Citalopram withdrawal due to ECG changes

[CP353]

Hi everyone,

Brand new to the forum, so hope I'm doing this right!

I wondered if anyone had been in a similar situation to me. I've been on citalopram (20-30 mg) for most of the past 15 years, however I had an ECG a few weeks back, which showed 'minor changes'. My GP advised me to come off citalopram completely, and I have tapered off 10 mg per week since then, and have now stopped taking it as of last night. Naturally, this is all happening during a bad episode for me, so keeping a lid on the anxiety is really hard!

I'm having a bad time with withdrawal symptoms, plus the underlying anxiety. I've got a repeat ECG next week, and can't help worrying about this as well.

Any advice for getting through this?

[panic_down_under]

Hi everyone,

to NMP,

I've been on citalopram (20-30 mg) for most of the past 15 years, however I had an ECG a few weeks back, which showed 'minor changes'.

Citalopram and the very similar escitalopram may cause prolongation of the QTc interval (PDF) which caused the FDA and other drug regulator agencies to reduce the recommended maximum dose from 60mg to 40mg (and 30mg to 20mg for escitalopram). Whether this was actually necessary was the subject of considerable debate at the time as the observed changes were minimal even at 60mg.

My GP advised me to come off citalopram completely, and I have tapered off 10 mg per week since then, and have now stopped taking it as of last night.

I'm having a bad time with withdrawal symptoms, plus the underlying anxiety.

Did your GP indicate how your disorder will be treated in the future? If with another SSRI then was any thought given for an overnight switch?

I've got a repeat ECG next week, and can't help worrying about this as well.

The 'minor changes' finding suggests this is just that, a minor issue which, at worst, will need regular monitoring. Imo, those with anxiety disorders and/or depression should have at least annual ECGs/EKGs anyway as anxiety/stress is itself a significant risk factor for cardiovascular disease. If fact it could have had more to do with the 'minor changes' than the citalopram given you were in the midst of a bad anxiety episode at the time.

Any advice for getting through this?

I suggest you ask your GP to prescribe something to ease the anxiety until a long-term treatment becomes effective.

[CP353]

Hi there panic_down_under,

Thanks so much for your reassuring reply. When I spoke to my GP, there was some vague mention of sertraline or fluoxetine, but there was nothing planned for sure. Certainly no mention of an overnight switch. To be honest, I don't have much faith in my GP, which is frustrating - I feel a bit abandoned with it all! It feels like a full-time job managing all this, and I'm trying to keep working throughout as well.

I agree, I think the next step is to get back in touch for something to ease the anxiety (and the withdrawal?) over the next few days. Just hoping I can get something sorted out before everything closes for Christmas.

Thanks again

[panic_down_under]

When I spoke to my GP, there was some vague mention of sertraline or fluoxetine, but there was nothing planned for sure. Certainly no mention of an overnight switch.

Sigh!

Either would have been a good choice, but sertraline would be my pick because fluoxetine has a very long half-life so can take longer to become active.

I agree, I think the next step is to get back in touch for something to ease the anxiety (and the withdrawal?)

At least some of your symptoms may be down to withdrawal, but I suspect the bigger factor is the added psychological burden from coming off citalopram, plus being unmedicated when your anxiety levels were already very high.

over the next few days. Just hoping I can get something sorted out before everything closes for Christmas.

I would make that a priority as the last thing you need atm is being forced to white-knuckle through all this because everything is closed for Christmas and the New Year. But remember hospital A&Es are still open and they're likely to have someone on duty who knows more than your GP apparently does.

[CP353]

An update!

My GP has prescribed mirtazapine, as he remains concerned about the effect on the ECG of SSRIs - not sure this is entirely accurate, but hey ho.

My quick read around is relatively positive on this, as I understand mirtazapine increases appetite. Loss of appetite is my major anxiety issue, as I fall into the "don't eat, feel faint and dizzy, increase anxiety" spiral very quickly. Be interested to hear any thoughts on this!

I'm definitely prepared to give it a good go. I've got some time off over Xmas with my (supportive) family, so they can help lighten the load a bit.

Thanks again for replying really appreciate it. Will keep you posted!

[panic_down_under]

My GP has prescribed mirtazapine, as he remains concerned about the effect on the ECG of SSRIs - not sure this is entirely accurate, but hey ho.

