The Hospice Clinician Blog

Based on post-marketing surveillance and a recently conducted QT study, the FDA has determined that the antidepressant citalopram (Celexa) should no longer be used at doses greater than 40 mg per day because it causes dose-dependent prolongation of the cardiac QT interval. Previously, the citalopram drug label stated that certain patients may require a dose of 60 mg per day, even though studies did not show a benefit in the treatment of depression at doses higher than 40 mg per day. 

Many hospice patients are at greater risk of developing QT prolongation, including:

• Patients with heart disease such as congestive heart failure or bradyarrhythmias.

• Patients predisposed to hypokalemia or hypomagnesemia because of concomitant illness or drugs (e.g., diuretics). Electrolyte imbalances should be corrected before administering citalopram and should be monitored as clinically indicated.

• Patients taking other medications that prolong the QT interval (including methadone, some antipsychotics, some quinolone antibiotics and amiodarone).

For these patients, citalopram should be used with caution. Consider limiting the dose to 20 mg per day or more frequent EKG monitoring.

Furthermore, 20 mg per day is the maximum recommended dose for patients with hepatic impairment, who are greater than 60 years of age, or who are taking concomitant cimetidine (Tagamet), because these factors lead to increased blood levels of citalopram. Citalopram should not be used at all in patients with congenital long QT syndrome.

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