D2, α1-, α2-, and β-
adrenergic, histamine H1, gamma aminobutyric acid (GABA), muscarinic cholinergic, and
benzodiazepine receptors. Antagonism of muscarinic, histaminergic, and adrenergic receptors
has been hypothesized to be associated with various anticholinergic, sedative, and cardiovascular
effects of other psychotropic drugs.
Pharmacokinetics
The single- and multiple-dose pharmacokinetics of citalopram are linear and dose-proportional in
a dose range of 10-60 mg/day. Biotransformation of citalopram is mainly hepatic, with a mean
terminal half-life of about 35 hours. With once daily dosing, steady state plasma concentrations
are achieved within approximately one week. At steady state, the extent of accumulation of
citalopram in plasma, based on the half-life, is expected to be 2.5 times the plasma
concentrations observed after a single dose. The tablet and oral solution dosage forms of
Citalopram HBr are bioequivalent.
Absorption and Distribution
Following a single oral dose (40 mg tablet) of citalopram, peak blood levels occur at about 4
hours. The absolute bioavailability of citalopram was about 80% relative to an intravenous dose,
and absorption is not affected by food. The volume of distribution of citalopram is about 12 L/kg
and the binding of citalopram (CT), demethylcitalopram (DCT) and didemethylcitalopram
(DDCT) to human plasma proteins is about 80%.
Metabolism and Elimination
Following intravenous administrations of citalopram, the fraction of drug recovered in the urine
as citalopram and DCT was about 10% and 5%, respectively. The systemic clearance of
citalopram was 330 mL/min, with approximately 20% of that due to renal clearance.
Citalopram is metabolized to demethylcitalopram (DCT), didemethylcitalopram (DDCT),
citalopram-N-oxide, and a deaminated propionic acid derivative. In humans, unchanged
citalopram is the predominant compound in plasma. At steady state, the concentrations of
citalopram's metabolites, DCT and DDCT, in plasma are approximately one-half and one-tenth,
respectively, that of the parent drug. In vitro studies show that citalopram is at least 8 times more
potent than its metabolites in the inhibition of serotonin reuptake, suggesting that the metabolites
evaluated do not likely contribute significantly to the antidepressant actions of citalopram.
In vitro studies using human liver microsomes indicated that CYP3A4 and CYP2C19 are the
primary isozymes involved in the N-demethylation of citalopram.
Population Subgroups
Age - Citalopram pharmacokinetics in subjects ≥ 60 years of age were compared to younger
subjects in two normal volunteer studies. In a single-dose study, citalopram AUC and half-life
were increased in the elderly subjects by 30% and 50%, respectively, whereas in a multiple-dose
study they were increased by 23% and 30%, respectively. 20 mg is the recommended dose for
most elderly patients (see DOSAGE AND ADMINISTRATION).
Gender - In three pharmacokinetic studies (total N=32), citalopram AUC in women was one and
a half to two times that in men. This difference was not observed in five other pharmacokinetic
studies (total N=114). In clinical studies, no differences in steady state serum citalopram levels
were seen between men (N=237) and women (N=388). There were no gender differences in the
pharmacokinetics of DCT and DDCT. No adjustment of dosage on the basis of gender is
recommended.
Reduced hepatic function - Citalopram oral clearance was reduced by 37% and half-life was
doubled in patients with reduced hepatic function compared to normal subjects. 20 mg is the
recommended dose for most hepatically impaired patients (see DOSAGE AND
ADMINISTRATION).
Reduced renal function - In patients with mild to moderate renal function impairment, oral
clearance of citalopram was reduced by 17% compared to normal subjects. No adjustment of
dosage for such patients is recommended. No information is available about the
pharmacokinetics of citalopram in patients with severely reduced renal function (creatinine
clearance < 20 mL/min).
Drug-Drug Interactions
In vitro enzyme inhibition data did not reveal an inhibitory effect of citalopram on CYP3A4, -
2C9, or -2E1, but did suggest that it is a weak inhibitor of CYP1A2, -2D6, and -2C19.
Citalopram would be expected to have little inhibitory effect on in vivo metabolism mediated by
these cytochromes. However, in vivo data to address this question are limited.
Since CYP3A4 and 2C19 are the primary enzymes involved in the metabolism of citalopram, it
is expected that potent inhibitors of 3A4 (e.g., ketoconazole, itraconazole, and macrolide
antibiotics) and potent inhibitors of CYP2C19 (e.g., omeprazole) might decrease the clearance of
citalopram. However, coadministration of citalopram and the potent 3A4 inhibitor ketoconazole
did not significantly affect the pharmacokinetics of citalopram. Because citalopram is
metabolized by multiple enzyme systems, inhibition of a single enzyme may not appreciably
decrease citalopram clearance. Citalopram steady state levels were not significantly different in
poor metabolizers and extensive 2D6 metabolizers after multiple-dose administration of
Citalopram HBr, suggesting that coadministration with Citalopram HBr, of a drug that inhibits
CYP2D6, is unlikely to have clinically significant effects on citalopram metabolism. See Drug
Interactions under PRECAUTIONS for more detailed information on available drug
interaction data.
Clinical Efficacy Trials
The efficacy of Citalopram HBr as a treatment for depression was established in two placebo-
controlled studies (of 4 to 6 weeks in duration) in adult outpatients (ages 18-66) meeting DSM-
III or DSM-III-R criteria for major depression. Study 1, a 6-week trial in which patients received
fixed Citalopram HBr doses of 10, 20, 40, and 60 mg/day, showed that Citalopram HBr at doses
of 40 and 60 mg/day was effective as measured by the Hamilton Depression Rating Scale
(HAMD) total score, the HAMD depressed mood item (Item 1), the Montgomery Asberg
Depression Rating Scale, and the Clinical Global Impression (CGI) Severity scale. This study
showed no clear effect of the 10 and 20 mg/day doses, and the 60 mg/day dose was not more
effective than the 40 mg/day dose. In study 2, a 4-week, placebo-controlled trial in depressed
patients, of whom 85% met criteria for melancholia, the initial dose was 20 mg/day, followed by
titration to the maximum tolerated dose or a maximum dose of 80 mg/day. Patients treated with
Citalopram HBr showed significantly greater improvement than placebo patients on the HAMD
total score, HAMD item 1, and the CGI Severity score. In three additional placebo-controlled
depression trials, the difference in response to treatment between patients receiving Citalopram
HBr and patients receiving placebo was not statistically significant, possibly due to high
spontaneous response rate, smaller sample size, or, in the case of one study, too low a dose.
In two long-term studies, depressed patients who had responded to Citalopram HBr during an
initial 6 or 8 weeks of acute treatment (fixed doses of 20 or 40 mg/day in one study and flexible
doses of 20-60 mg/day in the second study) were randomized to continuation of Citalopram HBr
or to placebo. In both studies, patients receiving continued Citalopram HBr treatment
experienced significantly lower relapse rates over the subsequent 6 months compared to those
receiving placebo. In the fixed-dose study, the decreased rate of depression relapse was similar in
patients receiving 20 or 40 mg/day of Citalopram HBr.
Analyses of the relationship between treatment outcome and age, gender, and race did not
suggest any differential responsiveness on the basis of these patient characteristics.
Comparison of Clinical Trial Results
Highly variable results have been seen in the clinical development of all antidepressant drugs.
Furthermore, in those circumstances when the drugs have not been studied in the same controlled
clinical trial(s), comparisons among the results of studies evaluating the effectiveness of different
antidepressant drug products are inherently unreliable. Because conditions of testing (e.g.,
patient samples, investigators, doses of the treatments administered and compared, outcome
measures, etc.) vary among trials, it is virtually impossible to distinguish a difference in drug
effect from a difference due to one of the confounding factors just enumerated.
INDICATIONS AND USAGE
Citalopram HBr is indicated for the treatment of depression.
The efficacy of Citalopram HBr in the treatment of depression was established in 4-6 week,
controlled trials of outpatients whose diagnosis corresponded most closely to the DSM-III and
DSM-III-R category of major depressive disorder (see CLINICAL PHARMACOLOGY).
