CYP2D6 metabolism. Modify Therapy/Monitor Closely. Assess need to reduce dose of CYP2D6-metabolized drug.tetrabenazineSerious - Use Alternative (1)citalopram and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.thioridazineSerious - Use Alternative (1)thioridazine and citalopram both increase QTc interval. Avoid or Use Alternate Drug. Thioridazine should be avoided in combination with drugs that are known to prolong QTc interval.thiothixeneMonitor Closely (1)thiothixene and citalopram both increase QTc interval. Use Caution/Monitor. ECG monitoring is recommended, along with drugs that may prolong the QT interval.ticagrelorMonitor Closely (1)citalopram increases effects of ticagrelor by pharmacodynamic synergism. Use Caution/Monitor. Combination may increase risk of bleeding.ticlopidineMonitor Closely (1)ticlopidine increases levels of citalopram by affecting hepatic enzyme CYP2C19 metabolism. Use Caution/Monitor. Citalopram 20 mg/day is the maximum recommended dose for patients taking CYP2C19 inhibitors because of the risk of QT prolongation.timololMonitor Closely (1)citalopram increases levels of timolol by decreasing metabolism. Use Caution/Monitor.tipranavirMonitor Closely (1)tipranavir increases levels of citalopram by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.tirofibanMonitor Closely (1)citalopram increases effects of tirofiban by pharmacodynamic synergism. Use Caution/Monitor. Combination may increase risk of bleeding.tizanidineMonitor Closely (1)citalopram will increase the level or effect of tizanidine by Other (see comment). Use Caution/Monitor. Monitor for increased psychomotor impairment and adverse effects.tolmetinMonitor Closely (1)citalopram, tolmetin. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of upper GI bleeding. If possible, avoid concurrent use.toremifeneMonitor Closely (1)toremifene and citalopram both increase QTc interval. Use Caution/Monitor. ECG monitoring is recommended, along with drugs that may prolong the QT interval.torsemideMonitor Closely (1)torsemide, citalopram. Mechanism: pharmacodynamic synergism. Use Caution/Monitor. Possible additive hyponatremia.tramadolMonitor Closely (1)citalopram and tramadol both increase serotonin levels. Use Caution/Monitor. Combination may increase risk of serotonin syndrome or neuroleptic malignant syndrome-like reactions.tranylcypromineContraindicated (1)tranylcypromine and citalopram both increase serotonin levels. Contraindicated. At least 2 weeks should elapse between discontinuation of MAOI therapy and the start of citalopram therapy, and at least 2 weeks between discontinuation of citalopram therapy and commencement of MAOI therapy.trazodoneMonitor Closely (1)citalopram and trazodone both increase serotonin levels. Use Caution/Monitor. Combination may increase risk of serotonin syndrome or neuroleptic malignant syndrome-like reactions.Serious - Use Alternative (1)citalopram and trazodone both increase QTc interval. Avoid or Use Alternate Drug.triclabendazoleMonitor Closely (2)triclabendazole and citalopram both increase QTc interval. Use Caution/Monitor. triclabendazole will increase the level or effect of citalopram by affecting hepatic enzyme CYP2C19 metabolism. Use Caution/Monitor. If plasma concentrations of the CYP2C19 substrates are elevated during triclabendazole, recheck plasma concentration of the CYP2C19 substrates after discontinuation of triclabendazole. trimipramineSerious - Use Alternative (2)citalopram and trimipramine both increase serotonin levels. Avoid or Use Alternate Drug. Citalopram may increase TCA levels. Increased risk of serotonin syndrome or neuroleptic malignant syndrome. Potential risk for QT prolongation. ECG monitoring is recommended. citalopram and trimipramine both increase QTc interval. Avoid or Use Alternate Drug.triptorelinSerious - Use Alternative (1)triptorelin increases toxicity of citalopram by QTc interval. Avoid or Use Alternate Drug. Increases risk of torsades de pointes.tucatinibSerious - Use Alternative (1)tucatinib will increase the level or effect of citalopram by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid concomitant use of tucatinib with CYP3A substrates, where minimal concentration changes may lead to serious or life-threatening toxicities. If unavoidable, reduce CYP3A substrate dose according to product labeling.umeclidinium bromide/vilanterol inhaledSerious - Use Alternative (1)citalopram increases toxicity of umeclidinium bromide/vilanterol inhaled by QTc interval. Avoid or Use Alternate Drug. Exercise extreme caution when vilanterol coadministered with drugs that prolong QTc interval; adrenergic agonist effects on the cardiovascular system may be potentiated.valbenazineMonitor Closely (1)valbenazine and citalopram both increase QTc interval. Use Caution/Monitor.valerianMonitor Closely (1)valerian and citalopram both increase sedation. Use Caution/Monitor.vandetanibMonitor Closely (1)vandetanib and citalopram both increase QTc interval. Use Caution/Monitor. ECG monitoring is recommended, along with drugs that may prolong the QT interval.Serious - Use Alternative (1)citalopram, vandetanib. Either increases toxicity of the other by QTc interval. Avoid or Use Alternate Drug. Avoid