Antidepressants: Quality prescribing - a guide for improvement
All antidepressants are associated with increasing risk of falls in older adults.43 SSRIs are also associated with an increased risk of gastrointestinal bleed, which is further increased when they are used in combination with antiplatelets, non-steroidal anti-inflammatory drugs (NSAIDs), direct oral anticoagulants (DOACs), and/or warfarin.92-95 Reviewing people in this group can ensure appropriate use and minimise avoidable adverse drug events and harms. For some individuals initiation of appropriate gastro-protection such as proton pump inhibitors may be advised in local and national guidelines.20,77
QTc prolongation can occur with a range of antidepressants and other medicines.96,97 However, higher doses of citalopram and escitalopram are associated with an increased risk of QTc prolongation. Therefore, all older adults (>65 years) prescribed more than citalopram 20mg or escitalopram 10mg daily should be reviewed and considered for dose reduction and/or cessation where appropriate.98 Where it is considered clinically appropriate, or people refuse to reduce their citalopram or escitalopram dose, discuss and document the risk of harm and arrange regular cardiac QTc monitoring as per the list below (Monitoring criteria for citalopram and escitalopram). Older and/or frail adults are at higher risk of QTc prolongation which is associated with ventricular tachycardia and sudden cardiac death.51 In part this due to ageing but can be exacerbated by comorbidities and multiple medicines e.g. antibiotics, cardiac, diuretic, psychotropics, respiratory, etc.6 Therefore, proactively reviewing polypharmacy will also help to reduce the risk of QTc prolongation and sudden death.
A list of medications known to prolong the QT interval99 can be found on Stockley’s Drug Interactions and the Credible Meds website.
Monitoring criteria for citalopram and escitalopram
- People with cardiac disease, consider an ECG review before starting treatment with citalopram and escitalopram.
- Electrolyte disturbances (e.g. hypokalaemia and hypomagnesaemia) should be corrected before treatment with citalopram and escitalopram. Monitoring of serum magnesium is advised, particularly in older adults, who may be taking diuretics or proton pump inhibitors.
- If cardiovascular symptoms, such as palpitations, vertigo, syncope, or seizures develop during treatment, cardiac evaluation including an ECG should be undertaken to exclude a possible malignant cardiac arrhythmia.
- If QTc interval is >500 milliseconds, treatment should be withdrawn gradually.
- If QTc interval duration is between 480 milliseconds and 500 milliseconds, the balance of benefits and risks of continued treatment should be carefully considered, alongside options for dose reduction or gradual withdrawal.