A major depressive episode (DSM-IV) implies a prominent and relatively persistent (nearly
every day for at least 2 weeks) depressed or dysphoric mood that usually interferes with daily
functioning, and includes at least five of the following nine symptoms: depressed mood, loss of
interest in usual activities, significant change in weight and/or appetite, insomnia or
hypersomnia, psychomotor agitation or retardation, increased fatigue, feelings of guilt or
worthlessness, slowed thinking or impaired concentration, a suicide attempt or suicidal ideation.
The antidepressant action of Citalopram HBr in hospitalized depressed patients has not been
adequately studied.
The efficacy of Citalopram HBr in maintaining an antidepressant response for up to 24 weeks
following 6 to 8 weeks of acute treatment was demonstrated in two placebo-controlled trials (see
CLINICAL PHARMACOLOGY). Nevertheless, the physician who elects to use Citalopram
HBr for extended periods should periodically re-evaluate the long-term usefulness of the drug for
the individual patient.
CONTRAINDICATIONS
Concomitant use in patients taking monoamine oxidase inhibitors (MAOIs) is contraindicated
(see WARNINGS).
Concomitant use in patients taking pimozide is contraindicated (see PRECAUTIONS).
Citalopram HBr is contraindicated in patients with a hypersensitivity to citalopram or any of the
inactive ingredients in Citalopram HBr.
WARNINGS
WARNINGS-Clinical Worsening and Suicide Risk
Clinical Worsening and Suicide Risk
Patients with major depressive disorder (MDD), both adult and pediatric, may experience
worsening of their depression and/or the emergence of suicidal ideation and behavior
(suicidality) or unusual changes in behavior, whether or not they are taking antidepressant
medications, and this risk may persist until significant remission occurs. Suicide is a known risk
of depression and certain other psychiatric disorders, and these disorders themselves are the
strongest predictors of suicide. There has been a long-standing concern, however, that
antidepressants may have a role in inducing worsening of depression and the emergence of
suicidality in certain patients during the early phases of treatment. Pooled analyses of short-term
placebo-controlled trials of antidepressant drugs (SSRIs and others) showed that these drugs
increase the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and
young adults (ages 18-24) with major depressive disorder (MDD) and other psychiatric
disorders. Short-term studies did not show an increase in the risk of suicidality with
antidepressants compared to placebo in adults beyond age 24; there was a reduction with
antidepressants compared to placebo in adults aged 65 and older.
The pooled analyses of placebo-controlled trials in children and adolescents with MDD,
obsessive compulsive disorder (OCD), or other psychiatric disorders included a total of 24 short-
term trials of 9 antidepressant drugs in over 4400 patients. The pooled analyses of placebo-
controlled trials in adults with MDD or other psychiatric disorders included a total of 295 short-
term trials (median duration of 2 months) of 11 antidepressant drugs in over 77,000 patients.
There was considerable variation in risk of suicidality among drugs, but a tendency toward an
increase in the younger patients for almost all drugs studied. There were differences in absolute
risk of suicidality across the different indications, with the highest incidence in MDD. The risk
differences (drug vs. placebo), however, were relatively stable within age strata and across
indications. These risk differences (drug-placebo difference in the number of cases of suicidality
per 1000 patients treated) are provided in Table 1.
Age Range
Drug-Placebo Difference in
Number of Cases of Suicidality per
1000 Patients Treated
Increases Compared to Placebo 14 additional cases Decreases Compared to Placebo No suicides occurred in any of the pediatric trials. There were suicides in the adult trials, but the
number was not sufficient to reach any conclusion about drug effect on suicide.
It is unknown whether the suicidality risk extends to longer-term use, i.e., beyond several
months. However, there is substantial evidence from placebo-controlled maintenance trials in
adults with depression that the use of antidepressants can delay the recurrence of depression.
All patients being treated with antidepressants for any indication should be monitored
appropriately and observed closely for clinical worsening, suicidality, and unusual changes
in behavior, especially during the initial few months of a course of drug therapy, or at times
of dose changes, either increases or decreases.

The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility,
aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have
been reported in adult and pediatric patients being treated with antidepressants for major
depressive disorder as well as for other indications, both psychiatric and nonpsychiatric.
Although a causal link between the emergence of such symptoms and either the worsening of
depression and/or the emergence of suicidal impulses has not been established, there is concern
that such symptoms may represent precursors to emerging suicidality.
Consideration should be given to changing the therapeutic regimen, including possibly
discontinuing the medication, in patients whose depression is persistently worse, or who are
experiencing emergent suicidality or symptoms that might be precursors to worsening depression
or suicidality, especially if these symptoms are severe, abrupt in onset, or were not part of the
patient's presenting symptoms.
If the decision has been made to discontinue treatment, medication should be tapered, as rapidly
as is feasible, but with recognition that abrupt discontinuation can be associated with certain
symptoms (see PRECAUTIONS and DOSAGE AND ADMINISTRATION—
Discontinuation of Treatment with Citalopram HBr, for a description of the risks of
discontinuation of Citalopram HBr).
Families and caregivers of patients being treated with antidepressants for major depressive
disorder or other indications, both psychiatric and nonpsychiatric, should be alerted about
the need to monitor patients for the emergence of agitation, irritability, unusual changes in
behavior, and the other symptoms described above, as well as the emergence of suicidality,
and to report such symptoms immediately to health care providers. Such monitoring
should include daily observation by families and caregivers. Prescriptions for Citalopram
HBr should be written for the smallest quantity of tablets consistent with good patient
management, in order to reduce the risk of overdose.
Screening Patients for Bipolar Disorder: A major depressive episode may be the initial
presentation of bipolar disorder. It is generally believed (though not established in controlled
trials) that treating such an episode with an antidepressant alone may increase the likelihood of
precipitation of a mixed/manic episode in patients at risk for bipolar disorder. Whether any of the
symptoms described above represent such a conversion is unknown. However, prior to initiating
treatment with an antidepressant, patients with depressive symptoms should be adequately
screened to determine if they are at risk for bipolar disorder; such screening should include a
detailed psychiatric history, including a family history of suicide, bipolar disorder, and
depression. It should be noted that Citalopram HBr is not approved for use in treating bipolar
depression.
Potential for Interaction with Monoamine Oxidase Inhibitors
In patients receiving serotonin reuptake inhibitor drugs in combination with a monoamine
oxidase inhibitor (MAOI), there have been reports of serious, sometimes fatal, reactions
including hyperthermia, rigidity, myoclonus, autonomic instability with possible rapid
fluctuations of vital signs, and mental status changes that include extreme agitation
progressing to delirium and coma. These reactions have also been reported in patients who
have recently discontinued SSRI treatment and have been started on an MAOI. Some cases
presented with features resembling neuroleptic malignant syndrome. Furthermore, limited
animal data on the effects of combined use of SSRIs and MAOIs suggest that these drugs
may act synergistically to elevate blood pressure and evoke behavioral excitation.
Therefore, it is recommended that Citalopram HBr should not be used in combination with
an MAOI, or within 14 days of discontinuing treatment with an MAOI. Similarly, at least
14 days should be allowed after stopping Citalopram HBr before starting an MAOI.
Serotonin Syndrome or Neuroleptic Malignant Syndrome (NMS)-like Reactions
The development of a potentially life-threatening serotonin syndrome or Neuroleptic Malignant
Syndrome (NMS)-like reactions have been reported with SNRIs and SSRIs alone, including
Citalopram HBr treatment, but particularly with concomitant use of serotonergic drugs
(including triptans) with drugs which impair metabolism of serotonin (including MAOIs), or
with antipsychotics or other dopamine antagonists. Serotonin syndrome symptoms may include
mental status changes (e.g., agitation, hallucinations, coma), autonomic instability (e.g.,
tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (e.g., hyperreflexia,
incoordination) and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Serotonin
syndrome, in its most severe form can resemble neuroleptic malignant syndrome, which includes
hyperthermia, muscle rigidity, autonomic instability with possible rapid fluctuation of vital signs,
and mental status changes. Patients should be monitored for the emergence of serotonin
syndrome or NMS-like signs and symptoms.

