Citalopram QTc Alert — MRCPsych Paper B MCQ

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ModerateOld Age PsychiatryCitalopram QTc AlertMRCPsych Paper B

A 75-year-old woman with depression has had a partial response to citalopram 10 mg daily, and a dose increase is being considered. She has no known congenital long-QT syndrome and is not taking another medicine known to prolong the QT interval. According to MHRA dose restrictions introduced because of dose-dependent QT prolongation, what is the maximum recommended daily dose of citalopram for this patient?

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Correct answer: A — 20 mg daily

The correct answer is A: 20 mg daily. Citalopram prolongs the QT interval in a dose-dependent manner, and older patients have increased exposure because of reduced metabolism and elimination. The MHRA therefore restricts the maximum dose to 20 mg daily in adults older than 65 years. Ten milligrams is commonly used as a starting dose in older adults but is not the maximum; it is also the maximum elderly dose for escitalopram. Forty milligrams is the citalopram maximum for younger adults, while 60 mg exceeds current recommendations. ECG monitoring is not mandated universally: the MHRA advises considering an ECG before treatment in patients with cardiac disease and obtaining cardiac assessment if relevant cardiovascular symptoms develop.

Reference: Medicines and Healthcare products Regulatory Agency. Citalopram and escitalopram: QT interval prolongation—maximum daily dose schedule and monitoring recommendations. Drug Safety Update, article date 2011; GOV.UK publication 2014. https://www.gov.uk/drug-safety-update/citalopram-and-escitalopram-qt-interval-prolongation