Citalopram + Lexapro?

[EC21]

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At the pharmacy where I work, I ran across a pt on both Citalopram 40mg + Lexapro 20mg (age = 55+). Is there any circumstance under which these are combined? The MD insists on the combination & they have been on it for years but I can't find any reason for prescribing both. Any thoughts?

 

[trailerpark]

Maybe the doc is wicked old and isn't familiar with enantiomers or the patient gets a placebo effect being on 2 antidepressants. I was under the impression the dose dependent qTc interval prolongation was most probably related to the R-enantiomer, so yeah I think the Lexapro 40mg daily would be a better choice, but nothing to worry too much about it if the doc or patient is fine with it.

 

[WhiteSnows]

This is one of the cases where you definitely can't fill both. Again, it is case to case basis.

 

[EC21]

This is one of the cases where you definitely can't fill both. Again, it is case to case basis.

Unfortunately, the MD insists on us filling both for the pt & ignores our questioning of this combination. Just wondering if there was any medical justification for prescribing both.

 

[pharmasaur]

It sounds like the md wanted to increase the dose of the celexa but was unable to due to fda restrictions of max 40mg so he just added lexapro.


Maybe he did this instead of switching to lexapro completely, but cost might have been an issue

 

[Old Timer]

Unfortunately, the MD insists on us filling both for the pt & ignores our questioning of this combination. Just wondering if there was any medical justification for prescribing both.

You need to find you why. Without that information hard to make a determination.

 

[WhiteSnows]

Unfortunately, the MD insists on us filling both for the pt & ignores our questioning of this combination. Just wondering if there was any medical justification for prescribing both.

I would document this to cover you. Both can cause QT prolongations and there is no justification to give both. And "Maybe" discuss with the patient about the potential risk. Otherwise, you should not fill this. You are the pharmacist.

 

[EC21]

I would document this to cover you. Both can cause QT prolongations and there is no justification to give both. And "Maybe" discuss with the patient about the potential risk. Otherwise, you should not fill this. You are the pharmacist.

I am coming into it late. Pt has been on it for 4+ years.

 

[WhiteSnows]

I am coming into it late. Pt has been on it for 4+ years.

Then it is fine. He is on it and there is no problem.

 

[trailerpark]

If 4 years then

 

[Wheresmyaricept]

It sounds like the md wanted to increase the dose of the celexa but was unable to due to fda restrictions of max 40mg so he just added lexapro.


Maybe he did this instead of switching to lexapro completely, but cost might have been an issue

Probably this. He didn't want to do a PA for lexapro 40 mg a day.

 

[BidingMyTime]

Probably this. He didn't want to do a PA for lexapro 40 mg a day.

I agree.

No medical reason to do both separate instead of just 1 (although possibly a placebo effect), the dosing with the 2 in combination is high, but not 'this will kill the patient' level high, so since the patient has been tolerating it well & has been for years, doctor is aware of the situation, I wouldn't worry about it either.

 

[EC21]

Probably this. He didn't want to do a PA for lexapro 40 mg a day.

Perhaps, good point. No clinical justification for Lexapro 40mg either though.

 

[Wheresmyaricept]

Perhaps, good point. No clinical justification for Lexapro 40mg either though.

Why don't you go talk to him then? I'm sure he'll love giving you the "I'm a board certified physician and a fellow of the academy of blah blah blah and graduated from XYZ medical school" speech. Or maybe this patient is a rapid metabolizer. It's rare, but that's what I like to think when I see stupid doses like this.

 

[zelman]

Perhaps, good point. No clinical justification for Lexapro 40mg either though.

Drug response fits a normal distribution in most cases. You will have patients 2.5 to 3 standard deviations from the mean. You will not see any studies large enough to reflect these patients, but if you do the math, they do exist. Now, if this MD has all his patients on 40mg escitalopram, there's another issue. But one is statistically valid. Let's all keep in mind that SSRIs are no more effective than older antidepressants; they are just better tolerated and safer in overdose. Save your argument for someone on 300mg of Elavil plus 150mg of Tofranil.

 

[Farcus]

It doesn't make sense but given this seem like a chronic med for this pt and all monitoring parameters are good, na/qtc/s/sx for ss you're good to go just document it.

 

[atpsynthase]

I highly suspect insurance issues here. Document interaction with MD if you're nervous about it and move on.

Clinically speaking...

SS seems very unlikely as citalopram and escitalopram have the same serotonergic action.

It wouldn't be unreasonable to recommend periodic EKGs to monitor QTc if it would make you feel better.