The concomitant use of Citalopram HBr with MAOIs intended to treat depression is
contraindicated.
If concomitant treatment of Citalopram HBr with a 5-hydroxytryptamine receptor agonist
(triptan) is clinically warranted, careful observation of the patient is advised, particularly during
treatment initiation and dose increases.

The concomitant use of Citalopram HBr with serotonin precursors (such as tryptophan) is not
recommended. Treatment with Citalopram HBr and any concomitant serotonergic or
antidopaminergic agents, including antipsychotics, should be discontinued immediately if the
above events occur and supportive symptomatic treatment should be initiated.

PRECAUTIONS
General
Discontinuation of Treatment with Citalopram HBr
During marketing of Citalopram HBr and other SSRIs and SNRIs (serotonin and norepinephrine
reuptake inhibitors), there have been spontaneous reports of adverse events occurring upon
discontinuation of these drugs, particularly when abrupt, including the following: dysphoric
mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesias such as electric
shock sensations), anxiety, confusion, headache, lethargy, emotional lability, insomnia, and
hypomania. While these events are generally self-limiting, there have been reports of serious
discontinuation symptoms.
Patients should be monitored for these symptoms when discontinuing treatment with Citalopram
HBr. A gradual reduction in the dose rather than abrupt cessation is recommended whenever
possible. If intolerable symptoms occur following a decrease in the dose or upon discontinuation
of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the
physician may continue decreasing the dose but at a more gradual rate (see DOSAGE AND
ADMINISTRATION).
Abnormal Bleeding
SSRIs and SNRIs, including Citalopram HBr, may increase the risk of bleeding events. Concomitant
use of aspirin, nonsteroidal anti-inflammatory drugs, warfarin, and other anticoagulants may add to
the risk. Case reports and epidemiological studies (case-control and cohort design) have demonstrated
an association between use of drugs that interfere with serotonin reuptake and the occurrence of
gastrointestinal bleeding. Bleeding events related to SSRIs and SNRIs use have ranged from
ecchymoses, hematomas, epistaxis, and petechiae to life-threatening hemorrhages.
Patients should be cautioned about the risk of bleeding associated with the concomitant use of
Citalopram HBr and NSAIDs, aspirin, or other drugs that affect coagulation.
Hyponatremia
Hyponatremia may occur as a result of treatment with SSRIs and SNRIs, including Citalopram HBr.
In many cases, this hyponatremia appears to be the result of the syndrome of inappropriate antidiuretic
hormone secretion (SIADH), and was reversible when Citalopram HBr was discontinued. Cases with
serum sodium lower than 110 mmol/L have been reported. Elderly patients may be at greater risk of
developing hyponatremia with SSRIs and SNRIs. Also, patients taking diuretics or who are otherwise
volume depleted may be at greater risk (see Geriatric Use). Discontinuation of Citalopram HBr
should be considered in patients with symptomatic hyponatremia and appropriate medical intervention
should be instituted.
Signs and symptoms of hyponatremia include headache, difficulty concentrating, memory
impairment, confusion, weakness, and unsteadiness, which may lead to falls. Signs and symptoms
associated with more severe and/or acute cases have included hallucination, syncope, seizure, coma,
respiratory arrest, and death.
Activation of Mania/Hypomania
In placebo-controlled trials of Citalopram HBr, some of which included patients with bipolar
disorder, activation of mania/hypomania was reported in 0.2% of 1063 patients treated with
Citalopram HBr and in none of the 446 patients treated with placebo. Activation of
mania/hypomania has also been reported in a small proportion of patients with major affective
disorders treated with other marketed antidepressants. As with all antidepressants, Citalopram
HBr should be used cautiously in patients with a history of mania.
Seizures
Although anticonvulsant effects of citalopram have been observed in animal studies, Citalopram
HBr has not been systematically evaluated in patients with a seizure disorder. These patients
were excluded from clinical studies during the product's premarketing testing. In clinical trials of
Citalopram HBr, seizures occurred in 0.3% of patients treated with Citalopram HBr (a rate of
one patient per 98 years of exposure) and 0.5% of patients treated with placebo (a rate of one
patient per 50 years of exposure). Like other antidepressants, Citalopram HBr should be
introduced with care in patients with a history of seizure disorder.
Interference with Cognitive and Motor Performance
In studies in normal volunteers, Citalopram HBr in doses of 40 mg/day did not produce
impairment of intellectual function or psychomotor performance. Because any psychoactive drug
may impair judgment, thinking, or motor skills, however, patients should be cautioned about
operating hazardous machinery, including automobiles, until they are reasonably certain that
Citalopram HBr therapy does not affect their ability to engage in such activities.
Use in Patients with Concomitant Illness
Clinical experience with Citalopram HBr in patients with certain concomitant systemic illnesses
is limited. Caution is advisable in using Citalopram HBr in patients with diseases or conditions
that produce altered metabolism or hemodynamic responses.
Citalopram HBr has not been systematically evaluated in patients with a recent history of
myocardial infarction or unstable heart disease. Patients with these diagnoses were generally
excluded from clinical studies during the product's premarketing testing. However, the
electrocardiograms of 1116 patients who received Citalopram HBr in clinical trials were
evaluated and the data indicate that Citalopram HBr is not associated with the development of
clinically significant ECG abnormalities.
In subjects with hepatic impairment, citalopram clearance was decreased and plasma
concentrations were increased. The use of Citalopram HBr in hepatically impaired patients
should be approached with caution and a lower maximum dosage is recommended (see
DOSAGE AND ADMINISTRATION).
Because citalopram is extensively metabolized, excretion of unchanged drug in urine is a minor
route of elimination. Until adequate numbers of patients with severe renal impairment have been
evaluated during chronic treatment with Citalopram HBr, however, it should be used with
caution in such patients (see DOSAGE AND ADMINISTRATION).
Information for Patients
Physicians are advised to discuss the following issues with patients for whom they prescribe
Citalopram HBr.
Patients should be cautioned about the risk of serotonin syndrome with the concomitant use of
Citalopram HBr and triptans, tramadol or other serotonergic agents.
Although in controlled studies Citalopram HBr has not been shown to impair psychomotor
performance, any psychoactive drug may impair judgment, thinking, or motor skills, so patients
should be cautioned about operating hazardous machinery, including automobiles, until they are
reasonably certain that Citalopram HBr therapy does not affect their ability to engage in such
activities.
Patients should be told that, although Citalopram HBr has not been shown in experiments with
normal subjects to increase the mental and motor skill impairments caused by alcohol, the
concomitant use of Citalopram HBr and alcohol in depressed patients is not advised.
Patients should be advised to inform their physician if they are taking, or plan to take, any
prescription or over-the-counter drugs, as there is a potential for interactions.
Patients should be cautioned about the concomitant use of Citalopram HBr and NSAIDs, aspirin,
warfarin, or other drugs that affect coagulation since combined use of psychotropic drugs that
interfere with serotonin reuptake and these agents has been associated with an increased risk of
bleeding.
Patients should be advised to notify their physician if they become pregnant or intend to become
pregnant during therapy.
Patients should be advised to notify their physician if they are breastfeeding an infant.
While patients may notice improvement with Citalopram HBr therapy in 1 to 4 weeks, they
should be advised to continue therapy as directed.
