Citalopram & Escitalopram

This section is designed to inform professionals.

(Consumers, see Fact Sheet on Citalopram & Escitalopram)

Available as Cipramil, Celapram and Lexapro.

Used in depression and anxiety disorders including Obsessive Compulsive Disorder

Use in Pregnancy

Category C

There is no specific data available on Escitalopram during pregnancy.
A recent review (1) suggests that SSRIs as a class do not increase the risk of common birth defects, although individual SSRIs may confer a small increased risk of heart defects.
Another recent study (2) suggested that there was an increased risk in the ‘pooled group’ of anencephaly, craniosynostosis and omphalocoele with Paroxetine and Citalopram, however the absolute risks were small and this has not been confirmed by other studies.
There have been two case studies on use of Escitalopram during pregnancy one was uneventful (3) and the other infant developed necrotising enterocolitis following in utero and breast milk exposure to Escitalopram (4).
Neonatal Adaptation Syndrome (5) can occur in babies of mothers who have used SSRIs near term.
There is increasing concern in the literature about perinatal toxicity or discontinuation related to SSRI use in later pregnancy (6) Generally the symptoms in the infant resolve spontaneously and there have been no reported deaths or ongoing complications from NAS (5), however occasionally specific or supportive treatment in Intensive Care Units may be required.
Hendrick et al (7) compared placental passage of different SSRIs and found that Citalopram produced the highest mean ratio of cord to maternal serum concentration (0.89) however there was no relationship between maternal dose and cord serum concentration of Citalopram (there was a significant correlation with Sertraline and Fluoxetine, however).
Although there is theoretical concern about long term neurobehavioural toxicity, infants who have been followed to 4 and 5 years old have not differed from those who have not been exposed to SSRIs (8)

Use in Lactation

Category L2

A recent review on SSRIs during breast feeding (9) suggests that Citalopram and its metabolites are present in breast milk in amounts ranging from 1.8% -5.4% with few adverse events in the infant reported. The peak milk concentration for Citalopram occurred at around 4 hours whereas the peak for the metabolite, desmethylcitalopram occurred at nearer 6 hours.
There has been one study on Escitalopram in breast feeding (10) which calculates that the ‘absolute infant dose’ is lower than that in Citalopram, and recommends that Escitalopram be preferred to Citalopram in breast feeding. In this study the majority of the babies’ serum levels of Escitalopram and its metabolites were undetectable.

References

(1)Louik C, Lin A, Werler M, Hernandez-Diaz S, Mitchell A: First trimester use of selective serotonin reuptake inhibitors and the risk of birth defects. The New England Journal of Medicine 2007; 356(26) 2675-2683

(2)Alwan S, Reefhuis J, Rasmussen SA, et al. Use of selective serotonin-reuptake inhibitors in pregnancy and the risk of birth defects. N Engl J Med 2007; 356:2684-92.

(3)Gentile S, Escitalopram in late pregnancy and while breastfeeding. The Annals of Pharmacotherapy 2006 ;40 (9):1696-1697

(4)` Potts A Necrotizing enterocolitis associated with in utero and breast milk exposure to the selective serotonin reuptake inhibitor, Escitalopram Journal of Perinatology 2007; 27, 120-122

(5)Koren G, Matsui D, Einarson A, Knoppert D and Steiner M: Is maternal use of selective serotonin reuptake inhibitors in the third trimester of pregnancy harmful to neonates? Canadian Medical Association Journal 2005;172:1457-1459

(6)Gentile S et al . Archives of Womens Mental Health 2007;10:39-51

(7)Hendrick V, Stowe ZN, Altshuler LL, Hwang S, Lee E and Haynes D:Placental passage of antidepressant medications The American Journal of Psychiatry 2003; 160: 993-996

(8) Rubinow DR: Antidepressant treatment during pregnancy: between Scylla and Cahribdis The American Journal of Psychiatry 2006; 163: 954-956

(9) Gentile S, Rossi A and Bellantuono C: SSRIs in breastfeeding: spotlight on milk to plasma ratio. Archives of Women’s Mental Health 2007 10:39-51

(10) Rampono J, Hackett LP, Kristensen J, Kohan R, Page-Sharp M and Ilett K. Transfer of Escitalopram and its metabolite demethylescitalopram into breastmilk. British Journal of Clinical Pharmacology 2006 62:316 -322