Ecg and 40mg citolapram

[pollynewsome]

Hello! Anybody taking 40mg of citolapram and has to go for a ECG? Spoke to doctor about increasing to 40mg cos feeling rubbish again at 30mg. She said that's fine will increase but it's important that you book in for a ECG. Not really sure why and didn't think to ask till I got out of surgery. Haven't started 40mg yet.. too scared! Cheers.

[panic_down_under]

Citalopram is one of many drugs which may, repeat may, affect the electrical system of the heart at high doses and your doctor is either being overcautious, or you're taking more than one such drug.

FWIW, I've taken the most cardio toxic antidepressant made, dosulepin, aka dothiepin, at well above the maximum dose for 20 years and my nearly 70yo heart is fine despite being under more than usual strain because I've had only one lung for the last decade (lungs act as shock absorbers smoothing out the pulse of blood after the heart contracts).

[pollynewsome]

Thanks for the info. She sent me in to a bit of a panic! I only take cit so I guess she just over cautious like you said. Thanks again. X

[panic_down_under]

I only take cit so I guess she just over cautious like you said.

The FDA reduced the maximum recommended dose of citalopram from 60mg to 40mg a few years ago because of concerns the higher dose may increase the heart QTc interval (http://lifeinthefastlane.com/ecg-library/basics/qt_interval/) too much potentially triggering arrhythmias even though the data suggests the increase isn't clinically significant. To quote from van Haelst IMM (http://www.psychiatrist.com/_layouts/PPP.Psych.Controls/ArticleViewer.ashx?ArticleURL=/JCP/article/Pages/2014/v75n01/v75n0103.aspx), 2013:

In a thorough QT/QTc study of citalopram, a mean change in QTc interval of 8.5 milliseconds was found for 20 mg per day and 18.5 milliseconds for 60 mg per day. On the basis of these findings, the FDA stated that citalopram should no longer be prescribed at doses of greater than 40 mg per day and that the maximum citalopram dose is 20 mg per day in elderly patients.12 (http://www.fda.gov/drugs/drugsafety/ucm297391.htm) However, there is still no consensus whether an increase in QTc of this magnitude (< 20 milliseconds) for a dosage of 60 mg is clinically relevant.4 (http://doi.wiley.com/10.1111/bcp.12040), 28 (http://dx.doi.org/10.1016/j.amjmed.2011.12.002) The guidelines of the Committee for Proprietary Medicinal Products (CMPC) suggest that individual changes of QTc interval length need to be at least between 30 and 60 milliseconds from baseline to raise concern for potential risk of drug-induced arrhythmias.23-PDF (http://www.fda.gov/ohrms/dockets/ac/03/briefing/pubs/cpmp.pdf) Another commonly accepted threshold for a clinically significant drug-induced change in QTc length is even higher, with an increase = 60 milliseconds 28 (http://dx.doi.org/10.1016/j.amjmed.2011.12.002), 30 (http://dx.doi.org/10.1186/1744-859X-4-1).

To compound the issue, recent studies have raised doubts about how accurately modern ECG/EKG machines calculate QTc suggesting some algorithms such as Bazett's formula don't adequately correct for factors such as bpm rates (see: Sano M (https://www.ncbi.nlm.nih.gov/pubmed/25229724), 2014; Barbey JT (https://www.ncbi.nlm.nih.gov/pubmed/25944685), 2015; Vandenberk B (https://www.ncbi.nlm.nih.gov/pubmed/27317349), 2016; Patel PJ (https://www.ncbi.nlm.nih.gov/pubmed/26552754), 2016).

For some reason the FDA appears to have a bias against antidepressants. The "black box" warning issued in 2004 was also based on dubious data. For example, in one of the studies cited to support the warning a girl taking antidepressants who stabbed herself in an ear with a pencil during a school test was listed as suicidal, as was another child observed banging its head against a wall in another study.