Prescribers or other health professionals should inform patients, their families, and their
caregivers about the benefits and risks associated with treatment with Citalopram HBr and
should counsel them in its appropriate use. A patient Medication Guide about "Antidepressant
Medicines, Depression and other Serious Mental Illness, and Suicidal Thoughts or Actions" is
available for Citalopram HBr. The prescriber or health professional should instruct patients, their
families, and their caregivers to read the Medication Guide and should assist them in understanding its contents. Patients should be given the opportunity to discuss the contents of the Medication Guide and to obtain answers to any questions they may have. The complete text of the Medication Guide is reprinted at the end of this document. Patients should be advised of the following issues and asked to alert their prescriber if these occur while taking Citalopram HBr. Clinical Worsening and Suicide Risk: Patients, their families, and their caregivers should be
encouraged to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability,
hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania,
other unusual changes in behavior, worsening of depression, and suicidal ideation, especially
early during antidepressant treatment and when the dose is adjusted up or down. Families and
caregivers of patients should be advised to look for the emergence of such symptoms on a day-
to-day basis, since changes may be abrupt. Such symptoms should be reported to the patient's
prescriber or health professional, especially if they are severe, abrupt in onset, or were not part of
the patient's presenting symptoms. Symptoms such as these may be associated with an increased
risk for suicidal thinking and behavior and indicate a need for very close monitoring and possibly
changes in the medication.
Laboratory Tests
There are no specific laboratory tests recommended.
Drug Interactions
Serotonergic Drugs: Based on the mechanism of action of SNRIs and SSRIs including
Citalopram HBr and the potential for serotonin syndrome, caution is advised when Citalopram
HBr is coadministered with other drugs that may affect the serotonergic neurotransmitter
systems, such as triptans, linezolid (an antibiotic which is a reversible non-selective MAOI),
lithium, tramadol, or St. John's Wort (see WARNINGS - Serotonin Syndrome). The
concomitant use of Citalopram HBr with other SSRIs, SNRIs or tryptophan is not
recommended (see PRECAUTIONS - Drug Interactions).
Triptans: There have been rare postmarketing reports of serotonin syndrome with use of an
SSRI and a triptan. If concomitant treatment of Citalopram HBr with a triptan is clinically
warranted, careful observation of the patient is advised, particularly during treatment initiation
and dose increases (see WARNINGS - Serotonin Syndrome).
CNS Drugs - Given the primary CNS effects of citalopram, caution should be used when it is
taken in combination with other centrally acting drugs.
Alcohol - Although citalopram did not potentiate the cognitive and motor effects of alcohol in a
clinical trial, as with other psychotropic medications, the use of alcohol by depressed patients
taking Citalopram HBr is not recommended.
Monoamine Oxidase Inhibitors (MAOIs) - See CONTRAINDICATIONS and WARNINGS.
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. Patients receiving warfarin therapy should be carefully monitored
when Citalopram HBr is initiated or discontinued.

Cimetidine - In subjects who had received 21 days of 40 mg/day Citalopram HBr, combined
administration of 400 mg/day cimetidine for 8 days resulted in an increase in citalopram AUC
and Cmax of 43% and 39%, respectively. The clinical significance of these findings is unknown.
Digoxin - In subjects who had received 21 days of 40 mg/day Citalopram HBr, combined
administration of Citalopram HBr and digoxin (single dose of 1 mg) did not significantly affect
the pharmacokinetics of either citalopram or digoxin.
Lithium - Coadministration of Citalopram HBr (40 mg/day for 10 days) and lithium (30
mmol/day for 5 days) had no significant effect on the pharmacokinetics of citalopram or lithium.
Nevertheless, plasma lithium levels should be monitored with appropriate adjustment to the
lithium dose in accordance with standard clinical practice. Because lithium may enhance the
serotonergic effects of citalopram, caution should be exercised when Citalopram HBr and
lithium are coadministered.
Pimozide - In a controlled study, a single dose of pimozide 2 mg co-administered with
citalopram 40 mg given once daily for 11 days was associated with a mean increase in QTc
values of approximately 10 msec compared to pimozide given alone. Citalopram did not alter the
mean AUC or Cmax of pimozide. The mechanism of this pharmacodynamic interaction is not
known. Theophylline - Combined administration of Citalopram HBr (40 mg/day for 21 days) and the CYP1A2 substrate theophylline (single dose of 300 mg) did not affect the pharmacokinetics of theophylline. The effect of theophylline on the pharmacokinetics of citalopram was not evaluated. Sumatriptan - There have been rare postmarketing reports describing patients with weakness, hyperreflexia, and incoordination following the use of an SSRI and sumatriptan. If concomitant treatment with sumatriptan and an SSRI (e.g., fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram) is clinically warranted, appropriate observation of the patient is advised. Warfarin - Administration of 40 mg/day Citalopram HBr for 21 days did not affect the pharmacokinetics of warfarin, a CYP3A4 substrate. Prothrombin time was increased by 5%, the clinical significance of which is unknown. Carbamazepine - Combined administration of Citalopram HBr (40 mg/day for 14 days) and carbamazepine (titrated to 400 mg/day for 35 days) did not significantly affect the pharmacokinetics of carbamazepine, a CYP3A4 substrate. Although trough citalopram plasma levels were unaffected, given the enzyme-inducing properties of carbamazepine, the possibility that carbamazepine might increase the clearance of citalopram should be considered if the two drugs are coadministered. Triazolam - Combined administration of Citalopram HBr (titrated to 40 mg/day for 28 days) and the CYP3A4 substrate triazolam (single dose of 0.25 mg) did not significantly affect the pharmacokinetics of either citalopram or triazolam. Ketoconazole - Combined administration of Citalopram HBr (40 mg) and ketoconazole (200 mg) decreased the Cmax and AUC of ketoconazole by 21% and 10%, respectively, and did not significantly affect the pharmacokinetics of citalopram. CYP3A4 and 2C19 Inhibitors - In vitro studies indicated that CYP3A4 and 2C19 are the primary enzymes involved in the metabolism of citalopram. However, coadministration of citalopram (40 mg) and ketoconazole (200 mg), a potent inhibitor of CYP3A4, did not significantly affect the pharmacokinetics of citalopram. Because citalopram is metabolized by multiple enzyme systems, inhibition of a single enzyme may not appreciably decrease citalopram clearance. Metoprolol - Administration of 40 mg/day Citalopram HBr for 22 days resulted in a two-fold
increase in the plasma levels of the beta-adrenergic blocker metoprolol. Increased metoprolol
plasma levels have been associated with decreased cardioselectivity. Coadministration of
Citalopram HBr and metoprolol had no clinically significant effects on blood pressure or heart
rate.
Imipramine and Other Tricyclic Antidepressants (TCAs) - In vitro studies suggest that
citalopram is a relatively weak inhibitor of CYP2D6. Coadministration of Citalopram HBr (40
mg/day for 10 days) with the TCA imipramine (single dose of 100 mg), a substrate for CYP2D6,
did not significantly affect the plasma concentrations of imipramine or citalopram. However, the
concentration of the imipramine metabolite desipramine was increased by approximately 50%.
The clinical significance of the desipramine change is unknown. Nevertheless, caution is
indicated in the coadministration of TCAs with Citalopram HBr.
Electroconvulsive Therapy (ECT) - There are no clinical studies of the combined use of
electroconvulsive therapy (ECT) and Citalopram HBr.
Carcinogenesis, Mutagenesis, Impairment of Fertility
Carcinogenesis
Citalopram was administered in the diet to NMRI/BOM strain mice and COBS WI strain rats for
18 and 24 months, respectively. There was no evidence for carcinogenicity of citalopram in mice
receiving up to 240 mg/kg/day, which is equivalent to 20 times the maximum recommended
human daily dose (MRHD) of 60 mg on a surface area (mg/m2) basis. There was an increased
incidence of small intestine carcinoma in rats receiving 8 or 24 mg/kg/day, doses which are
approximately 1.3 and 4 times the MRHD, respectively, on a mg/m2 basis. A no-effect dose for
this finding was not established. The relevance of these findings to humans is unknown.
