What are the potential adverse effects of selective serotonin reuptake inhibitors (SSRIs) in the management of panic disorder?

Updated: Mar 21, 2018
  • Author: Mohammed A Memon, MD; Chief Editor: Randon S Welton, MD  more...
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Answer

However, the FDA issued a Drug Safety Communication in August 2011 stating that citalopram (Celexa) should not be used at doses greater than 40 mg per day, owing to the potential for dangerous abnormalities in cardiac electrical activity. [57] Citalopram 20 mg per day is the maximum recommended dose in patients with hepatic impairment, who are older than 50 years, who are CYP 2C19 poor metabolizers, or who are taking concomitant cimetidine (Tagamet) or another CYP 2C19 inhibitor. Such individuals can have higher blood levels of citalopram, leading them to have an increased risk of prolonged QT interval and torsade de pointes. [57]

Additional warnings as of March 2012 discourage the use of citalopram at any dose in patients with certain conditions (congenital long QT syndrome, bradycardia, hypokalemia, hypomagnesemia, recent acute myocardial infarction, uncompensated heart failure) due to potentially dangerous prolongation of the QT interval. [57]

Escitalopram seems to be well tolerated in preliminary studies, but costs more than citalopram and does not appear to offer any significant advantage. Fluoxetine (Prozac) can be used, especially if panic disorder occurs with depression. Patients may have poor tolerance for it at the start because the drug may initially increase anxiety, except at very low starting doses. Fluoxetine has a long half-life, making it a good choice in marginally compliant patients. However, this agent alters the metabolism of cytochrome P-450 2D6-cleared agents.


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