CredibleMeds maintains a list of medications which may affect the electrical system of the heart for the FDA. It lists mirtazapine as having a 'Possible Risk of TdP'. Both sertraline and fluoxetine are in the lower ' Conditional Risk of TdP Under Certain Conditions' category (citalopram and escitalopram are in the top 'Known Risk of TdP' category).

Known Risk of TdP(Torsades de Pointes) - These drugs prolong the QT interval AND are clearly associated with a known risk of TdP, even when taken as recommended.

Possible Risk of TdP - These drugs can cause QT prolongation BUT currently lack evidence for a risk of TdP when taken as recommended.

Conditional Risk of TdP Under Certain Conditions - These drugs are associated with TdP BUT only under certain conditions of their use (e.g. excessive dose, in patients with conditions such as hypokalemia, or when taken with interacting drugs) OR by creating conditions that facilitate or induce TdP (e.g. by inhibiting metabolism of a QT-prolonging drug or by causing an electrolyte disturbance that induces TdP)

There is a reason why SSRIs except citalopram and escitalopram are the ADs of choice for heart attack survivors!

as I understand mirtazapine increases appetite. Loss of appetite is my major anxiety issue, as I fall into the "don't eat, feel faint and dizzy, increase anxiety" spiral very quickly. Be interested to hear any thoughts on this!

If you want to put on weight then mirtazapine is likely to be the med for you. It can trigger strong carbohydrate cravings and most put on weight while taking it. Although it is marketed as an AD, it is really only a potent sedating antihistamine.

I'm definitely prepared to give it a good go. I've got some time off over Xmas with my (supportive) family, so they can help lighten the load a bit.

It is usually effective as a sedative so it should help until your GP extracts the digit and prescribes a new AD.

[CP353]

Unfortunately, GP appointments are still over the phone, and I'm pretty foggy as well from the citalopram withdrawal, so it's hard to have a really good conversation about it all. In the meantime, it looks like this is what I'm getting, and it's better than the nothing I'm currently on!

Will definitely be keeping an eye on the weight gain, as I'm already a fair bit heavier than I should be. I'm normally a comfort eater, with the exception of when the anxiety flares badly. I've lost something like 2.5 stone in the last 6 months through not eating (complete lack of appetite + nausea), which has done me no physical harm, but as I say, I find it mentally very difficult, and easy to fall into spiralling worry.

Anyway, repeat ECG on Wednesday afternoon, see how that goes, and if that changes matters...

[panic_down_under]

Will definitely be keeping an eye on the weight gain, as I'm already a fair bit heavier than I should be.

Maybe try exercising more. Not only does it help with weight gain, but it also has the same positive effect on hippocampal neurogenesis as ADs. You don't need to run a daily marathon to get these benefits. A brisk stroll 4-5 times a week may do wonders.

Anyway, repeat ECG on Wednesday afternoon, see how that goes, and if that changes matters...

🤞

[CP353]

Yes, hoping that with a bit more appetite, I can get out and moving a bit more, as well as not just slumped on the sofa!

Biggest problem at the moment is the withdrawal brain zaps - I KNOW they aren't harmful, but it still takes a toll constantly waiting for my brain to catch up with my eyes. Still waiting for the mirt prescription to work its way through the pharmacy system. Honestly, I love the NHS (and have worked for it for a long time!), but these things could be so much more efficient.

Still, 3 more days in work, then a good break over Xmas.

Thanks again for your advice, really do appreciate it

[panic_down_under]

it still takes a toll constantly waiting for my brain to catch up with my eyes.

Much of what we 'see' is created by the brain, not a direct 'feed' from the eyes, so it's mostly one part of the brain trying to keep up with another.

Still waiting for the mirt prescription to work its way through the pharmacy system. Honestly, I love the NHS (and have worked for it for a long time!), but these things could be so much more efficient.

How long does it take, and why so long? Here my GP sends the prescription to my mobile phone while I'm still in her office and if I need it immediately I forward the SMS to the pharmacy so the med is waiting when I get there.

Still, 3 more days in work, then a good break over Xmas.

For me it's another couple of days of peacefully annoying the local trout before the mainland fisher hoards descend on Tasmania to pillage the streams and lakes through to the end of January.