Mutagenesis
Citalopram was mutagenic in the in vitro bacterial reverse mutation assay (Ames test) in 2 of 5
bacterial strains (Salmonella TA98 and TA1537) in the absence of metabolic activation. It was
clastogenic in the in vitro Chinese hamster lung cell assay for chromosomal aberrations in the
presence and absence of metabolic activation. Citalopram was not mutagenic in the in vitro
mammalian forward gene mutation assay (HPRT) in mouse lymphoma cells or in a coupled in
vitro/in vivo unscheduled DNA synthesis (UDS) assay in rat liver. It was not clastogenic in the in
vitro chromosomal aberration assay in human lymphocytes or in two in vivo mouse micronucleus assays. Impairment of Fertility
When citalopram was administered orally to 16 male and 24 female rats prior to and throughout
mating and gestation at doses of 32, 48, and 72 mg/kg/day, mating was decreased at all doses,
and fertility was decreased at doses ≥ 32 mg/kg/day, approximately 5 times the MRHD of 60
mg/day on a body surface area (mg/m2) basis. Gestation duration was increased at 48 mg/kg/day,
approximately 8 times the MRHD.
Pregnancy
Pregnancy Category C
In animal reproduction studies, citalopram has been shown to have adverse effects on
embryo/fetal and postnatal development, including teratogenic effects, when administered at
doses greater than human therapeutic doses.
In two rat embryo/fetal development studies, oral administration of citalopram (32, 56, or 112
mg/kg/day) to pregnant animals during the period of organogenesis resulted in decreased
embryo/fetal growth and survival and an increased incidence of fetal abnormalities (including
cardiovascular and skeletal defects) at the high dose, which is approximately 18 times the
MRHD of 60 mg/day on a body surface area (mg/m2) basis. This dose was also associated with
maternal toxicity (clinical signs, decreased body weight gain). The developmental, no-effect dose
of 56 mg/kg/day is approximately 9 times the MRHD on a mg/m2 basis. In a rabbit study, no
adverse effects on embryo/fetal development were observed at doses of up to 16 mg/kg/day, or
approximately 5 times the MRHD on a mg/m2 basis. Thus, teratogenic effects were observed at a
maternally toxic dose in the rat and were not observed in the rabbit.
When female rats were treated with citalopram (4.8, 12.8, or 32 mg/kg/day) from late gestation
through weaning, increased offspring mortality during the first 4 days after birth and persistent
offspring growth retardation were observed at the highest dose, which is approximately 5 times
the MRHD on a mg/m2 basis. The no-effect dose of 12.8 mg/kg/day is approximately 2 times the
MRHD on a mg/m2 basis. Similar effects on offspring mortality and growth were seen when
dams were treated throughout gestation and early lactation at doses ≥ 24 mg/kg/day,
approximately 4 times the MRHD on a mg/m2 basis. A no-effect dose was not determined in that
study.
There are no adequate and well-controlled studies in pregnant women; therefore, citalopram
should be used during pregnancy only if the potential benefit justifies the potential risk to the
fetus.
Pregnancy-Nonteratogenic Effects
Neonates exposed to Citalopram HBr and other SSRIs or SNRIs, late in the third trimester, have
developed complications requiring prolonged hospitalization, respiratory support, and tube
feeding. Such complications can arise immediately upon delivery. Reported clinical findings
have included respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding
difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness,
irritability, and constant crying. These features are consistent with either a direct toxic effect of
SSRIs and SNRIs or, possibly, a drug discontinuation syndrome. It should be noted that, in some
cases, the clinical picture is consistent with serotonin syndrome (see WARNINGS).
Infants exposed to SSRIs in late pregnancy may have an increased risk for persistent pulmonary
hypertension of the newborn (PPHN). PPHN occurs in 1—2 per 1000 live births in the general
population and is associated with substantial neonatal morbidity and mortality. In a retrospective,
case-control study of 377 women whose infants were born with PPHN and 836 women whose
infants were born healthy, the risk for developing PPHN was approximately six-fold higher for
infants exposed to SSRIs after the 20th week of gestation compared to infants who had not been
exposed to antidepressants during pregnancy. There is currently no corroborative evidence
regarding the risk for PPHN following exposure to SSRIs in pregnancy; this is the first study that
has investigated the potential risk. The study did not include enough cases with exposure to
individual SSRIs to determine if all SSRIs posed similar levels of PPHN risk.
When treating a pregnant woman with Citalopram HBr during the third trimester, the physician
should carefully consider both the potential risks and benefits of treatment (see DOSAGE AND
ADMINISTRATION). Physicians should note that in a prospective longitudinal study of 201
women with a history of major depression who were euthymic at the beginning of pregnancy,
women who discontinued antidepressant medication during pregnancy were more likely to
experience a relapse of major depression than women who continued antidepressant medication.
Labor and Delivery
The effect of Citalopram HBr on labor and delivery in humans is unknown.
Nursing Mothers
As has been found to occur with many other drugs, citalopram is excreted in human breast milk.
There have been two reports of infants experiencing excessive somnolence, decreased feeding,
and weight loss in association with breastfeeding from a citalopram-treated mother; in one case,
the infant was reported to recover completely upon discontinuation of citalopram by its mother
and in the second case, no follow-up information was available. The decision whether to
continue or discontinue either nursing or Citalopram HBr therapy should take into account the risks of citalopram exposure for the infant and the benefits of Citalopram HBr treatment for the mother. Pediatric Use
Safety and effectiveness in the pediatric population have not been established (see BOX
WARNING and WARNINGS—Clinical Worsening and Suicide Risk). Two placebo-
controlled trials in 407 pediatric patients with MDD have been conducted with Citalopram HBr,
and the data were not sufficient to support a claim for use in pediatric patients. Anyone
considering the use of Citalopram HBr in a child or adolescent must balance the potential risks
with the clinical need.
Geriatric Use
Of 4422 patients in clinical studies of Citalopram HBr, 1357 were 60 and over, 1034 were 65
and over, and 457 were 75 and over. No overall differences in safety or effectiveness were
observed between these subjects and younger subjects, and other reported clinical experience has
not identified differences in responses between the elderly and younger patients, but greater
sensitivity of some older individuals cannot be ruled out. Most elderly patients treated with
Citalopram HBr in clinical trials received daily doses between 20 and 40 mg (see DOSAGE
AND ADMINISTRATION).
SSRIs and SNRIs, including Citalopram HBr, have been associated with cases of clinically
significant hyponatremia in elderly patients, who may be at greater risk for this adverse event
(see PRECAUTIONS, Hyponatremia).
In two pharmacokinetic studies, citalopram AUC was increased by 23% and 30%, respectively,
in elderly subjects as compared to younger subjects, and its half-life was increased by 30% and
50%, respectively (see CLINICAL PHARMACOLOGY).
20 mg/day is the recommended dose for most elderly patients (see DOSAGE AND
ADMINISTRATION).
ADVERSE REACTIONS
The premarketing development program for Citalopram HBr included citalopram exposures in
patients and/or normal subjects from 3 different groups of studies: 429 normal subjects in clinical
pharmacology/pharmacokinetic studies; 4422 exposures from patients in controlled and
uncontrolled clinical trials, corresponding to approximately 1370 patient-exposure years. There
were, in addition, over 19,000 exposures from mostly open-label, European postmarketing
studies. The conditions and duration of treatment with Citalopram HBr varied greatly and
included (in overlapping categories) open-label and double-blind studies, inpatient and outpatient
studies, fixed-dose and dose-titration studies, and short-term and long-term exposure. Adverse
reactions were assessed by collecting adverse events, results of physical examinations, vital
signs, weights, laboratory analyses, ECGs, and results of ophthalmologic examinations.
Adverse events during exposure were obtained primarily by general inquiry and recorded by
clinical investigators using terminology of their own choosing. Consequently, it is not possible to
provide a meaningful estimate of the proportion of individuals experiencing adverse events
without first grouping similar types of events into a smaller number of standardized event
categories. In the tables and tabulations that follow, standard World Health Organization (WHO)
terminology has been used to classify reported adverse events.
The stated frequencies of adverse events represent the proportion of individuals who
experienced, at least once, a treatment-emergent adverse event of the type listed. An event was
considered treatment-emergent if it occurred for the first time or worsened while receiving
therapy following baseline evaluation.
