• Home
  • Store
    • Newsletter Subscriptions
    • Multimedia Subscriptions
    • Books
    • eBooks
    • ABPN SA Courses
  • CME Center
  • Multimedia
    • Podcast
    • Webinars
    • Blog
  • Newsletters
    • General Psychiatry
    • Child Psychiatry
    • Addiction Treatment
    • Hospital Psychiatry
    • Geriatric Psychiatry
  • Log In
  • Register
  • Welcome
  • Sign Out
  • Subscribe
Home » Uncommon Tips: Which Is Better—Citalopram or Escitalopram?

Uncommon Tips: Which Is Better—Citalopram or Escitalopram?

citalopram
June 1, 2022
Chris ­Aiken, MD.
From The Carlat Psychiatry Report
Issue Links: Learning Objectives | Editorial Information | PDF of Issue

Chris Aiken, MD. Editor-in-Chief, The Carlat Psychiatry Report. Dr. Aiken has disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Editor’s note: We’re pleased to introduce the new feature “Uncommon Tips.” In this series, Dr. Aiken will discuss little-known pearls about commonly used medications. The series starts with a comparison of citalopram and escitalopram.

The rivalry between these two SSRIs began in 2002 when the Lundbeck pharmaceutical company split citalopram (Celexa) into its two mirror-image enantiomers, releasing the active enantiomer (escitalopram) as Lexapro and leaving behind the inactive one (R-citalopram). With Celexa’s patent about to expire and Lexapro’s extended for another decade, Lundbeck scurried to convince doctors that escitalopram was the better choice.

Lundbeck argued that R-citalopram was not a neutral bystander but actually interfered with escitalopram’s ability to raise serotonin by blocking it at the serotonin transporter. The evidence came from animal studies, but it seemed confirmed by a series of head-to-head clinical trials showing slightly higher efficacy and faster onset with escitalopram than citalopram in major depression and panic disorder (Sánchez C et al, Psychopharmacology (Berl) 2004;174(2):163–176).

How well has that claim held up? Marginally. Although most of the 10 trials comparing the two SSRIs favor escitalopram, the difference is slight. When narrowed down to equidose comparisons (eg, citalopram 40 mg vs escitalopram 20 mg), only 5%–10% of patients have a meaningful response on escitalopram that they wouldn’t have experienced on citalopram (Trkulja V, Croat Med J 2010;51(1):61–73).

Instead, a different reason to prefer escitalopram has arisen from the FDA, which placed a warning about QTc prolongation on citalopram in 2011. This risk is dose dependent, so the FDA capped citalopram’s dose at 40 mg/day, or 20 mg/day in patients who are (1) over age 60; (2) poor metabolizers at the CYP2C19 enzyme that clears citalopram; or (3) taking strong CYP2C19 inhibitors like omeprazole or cimetidine.

However, the FDA’s dosing guidelines can have unintended consequences. When the VA attempted to lower citalopram into the acceptable range for 35,848 veterans, they saw a sharp increase in all-cause hospitalizations and deaths without any decline in arrhythmias (Rector TS et al, Am J Psychiatry 2016;173(9):896–902). What, then, is an FDA-abiding clinician to do?

One approach is to switch to escitalopram, which is free of this FDA warning because it only causes about half as much QTc prolongation as citalopram at equivalent doses (citalopram 60 mg = 18.5 ms; escitalopram 30 mg = 10.7 ms). Even though actual cardiac problems are very rare on either drug, there is evidence that this difference in QTc interval has a real-world effect on cardiac outcomes. Two studies that examined large, diverse populations found higher rates of cardiac arrest and serious arrhythmias with citalopram than escitalopram (Qirjazi E et al, PLoS One 2016;11(8):e0160768; Weeke P et al, Clin Pharmacol Ther 2012;92(1):72–79).

If you choose this route, I’d suggest a gradual cross-taper, such as adding in escitalopram at 5 mg and titrating to half the original citalopram dose while tapering citalopram off over two to four weeks. We don’t know much about the long-term effects of citalopram’s R-enantiomer, and sudden shifts in a stable pharmacodynamic system may have unintended consequences of their own.

CARLAT VERDICT

Escitalopram is generally safer and possibly more effective than citalopram, but psychiatric practice is full of the unexpected. Be careful if you decide to cross-taper from one to the other.

General Psychiatry
KEYWORDS anxiety citalopram depression escitalopram ssris
Chris ­Aiken, MD.

A Practical Guide to Light Therapy

More from this author
www.thecarlatreport.com
Issue Date: June 1, 2022
SUBSCRIBE NOW
Table Of Contents
Quetiapine Reconsidered
Psychosis During Depression
Can TMS Turn on the Switch?
Uncommon Tips: Which Is Better—Citalopram or Escitalopram?
Benzodiazepines: A Reevaluation of Their Benefits and Dangers
How Essential Is Antidepressant Continuation?
Hypothyroidism and Depression: Just How Related Are They?
Topiramate Improves Weight in Schizophrenia in South Asians
CME Post-Test - Psychotic Depression, TCPR, June/July 2022
DOWNLOAD NOW
Featured Book
  • MFB6eCover.jpg

    Medication Fact Book for Psychiatric Practice, Sixth Edition (2022)

    Guidance, clinical pearls, and bottom-line assessments covering the medications you use in your...
    READ MORE
Featured Video
  • therapist_canstockphoto9201097.jpg
    General Psychiatry

    Using SAMe In Clinical Practice with Garrett Rossi, MD

    Read More
Featured Podcast
  • canstockphoto4921771.jpg
    General Psychiatry

    Psychopharm Commandment #6: MAOIs

    MAOIs rank high in efficacy and are pretty well tolerated too, as long as you watch for two critical interactions.

    Listen now
Recommended
  • Approaches to Autism Intervention

    January 31, 2022
    canstockphoto2240982_child-bubbles_thumb.jpg
  • Currently Available Cannabis Products

    September 1, 2022
  • Interpreting Assessment Discrepancies from Multiple Sources

    October 17, 2022
    ChildAssessment.png
  • Approaches to Autism Intervention

    January 31, 2022
    canstockphoto2240982_child-bubbles_thumb.jpg
  • Currently Available Cannabis Products

    September 1, 2022
  • Interpreting Assessment Discrepancies from Multiple Sources

    October 17, 2022
    ChildAssessment.png
  • Approaches to Autism Intervention

    January 31, 2022
    canstockphoto2240982_child-bubbles_thumb.jpg
  • Currently Available Cannabis Products

    September 1, 2022
  • Interpreting Assessment Discrepancies from Multiple Sources

    October 17, 2022
    ChildAssessment.png

About

  • About Us
  • CME Center
  • FAQ
  • Contact Us

Shop Online

  • Newsletters
  • Multimedia Subscriptions
  • Books
  • eBooks
  • ABPN Self-Assessment Courses

Newsletters

  • The Carlat Psychiatry Report
  • The Carlat Child Psychiatry Report
  • The Carlat Addiction Treatment Report
  • The Carlat Hospital Psychiatry Report
  • The Carlat Geriatric Psychiatry Report

Contact

info@thecarlatreport.com

866-348-9279

PO Box 626, Newburyport MA 01950

Follow Us

Please see our Terms and Conditions, Privacy Policy, Subscription Agreement, Use of Cookies, and Hardware/Software Requirements to view our website.

© 2023 Carlat Publishing, LLC and Affiliates, All Rights Reserved.