coadministration with drugs known to prolong QT interval; if a drug known to prolong QT interval must be used, more frequent ECG monitoring is recommended.vardenafilMonitor Closely (1)vardenafil and citalopram both increase QTc interval. Use Caution/Monitor. ECG monitoring is recommended, along with drugs that may prolong the QT interval.vemurafenibSerious - Use Alternative (1)vemurafenib and citalopram both increase QTc interval. Avoid or Use Alternate Drug. Concomitant use of vemurafenib with drugs that prolong QT interval is not recommended.venlafaxineSerious - Use Alternative (1)citalopram and venlafaxine both increase serotonin levels. Avoid or Use Alternate Drug. Combination may increase risk of serotonin syndrome or neuroleptic malignant syndrome-like reactions.vilanterol/fluticasone furoate inhaledSerious - Use Alternative (1)citalopram increases toxicity of vilanterol/fluticasone furoate inhaled by QTc interval. Avoid or Use Alternate Drug. Exercise extreme caution when vilanterol coadministered with drugs that prolong QTc interval; adrenergic agonist effects on the cardiovascular system may be potentiated.vilazodoneSerious - Use Alternative (1)citalopram, vilazodone. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug. Combination may increase risk of serotonin syndrome or neuroleptic malignant syndrome-like reactions.voclosporinMonitor Closely (1)voclosporin, citalopram. Either increases effects of the other by QTc interval. Use Caution/Monitor.vorapaxarMonitor Closely (1)citalopram, vorapaxar. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Additive antiplatelet effect may occur; SSRIs and SNRIs may cause platelet serotonin depletion .voriconazoleMonitor Closely (1)voriconazole increases levels of citalopram by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. ECG monitoring is recommended, along with drugs that may prolong the QT interval.Serious - Use Alternative (1)citalopram and voriconazole both increase QTc interval. Avoid or Use Alternate Drug.vorinostatMonitor Closely (1)vorinostat and citalopram both increase QTc interval. Use Caution/Monitor. ECG monitoring is recommended, along with drugs that may prolong the QT interval.Serious - Use Alternative (1)citalopram and vorinostat both increase QTc interval. Avoid or Use Alternate Drug.vortioxetineSerious - Use Alternative (1)citalopram, vortioxetine. Either increases effects of the other by serotonin levels. Avoid or Use Alternate Drug.voxelotorSerious - Use Alternative (1)voxelotor will increase the level or effect of citalopram by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Voxelotor increases systemic exposure of sensitive CYP3A4 substrates. Avoid coadministration with sensitive CYP3A4 substrates with a narrow therapeutic index. Consider dose reduction of the sensitive CYP3A4 substrate(s) if unable to avoid.warfarinMonitor Closely (1)citalopram, warfarin. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Serotonin release by platelets plays an important role in hemostasis. SSRIs and SNRIs may increase anticoagulation effect of warfarin. .zanubrutinibMonitor Closely (1)citalopram, zanubrutinib. Either increases effects of the other by anticoagulation. Modify Therapy/Monitor Closely. Zanubrutinib-induced cytopenias increases risk of hemorrhage. Coadministration of zanubritinib with antiplatelets or anticoagulants may further increase this risk.ziprasidoneContraindicated (1)ziprasidone and citalopram both increase QTc interval. Contraindicated.Serious - Use Alternative (1)citalopram and ziprasidone both increase QTc interval. Contraindicated.zolmitriptanSerious - Use Alternative (1)citalopram, zolmitriptan. Mechanism: unknown. Avoid or Use Alternate Drug. Combination may increase risk of serotonin syndrome. If concomitant treatment with citalopram and a triptan is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases. >10% Dry mouth (20%) Nausea (21%) Somnolence (18%) Insomnia (15%) Xerostomia (20%) Increased sweating (11%) 1-10% Tremor (8%) Diarrhea (8%) Ejaculation disorder (6%) Rhinitis (5%) Upper respiratory infection (5%) Dyspepsia (5%) Fatigue (5%) Vomiting (4%) Anxiety (4%) Anorexia (4%) Abdominal pain (3%) Agitation (3%) Impotence (3%) Sinusitis (3%) Dysmenorrhea (3%) Decreased libido (2%) Yawning (2%) Arthralgia (2%) Myalgia (2%) Amenorrhea (>1%) Confusion (>1%) Cough (>1%) Flatulence (>1%) Increased saliva (>1%) Migraine (>1%) Orthostatic hypotension (>1%) Paresthesia (>1%) Polyuria (>1%) Pruritus (>1%) Rash (>1%) Tachycardia (>1%) Weight change (>1%) Black Box Warnings In short-term studies, antidepressants increased the risk of suicidal thinking and behavior in children, adolescents, and young adults (<24 years) taking antidepressants for major depressive disorders and other psychiatric illnesses This increase was not seen in patients >24 years; a slight decrease in suicidal thinking was seen in adults >65 years In children and young adults, the risks must be weighed against the benefits of taking antidepressants Patients should be monitored closely for changes in behavior, clinical worsening, emergence of suicidal thoughts and behavior, and suicidal tendencies; this should be done during initial 1-2 months of therapy and