Adverse Findings Observed in Short-Term, Placebo-Controlled Trials
Adverse Events Associated with Discontinuation of Treatment
Among 1063 depressed patients who received Citalopram HBr at doses ranging from 10 to 80
mg/day in placebo-controlled trials of up to 6 weeks in duration, 16% discontinued treatment due
to an adverse event, as compared to 8% of 446 patients receiving placebo. The adverse events
associated with discontinuation and considered drug-related (i.e., associated with discontinuation
in at least 1% of Citalopram HBr-treated patients at a rate at least twice that of placebo) are
shown in TABLE 2. It should be noted that one patient can report more than one reason for
discontinuation and be counted more than once in this table.
Adverse Events Associated with Discontinuation of Treatment in
Short- Term, Placebo-Controlled, Depression Trials
Percentage of Patients Discontinuing
Due to Adverse Event
Citalopram
Body System/Adverse Event
Gastrointestinal Disorders
Central and Peripheral Nervous System Disorders
Dizziness 2%
Psychiatric Disorders

Adverse Events Occurring at an Incidence of 2% or More Among Citalopram HBr-Treated
Patients
Table 3 enumerates the incidence, rounded to the nearest percent, of treatment-emergent adverse
events that occurred among 1063 depressed patients who received Citalopram HBr at doses
ranging from 10 to 80 mg/day in placebo-controlled trials of up to 6 weeks in duration. Events
included are those occurring in 2% or more of patients treated with Citalopram HBr and for
which the incidence in patients treated with Citalopram HBr was greater than the incidence in
placebo-treated patients.
The prescriber should be aware that these figures cannot be used to predict the incidence of
adverse events in the course of usual medical practice where patient characteristics and other
factors differ from those which prevailed in the clinical trials. Similarly, the cited frequencies
cannot be compared with figures obtained from other clinical investigations involving different
treatments, uses, and investigators. The cited figures, however, do provide the prescribing
physician with some basis for estimating the relative contribution of drug and non-drug factors to
the adverse event incidence rate in the population studied.
The only commonly observed adverse event that occurred in Citalopram HBr patients with an
incidence of 5% or greater and at least twice the incidence in placebo patients was ejaculation
disorder (primarily ejaculatory delay) in male patients (see TABLE 3).
Treatment-Emergent Adverse Events:
Incidence in Placebo-Controlled Clinical Trials*
(Percentage of Patients Reporting Event)

Body System/Adverse Event
Citalopram HBr Placebo
(N=1063)
Autonomic Nervous System Disorders
Dry Mouth
Sweating Increased Central & Peripheral Nervous System Disorders
Tremor
Gastrointestinal Disorders
Nausea
General
Fatigue
Musculoskeletal System Disorders
Arthralgia 2%
Psychiatric Disorders
Somnolence
Dysmenorrhea1 3% Libido Decreased Respiratory System Disorders
Upper Respiratory Tract Infection
Urogenital
Ejaculation Disorder2,3 6%
*Events reported by at least 2% of patients treated with Citalopram HBr are reported, except for the following events which had an incidence on placebo ≥ Citalopram HBr: headache, asthenia, dizziness, constipation, palpitation, vision abnormal, sleep disorder, nervousness, pharyngitis, micturition disorder, back pain. 1Denominator used was for females only (N=638 Citalopram HBr; N=252 placebo). 2Primarily ejaculatory delay. 3Denominator used was for males only (N=425 Citalopram HBr; N=194 placebo). Dose Dependency of Adverse Events The potential relationship between the dose of Citalopram HBr administered and the incidence of adverse events was examined in a fixed-dose study in depressed patients receiving placebo or Citalopram HBr 10, 20, 40, and 60 mg. Jonckheere's trend test revealed a positive dose response (p<0.05) for the following adverse events: fatigue, impotence, insomnia, sweating increased, somnolence, and yawning. Male and Female Sexual Dysfunction with SSRIs Although changes in sexual desire, sexual performance, and sexual satisfaction often occur as manifestations of a psychiatric disorder, they may also be a consequence of pharmacologic treatment. In particular, some evidence suggests that SSRIs can cause such untoward sexual experiences. Reliable estimates of the incidence and severity of untoward experiences involving sexual desire, performance, and satisfaction are difficult to obtain, however, in part because patients and physicians may be reluctant to discuss them. Accordingly, estimates of the incidence of untoward sexual experience and performance cited in product labeling, are likely to underestimate their actual incidence. The table below displays the incidence of sexual side effects reported by at least 2% of patients taking Citalopram HBr in a pool of placebo-controlled clinical trials in patients with depression. Treatment Citalopram Abnormal Ejaculation (mostly ejaculatory delay) Libido Decreased In female depressed patients receiving Citalopram HBr, the reported incidence of decreased libido and anorgasmia was 1.3% (n=638 females) and 1.1% (n=252 females), respectively. There are no adequately designed studies examining sexual dysfunction with citalopram treatment. Priapism has been reported with all SSRIs. While it is difficult to know the precise risk of sexual dysfunction associated with the use of SSRIs, physicians should routinely inquire about such possible side effects. Vital Sign Changes Citalopram HBr and placebo groups were compared with respect to (1) mean change from baseline in vital signs (pulse, systolic blood pressure, and diastolic blood pressure) and (2) the incidence of patients meeting criteria for potentially clinically significant changes from baseline in these variables. These analyses did not reveal any clinically important changes in vital signs associated with Citalopram HBr treatment. In addition, a comparison of supine and standing vital sign measures for Citalopram HBr and placebo treatments indicated that Citalopram HBr treatment is not associated with orthostatic changes. Weight Changes Patients treated with Citalopram HBr in controlled trials experienced a weight loss of about 0.5 kg compared to no change for placebo patients.
Laboratory Changes
Citalopram HBr and placebo groups were compared with respect to (1) mean change from
baseline in various serum chemistry, hematology, and urinalysis variables, and (2) the incidence
of patients meeting criteria for potentially clinically significant changes from baseline in these
variables. These analyses revealed no clinically important changes in laboratory test parameters
associated with Citalopram HBr treatment.
ECG Changes
Electrocardiograms from Citalopram HBr (N=802) and placebo (N=241) groups were compared
with respect to (1) mean change from baseline in various ECG parameters, and (2) the incidence
of patients meeting criteria for potentially clinically significant changes from baseline in these
variables. The only statistically significant drug-placebo difference observed was a decrease in
heart rate for Citalopram HBr of 1.7 bpm compared to no change in heart rate for placebo. There
were no observed differences in QT or other ECG intervals.
Other Events Observed During the Premarketing Evaluation of Citalopram HBr
Following is a list of WHO terms that reflect treatment-emergent adverse events, as defined in
the introduction to the ADVERSE REACTIONS section, reported by patients treated with
Citalopram HBr at multiple doses in a range of 10 to 80 mg/day during any phase of a trial
within the premarketing database of 4422 patients. All reported events are included except those
already listed in Table 3 or elsewhere in labeling, those events for which a drug cause was
remote, those event terms which were so general as to be uninformative, and those occurring in
only one patient. It is important to emphasize that, although the events reported occurred during
treatment with Citalopram HBr, they were not necessarily caused by it.
Events are further categorized by body system and listed in order of decreasing frequency
according to the following definitions: frequent adverse events are those occurring on one or
more occasions in at least 1/100 patients; infrequent adverse events are those occurring in less
than 1/100 patients but at least 1/1000 patients; rare events are those occurring in fewer than
1/1000 patients.
Cardiovascular - Frequent: tachycardia, postural hypotension, hypotension. Infrequent:
hypertension, bradycardia, edema (extremities), angina pectoris, extrasystoles, cardiac failure,
flushing, myocardial infarction, cerebrovascular accident, myocardial ischemia. Rare: transient
ischemic attack, phlebitis, atrial fibrillation, cardiac arrest, bundle branch block.

Central and Peripheral Nervous System Disorders - Frequent: paresthesia, migraine.
Infrequent: hyperkinesia, vertigo, hypertonia, extrapyramidal disorder, leg cramps, involuntary
muscle contractions, hypokinesia, neuralgia, dystonia, abnormal gait, hypesthesia, ataxia. Rare:
abnormal coordination, hyperesthesia, ptosis, stupor.
