Citalopram with Methylene Blue Interaction Details
Brand Names Associated with Citalopram
- Celexa®
- Citalopram
Medical Content Editor Dr. Brian Staiger, PharmD
Last updated
Nov 11, 2023
Interaction Effect
An increased risk of serotonin syndrome (hypertension, tachycardia, hyperthermia, myoclonus, mental status changes)
Interaction Summary
Concurrent use of citalopram and IV methylene blue, an MAOI, is contraindicated. No cases have been identified in patients receiving methylene blue up to 5 mg for lymphatic mapping in breast cancer , nor with other routes of administration (eg, oral, local tissue injection), or at lower doses; however, the potential for serotonin syndrome may still exist. Wait at least 14 days after discontinuing an MAOI intended to treat psychiatric disorders before initiating citalopram. Wait at least 14 days after discontinuing citalopram before initiating therapy with an MAOI intended to treat psychiatric disorders. If urgent treatment with IV methylene blue is necessary in a patient receiving citalopram, alternatives are not available, promptly discontinue citalopram and then administer IV methylene blue . Use lowest possible dose of methylene blue .
Severity
Contraindicated
Onset
Unspecified
Evidence
Probable
How To Manage Interaction
Concurrent use of citalopram and IV methylene blue (an MAOI) is contraindicated. Wait at least 14 days after discontinuing an MAOI intended to treat psychiatric disorders before initiating citalopram. Wait at least 14 days after discontinuing citalopram before initiating therapy with an MAOI intended to treat psychiatric disorders. If urgent treatment with IV methylene blue is necessary in a patient receiving citalopram, alternatives are not available, promptly discontinue citalopram and then administer IV methylene blue. Use lowest possible dose of methylene blue .
Mechanism Of Interaction
Additive serotonergic effects
Literature Reports
A) Serious CNS reactions have occurred following administration of methylene blue in a patient currently receiving an SSRI, such as citalopram. In most reported cases, the patient was undergoing parathyroid surgery, with use of methylene blue as a visualizing agent in doses ranging from 1 to 8 mg/kg. The risk of serotonin syndrome in patients taking SSRIs who receive methylene blue by alternative routes (eg, orally or by local tissue injection) or at doses lower than 1 mg/kg is unknown .
B) Patients treated with SSRIs who are undergoing lymphatic mapping for breast cancer are not expected to experience an interaction with concomitant use of methylene blue. Doses of methylene blue used in lymphatic mapping are many times lower (5 mg total) compared with doses used when serotonin syndrome occurred with concomitant use of an SSRI and methylene blue (eg, 1 to 8 mg/kg). No case reports of serotonin syndrome have been reported in patients taking SSRIs who received methylene blue in lymphatic mapping; however, healthcare providers should still be aware of the potential for an interaction between methylene blue and SSRIs in this setting .
C) Serotonin toxicity, subsequent to concomitant use of citalopram and methylene blue, occurred in a 44-year-old woman following a partial parathyroidectomy. The patient had been taking citalopram 20 mg/day as well other maintenance medications, including aspirin, simvastatin, atenolol, isosorbide mononitrate, and bendroflumethiazide. Prior to surgery, a methylene blue infusion of 560 mg in 500 mL NS was given over 2 hours, in addition to propofol, remifentanil, rocuronium, dexAMETHasone, and morphine analgesia, all administered the day of surgery. Three hours after surgery, symptoms indicating serotonin toxicity manifested, with the patient becoming agitated, restless, staring into space, and making incomprehensible sounds. Her Glasgow coma scale was 11/15, scoring a 2 and 5 for verbal and motor response, respectively, and a 4 for eye opening. There were no focal deficits on neurological examination; however, both pupils were dilated with a slow response to light, with myoclonic movements in the lower limbs, brisk reflexes throughout, and downgoing plantar responses. Vital signs were all within normal limits and there were no significant findings on a CT scan of the head; the patient had received general anesthesia in the past without complications. Citalopram was discontinued and the patient was transferred to the ICU for supportive treatment and was sedated for 12 hours with propofol and ALfentanil. Upon discharge 3 days later, she resumed citalopram therapy and experienced no long-term effects .
Citalopram Overview
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Citalopram is used to treat depression. Citalopram is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance.
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Definitions
Severity Categories
Contraindicated
These drugs, generally, should not be used together simultaneously due to the high risk of severe adverse effects. Combining these medications can lead to dangerous health outcomes and should be strictly avoided unless otherwise instructed by your provider.
Major
This interaction could result in very serious and potentially life-threatening consequences. If you are taking this drug combination, it is very important to be under close medical supervision to minimize severe side effects and ensure your safety. It may be necessary to change a medication or dosage to prevent harm.
Moderate
This interaction has the potential to worsen your medical condition or alter the effectiveness of your treatment. It's important that you are monitored closely and you potentially may need to make adjustments in your treatment plan or drug dosage to maintain optimal health.
Minor
While this interaction is unlikely to cause significant problems, it could intensify side effects or reduce the effectiveness of one or both medications. Monitoring for changes in symptoms and your condition is recommended, and adjustments may be made if needed to manage any increased or more pronounced side effects.
Onset
Rapid: Onset of drug interaction typically occurs within 24 hours of co-administration.
Delayed: Onset of drug interaction typically occurs more than 24 hours after co-administration.
Evidence
Level of documentation of the interaction.
Established: The interaction is documented and substantiated in peer-reviewed medical literature.
Theoretical: This interaction is not fully supported by current medical evidence or well-documented sources, but it is based on known drug mechanisms, drug effects, and other relevant information.
How To Manage The Interaction
Provides a detailed discussion on how patients and clinicians can approach the identified drug interaction as well as offers guidance on what to expect and strategies to potentially mitigate the effects of the interaction. This may include recommendations on adjusting medication dosages, altering the timing of drug administration, or closely monitoring for specific symptoms.
It's important to note that all medical situations are unique, and management approaches should be tailored to individual circumstances. Patients should always consult their healthcare provider for personalized advice and guidance on managing drug interactions effectively.
Mechanism Of Interaction
The theorized or clinically determined reason (i.e., mechanism) why the drug-drug interaction occurs.
Disclaimer: The information provided on this page is for informational purposes only and should not be considered medical advice. Always consult with a qualified healthcare professional regarding your specific circumstances and medical conditions.
Where Does Our Information Come From?
Information for our drug interactions is compiled from several drug compendia, including:
The prescribing information for each drug, as published on DailyMED, is also used.
Individual drug-drug interaction detail pages contain references specific to that interaction. You can click on the reference number within brackets '[]' to see what reference was utilized.
The information posted is fact-checked by HelloPharmacist clinicians and reviewed quarterly.