dosage adjustments The patient’s family should communicate any abrupt changes in behavior to the healthcare provider Worsening behavior and suicidal tendencies that are not part of the presenting symptoms may require discontinuation of therapy Not FDA approved for the treatment of bipolar disorder This drug is not FDA approved for use in pediatric patientsContraindications Hypersensitivity Coadministration with pimozide Coadministration with serotonergic drugs Concomitant use or within 14 days of MAOIs increases risk of serotonin syndrome Symptoms include tremor, myoclonus, diaphoresis, nausea, vomiting, flushing, dizziness, hyperthermia with features resembling neuroleptic malignant syndrome, seizures, rigidity, autonomic instability with possible rapid fluctuations of vital signs, and mental status changes that include extreme agitation progressing to delirium and coma Starting citalopram in a patient who is being treated with linezolid or IV methylene blue is contraindicated because of an increased risk of serotonin syndrome If linezolid or IV methylene blue must be administered, discontinue SSRI immediately and monitor for CNS toxicity; may resume 24 hr after last linezolid or methylene blue dose, or after 2 weeks of monitoring (5 weeks for fluoxetine), whichever comes first Cautions Pregnancy: Conflicting evidence regarding use of SSRIs during pregnancy and increased risk of persistent pulmonary hypertension of the newborn, or PPHN (see Pregnancy) Neonates exposed to SNRIs/SSRIs late in third trimester: Risk of complications such as feeding difficulties, irritability, and respiratory problems Clinical worsening and suicide ideation may occur despite medication in adolescents and young adults (18-24 years) Risk of mydriasis; may trigger angle closure attack in patients with angle closure glaucoma with anatomically narrow angles without a patent iridectomy Risk of hyponatremia, abnormal bleeding (increased if concomitant aspirin, NSAIDs, or anticoagulants, or hemorrhagic diathesis), and impairment of cognitive and motor functions Risk of serotonin syndrome or neuroleptic malignant syndrome (NMS)-like reactions have been reported with SSRIs alone or with concomitant use of serotonergic drugs, with drugs that impair metabolism of serotonin, or with antipsychotics or other dopamine antagonists Activation of mania/hypomania has been reported; use caution when treating patients with history of mania Increased risk of bone fractures reported with antidepressant use; use caution; consider possibility of fracture it patient presents with bone pain May cause or exacerbate sexual dysfunction Use caution when treating patients with history of seizure disorder Rare cases of hyponatremia and development of SIADH reported with either SSRI or SNRI use Consider risk of serotonin syndrome if administered concomitantly with other serotonergic drugs including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. John’s Wort Not recommended in patients with uncompensated heart failure Sexual dysfunction Use may cause symptoms of sexual dysfunction in both male and female patients; inform patients that they should discuss any changes in sexual function and potential management strategies with their healthcare provider Use of SSRIs, may cause symptoms of sexual dysfunction; in male patients, SSRI use may result in ejaculatory delay or failure, decreased libido, and erectile dysfunction In female patients, SSRI/SNRI use may result in decreased libido and delayed or absent orgasm Important for prescribers to inquire about sexual function prior to initiation of therapy and to inquire specifically about changes in sexual function during treatment, because sexual function may not be spontaneously reported When evaluating changes in sexual function, obtaining a detailed history (including timing of symptom onset) is important because sexual symptoms may have other causes, including underlying psychiatric disorder Discuss potential management strategies to support patients in making informed decisions about treatment QT prolongation Dose-dependent QT prolongation reported; do not exceed dose of 40 mg/day Correct hypokalemia and hypomagnesemia before initiating and monitor periodically ECG monitoring recommended in patients with CHF, bradyarrhythmias, or concomitant medications known to prolong QT interval Do not exceed 20 mg/day if administered in CYP2C19 poor metabolizers, or in patients taking concomitant cimetidine or another CYP2C19 inhibitor (eg, fluconazole, omeprazole) Do not exceed 20 mg/day in individuals aged 60 yr or older, or those with hepatic impairment Pregnancy There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to antidepressants during pregnancy; healhcare providers are encouraged to register patients by calling the National Pregnancy Registry for Antidepressants at 1-844-405-6185 or visiting online athttps://womensmentalhealth.org/research/pregnancyregistry/antidepressants Available data from published epidemiologic studies and postmarketing reports with citalopram use in pregnancy have not established an increased risk of major birth defects or miscarriage; published studies demonstrated that citalopram levels in both cord blood and