Endocrine Disorders - Rare: hypothyroidism, goiter, gynecomastia.
Gastrointestinal Disorders - Frequent: saliva increased, flatulence. Infrequent: gastritis,
gastroenteritis, stomatitis, eructation, hemorrhoids, dysphagia, teeth grinding, gingivitis,
esophagitis. Rare: colitis, gastric ulcer, cholecystitis, cholelithiasis, duodenal ulcer,
gastroesophageal reflux, glossitis, jaundice, diverticulitis, rectal hemorrhage, hiccups.
General - Infrequent: hot flushes, rigors, alcohol intolerance, syncope, influenza-like symptoms.
Rare: hayfever. Hemic and Lymphatic Disorders - Infrequent: purpura, anemia, epistaxis, leukocytosis,
leucopenia, lymphadenopathy. Rare: pulmonary embolism, granulocytopenia, lymphocytosis,
lymphopenia, hypochromic anemia, coagulation disorder, gingival bleeding.
Metabolic and Nutritional Disorders - Frequent: decreased weight, increased weight.
Infrequent: increased hepatic enzymes, thirst, dry eyes, increased alkaline phosphatase, abnormal
glucose tolerance. Rare: bilirubinemia, hypokalemia, obesity, hypoglycemia, hepatitis,
dehydration.
Musculoskeletal System Disorders - Infrequent: arthritis, muscle weakness, skeletal pain.
Rare: bursitis, osteoporosis.
Psychiatric Disorders - Frequent: impaired concentration, amnesia, apathy, depression,
increased appetite, aggravated depression, suicide attempt, confusion. Infrequent: increased
libido, aggressive reaction, paroniria, drug dependence, depersonalization, hallucination,
euphoria, psychotic depression, delusion, paranoid reaction, emotional lability, panic reaction,
psychosis. Rare: catatonic reaction, melancholia.
Reproductive Disorders/Female* - Frequent: amenorrhea. Infrequent: galactorrhea, breast
pain, breast enlargement, vaginal hemorrhage.
*% based on female subjects only: 2955
Respiratory System Disorders - Frequent: coughing. Infrequent: bronchitis, dyspnea,
pneumonia. Rare: asthma, laryngitis, bronchospasm, pneumonitis, sputum increased.
Skin and Appendages Disorders - Frequent: rash, pruritus. Infrequent: photosensitivity
reaction, urticaria, acne, skin discoloration, eczema, alopecia, dermatitis, skin dry, psoriasis.
Rare: hypertrichosis, decreased sweating, melanosis, keratitis, cellulitis, pruritus ani.
Special Senses - Frequent: accommodation abnormal, taste perversion. Infrequent: tinnitus,
conjunctivitis, eye pain. Rare: mydriasis, photophobia, diplopia, abnormal lacrimation, cataract,
taste loss.
Urinary System Disorders - Frequent: polyuria. Infrequent: micturition frequency, urinary
incontinence, urinary retention, dysuria. Rare: facial edema, hematuria, oliguria, pyelonephritis,
renal calculus, renal pain.
Other Events Observed During the Postmarketing Evaluation of Citalopram HBr
It is estimated that over 30 million patients have been treated with Citalopram HBr since market
introduction. Although no causal relationship to Citalopram HBr treatment has been found, the
following adverse events have been reported to be temporally associated with Citalopram HBr
treatment, and have not been described elsewhere in labeling: acute renal failure, akathisia,
allergic reaction, anaphylaxis, angioedema, choreoathetosis, chest pain, delirium, dyskinesia,
ecchymosis, epidermal necrolysis, erythema multiforme, gastrointestinal hemorrhage, glaucoma,
grand mal convulsions, hemolytic anemia, hepatic necrosis, myoclonus, nystagmus, pancreatitis,
photosensitivity reaction, priapism, prolactinemia, prothrombin decreased, QT prolonged,
rhabdomyolysis, spontaneous abortion, thrombocytopenia, thrombosis, ventricular arrhythmia,
torsade de pointes, and withdrawal syndrome.
DRUG ABUSE AND DEPENDENCE
Controlled Substance Class
Citalopram HBr is not a controlled substance.
Physical and Psychological Dependence
Animal studies suggest that the abuse liability of Citalopram HBr is low. Citalopram HBr has not
been systematically studied in humans for its potential for abuse, tolerance, or physical
dependence. The premarketing clinical experience with Citalopram HBr did not reveal any drug-
seeking behavior. However, these observations were not systematic and it is not possible to
predict, on the basis of this limited experience, the extent to which a CNS-active drug will be
misused, diverted, and/or abused once marketed. Consequently, physicians should carefully
evaluate Citalopram HBr patients for history of drug abuse and follow such patients closely,
observing them for signs of misuse or abuse (e.g., development of tolerance, incrementations of
dose, drug-seeking behavior).
OVERDOSAGE
Human Experience
In clinical trials of Citalopram HBr, there were reports of citalopram overdose, including
overdoses of up to 2000mg, with no associated fatalities. During the postmarketing evaluation of
Citalopram HBr, citalopram overdoses, including overdoses of up to 6000 mg, have been
reported. As with other SSRIs, a fatal outcome in a patient who has taken an overdose of
citalopram has been rarely reported.
Symptoms most often accompanying Citalopram HBr overdose, alone or in combination with
other drugs and/or alcohol, included dizziness, sweating, nausea, vomiting, tremor, somnolence,
and sinus tachycardia. In more rare cases, observed symptoms included amnesia, confusion,
coma, convulsions, hyperventilation, cyanosis, rhabdomyolysis, and ECG changes (including
QTc prolongation, nodal rhythm, ventricular arrhythmia, and very rare cases of torsade de
pointes). Acute renal failure has been very rarely reported accompanying overdose.
Management of Overdose
Establish and maintain an airway to ensure adequate ventilation and oxygenation. Gastric
evacuation by lavage and use of activated charcoal should be considered. Careful observation
and cardiac and vital sign monitoring are recommended, along with general symptomatic and
supportive care. Due to the large volume of distribution of citalopram, forced diuresis, dialysis,
hemoperfusion, and exchange transfusion are unlikely to be of benefit. There are no specific
antidotes for Citalopram HBr.
In managing overdosage, consider the possibility of multiple-drug involvement. The physician
should consider contacting a poison control center for additional information on the treatment of
any overdose.
DOSAGE AND ADMINISTRATION
Initial Treatment
Citalopram HBr should be administered at an initial dose of 20 mg once daily, generally with an
increase to a dose of 40 mg/day. Dose increases should usually occur in increments of 20 mg at
intervals of no less than one week. Although certain patients may require a dose of 60 mg/day,
the only study pertinent to dose response for effectiveness did not demonstrate an advantage for
the 60 mg/day dose over the 40 mg/day dose; doses above 40 mg are therefore not ordinarily
recommended.
Citalopram HBr should be administered once daily, in the morning or evening, with or without
food.
Special Populations
20 mg/day is the recommended dose for most elderly patients and patients with hepatic
impairment, with titration to 40 mg/day only for nonresponding patients.
No dosage adjustment is necessary for patients with mild or moderate renal impairment.
Citalopram HBr should be used with caution in patients with severe renal impairment.
Treatment of Pregnant Women During the Third Trimester
Neonates exposed to Citalopram HBr and other SSRIs or SNRIs, late in the third trimester, have
developed complications requiring prolonged hospitalization, respiratory support, and tube
feeding (see PRECAUTIONS). When treating pregnant women with Citalopram HBr during the
third trimester, the physician should carefully consider the potential risks and benefits of
treatment. The physician may consider tapering Citalopram HBr in the third trimester.
Maintenance Treatment
It is generally agreed that acute episodes of depression require several months or longer of
sustained pharmacologic therapy. Systematic evaluation of Citalopram HBr in two studies has
shown that its antidepressant efficacy is maintained for periods of up to 24 weeks following 6 or
8 weeks of initial treatment (32 weeks total). In one study, patients were assigned randomly to
placebo or to the same dose of Citalopram HBr (20-60 mg/day) during maintenance treatment as
they had received during the acute stabilization phase, while in the other study, patients were
assigned randomly to continuation of Citalopram HBr 20 or 40 mg/day, or placebo, for
maintenance treatment. In the latter study, the rates of relapse to depression were similar for the
two dose groups (see Clinical Trials under CLINICAL PHARMACOLOGY). Based on these
limited data, it is not known whether the dose of citalopram needed to maintain euthymia is
identical to the dose needed to induce remission. If adverse reactions are bothersome, a decrease
in dose to 20 mg/day can be considered.
Discontinuation of Treatment with Citalopram HBr
Symptoms associated with discontinuation of Citalopram HBr and other SSRIs and SNRIs have
been reported (see PRECAUTIONS). Patients should be monitored for these symptoms when
discontinuing treatment. A gradual reduction in the dose rather than abrupt cessation is
recommended whenever possible. If intolerable symptoms occur following a decrease in the dose
or upon discontinuation of treatment, then resuming the previously prescribed dose may be
considered. Subsequently, the physician may continue decreasing the dose but at a more gradual
rate.
Switching Patients To or From a Monoamine Oxidase Inhibitor
At least 14 days should elapse between discontinuation of an MAOI and initiation of Citalopram
HBr therapy. Similarly, at least 14 days should be allowed after stopping Citalopram HBr before
starting an MAOI (see CONTRAINDICATIONS and WARNINGS).
HOW SUPPLIED
Tablets:
10 mg
NDC # 0258-3695-01 NDC # 0258-3695-05 Beige, oval, film-coated. Imprint on one side with "IL". Imprint on the other side with "10 mg". 20 mg NDC # 0258-3696-01 NDC # 0258-3696-10 Pink, oval, scored, film-coated. Imprint on scored side with "I" on the left side and "L" on the right side. Imprint on the non-scored side with "20 mg". 40 mg NDC # 0258-3697-01 NDC # 0258-3697-10 White, oval, scored, film-coated.
Imprint on scored side with "I" on the left side and "L" on the right side.
Imprint on the non-scored side with "40 mg".

Store at 25°C (77°F); excursions permitted to 15 - 30°C (59-86°F).
ANIMAL TOXICOLOGY
Retinal Changes in Rats
Pathologic changes (degeneration/atrophy) were observed in the retinas of albino rats in the 2-
year carcinogenicity study with citalopram. There was an increase in both incidence and severity
of retinal pathology in both male and female rats receiving 80 mg/kg/day (13 times the
maximum recommended daily human dose of 60 mg on a mg/m2 basis). Similar findings were
not present in rats receiving 24 mg/kg/day for two years, in mice treated for 18 months at doses
up to 240 mg/kg/day, or in dogs treated for one year at doses up to 20 mg/kg/day (4, 20, and 10
times, respectively, the maximum recommended daily human dose on a mg/m2 basis).
Additional studies to investigate the mechanism for this pathology have not been performed, and
the potential significance of this effect in humans has not been established.
Cardiovascular Changes in Dogs
In a one-year toxicology study, 5 of 10 beagle dogs receiving oral doses of 8 mg/kg/day (4 times
the maximum recommended daily human dose of 60 mg on a mg/m2 basis) died suddenly
between weeks 17 and 31 following initiation of treatment. Although appropriate data from that
study are not available to directly compare plasma levels of citalopram (CT) and its metabolites,
demethylcitalopram (DCT) and didemethylcitalopram (DDCT), to levels that have been achieved
in humans, pharmacokinetic data indicate that the relative dog-to-human exposure was greater
for the metabolites than for citalopram. Sudden deaths were not observed in rats at doses up to
120 mg/kg/day, which produced plasma levels of CT, DCT, and DDCT similar to those observed
in dogs at doses of 8 mg/kg/day. A subsequent intravenous dosing study demonstrated that in
beagle dogs, DDCT caused QT prolongation, a known risk factor for the observed outcome in
dogs. This effect occurred in dogs at doses producing peak DDCT plasma levels of 810 to 3250
nM (39-155 times the mean steady state DDCT plasma level measured at the maximum
recommended human daily dose of 60 mg). In dogs, peak DDCT plasma concentrations are
approximately equal to peak CT plasma concentrations, whereas in humans, steady state DDCT
plasma concentrations are less than 10% of steady state CT plasma concentrations. Assays of
DDCT plasma concentrations in 2020 citalopram-treated individuals demonstrated that DDCT
levels rarely exceeded 70 nM; the highest measured level of DDCT in human overdose was 138
nM. While DDCT is ordinarily present in humans at lower levels than in dogs, it is unknown
whether there are individuals who may achieve higher DDCT levels. The possibility that DCT, a
principal metabolite in humans, which may prolong the QT interval in dogs has not been directly
examined because DCT is rapidly converted to DDCT in that species.
Inwood Laboratories, Inc.
Subsidiary of Forest Laboratories, Inc.
Commack, NY 11725
Licensed from H. Lundbeck A/S Rev. 01/09 2009 Forest Laboratories, Inc. Medication Guide
Antidepressant Medicines, Depression and other Serious Mental Illnesses,
and Suicidal Thoughts or Actions

Read the Medication Guide that comes with you or your family member's antidepressant
medicine. This Medication Guide is only about the risk of suicidal thoughts and actions with
antidepressant medicines. Talk to your, or your family member's, healthcare provider
about:

• all risks and benefits of treatment with antidepressant medicines
• all treatment choices for depression or other serious mental illness
What is the most important information I should know about antidepressant medicines,
depression and other serious mental illnesses, and suicidal thoughts or actions?

1. Antidepressant medicines may increase suicidal thoughts or actions in some children,
teenagers, and young adults within the first few months of treatment.
2. Depression and other serious mental illnesses are the most important causes of suicidal
thoughts and actions. Some people may have a particularly high risk of having suicidal
thoughts or actions. These include people who have (or have a family history of) bipolar
illness (also called manic-depressive illness) or suicidal thoughts or actions.
3. How can I watch for and try to prevent suicidal thoughts and actions in myself or a
family member?
• Pay close attention to any changes, especially sudden changes, in mood, behaviors,
thoughts, or feelings. This is very important when an antidepressant medicine is started or when the dose is changed. • Call the healthcare provider right away to report new or sudden changes in mood, behavior, thoughts, or feelings. • Keep all follow-up visits with the healthcare provider as scheduled. Call the healthcare provider between visits as needed, especially if you have concerns about symptoms. Call a healthcare provider right away if you or your family member has any of the
following symptoms, especially if they are new, worse, or worry you:
• thoughts about suicide or dying • attempts to commit suicide • new or worse depression • new or worse anxiety • feeling very agitated or restless • panic attacks • trouble sleeping (insomnia) • new or worse irritability • acting aggressive, being angry, or violent • acting on dangerous impulses • an extreme increase in activity and talking (mania) • other unusual changes in behavior or mood Call your doctor for medical advice about side effects. You may report side effects to FDA
at 1-800-FDA-1088
What else do I need to know about antidepressant medicines?

• Never stop an antidepressant medicine without first talking to a healthcare provider.
Stopping an antidepressant medicine suddenly can cause other symptoms. • Antidepressants are medicines used to treat depression and other illnesses. It is
important to discuss all the risks of treating depression and also the risks of not treating it. Patients and their families or other caregivers should discuss all treatment choices with the healthcare provider, not just the use of antidepressants. • Antidepressant medicines have other side effects. Talk to the healthcare provider about the
side effects of the medicine prescribed for you or your family member. • Antidepressant medicines can interact with other medicines. Know all of the medicines
that you or your family member takes. Keep a list of all medicines to show the healthcare provider. Do not start new medicines without first checking with your healthcare provider. • Not all antidepressant medicines prescribed for children are FDA approved for use in
children. Talk to your child's healthcare provider for more information.
This Medication Guide has been approved by the U.S. Food and Drug Administration for all antidepressants. Rev. 01/09

Source: http://citalopram.ru/Citalopram_pi.pdf