Serotonergic Drugs: Based on the mechanism of action of SNRIs and SSRIs including Citalopram hydrobromide, and the potential for serotonin syndrome, caution is advised when Citalopram hydrobromide is coadministered with other drugs that may affect the serotonergic neurotransmitter systems, such as triptans, linezolid (an antibiotic which is a reversible non-selective MAOI), lithium, tramadol, or St. John's Wort (see WARNINGS-Serotonin Syndrome). The concomitant use of Citalopram hydrobromide with other SSRIs, SNRIs or tryptophan is not recommended (see PRECAUTIONS \- Drug Interactions).

Triptans: There have been rare postmarketing reports of serotonin syndrome with use of an SSRI and a triptan. If concomitant treatment of Citalopram hydrobromide with a triptan is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases (seeWARNINGS \- Serotonin Syndrome).

CNS Drugs \- Given the primary CNS effects of citalopram, caution should be used when it is taken in combination with other centrally acting drugs.

Alcohol \- Although citalopram did not potentiate the cognitive and motor effects of alcohol in a clinical trial, as with other psy¬chotropic medications, the use of alcohol by depressed patients taking Citalopram hydrobromide is not recommended.

Monoamine Oxidase Inhibitors (MAOIs) \- See CONTRAINDICATIONS and WARNINGS.

Drugs That Interfere With Hemostasis (NSAIDs, Aspirin, Warfarin, etc.)\- Serotonin release by platelets plays an important role in hemostasis. Epidemiological studies of the case-control and cohort design that have demonstrated an association between use of psychotropic drugs that interfere with serotonin reuptake and the occurrence of upper gastrointestinal bleeding have also shown that concurrent use of an NSAID or aspirin potentiated the risk of bleeding. Altered anticoagulant effects, including increased bleeding, have been reported when SSRIs and SNRIs are coadministered with warfarin. Patients receiving warfarin therapy should be carefully monitored when Citalopram hydrobromide is initiated or discontinued.

Cimetidine \- In subjects who had received 21 days of 40 mg/day Citalopram hydrobromide, combined administration of 400 mg/day cimetidine for 8 days resulted in an increase in citalopram AUC and Cmax of 43% and 39%, respectively. The clinical significance of these findings is unknown.

Digoxin \- In subjects who had received 21 days of 40 mg/day Citalopram hydrobromide, combined administration of Citalopram hydrobromide and digoxin (single dose of 1 mg) did not significantly affect the pharmacokinetics of either citalopram or digoxin.

Lithium \- Coadministration of Citalopram hydrobromide (40 mg/day for 10 days) and lithium (30 mmol/day for 5 days) had no significant effect on the pharmacokinetics of citalopram or lithium. Nevertheless, plasma lithium levels should be monitored with appropriate adjustment to the lithium dose in accordance with standard clinical practice. Because lithium may enhance the serotonergic effects of citalo¬pram, caution should be exercised when Citalopram hydrobromide and lithium are coadministered.

Pimozide \- In a controlled study, a single dose of pimozide 2 mg co-administered with citalopram 40 mg given once daily for 11 days was associated with a mean increase in QTc values of approximately 10 msec compared to pimozide given alone. Citalopram did not alter the mean AUC or Cmax of pimozide. The mechanism of this pharmacodynamic interaction is not known.

Theophylline \- Combined administration of Citalopram hydrobromide (40 mg/day for 21 days) and the CYP1A2 substrate theophylline (single dose of 300 mg) did not affect the pharmacokinetics of theophylline. The effect of theophylline on the pharmacokinetics of citalopram was not evaluated.

Sumatriptan \- There have been rare postmarketing reports describing patients with weakness, hyperreflexia, and incoordina¬tion following the use of a SSRI and sumatriptan. If concomitant treatment with sumatriptan and an SSRI (e.g., fluoxetine, fluvox¬amine, paroxetine, sertraline, citalopram) is clinically warranted, appropriate observation of the patient is advised.

Warfarin \- Administration of 40 mg/day Citalopram hydrobromide for 21 days did not affect the pharmacokinetics of warfarin, a CYP3A4 substrate. Prothrombin time was increased by 5%, the clinical significance of which is unknown.

Carbamazepine \- Combined administration of Citalopram hydrobromide (40 mg/day for 14 days) and carbamazepine (titrated to 400 mg/day for 35 days) did not significantly affect the pharmacokinetics of carba¬mazepine, a CYP3A4 substrate. Although trough citalopram plasma levels were unaffected, given the enzyme-inducing prop¬erties of carbamazepine, the possibility that carbamazepine might increase the clearance of citalopram should be considered if the two drugs are coadministered.

Triazolam \- Combined administration of Citalopram hydrobromide (titrated to 40 mg/day for 28 days) and the CYP3A4 substrate triazolam (sin¬gle dose of 0.25 mg) did not significantly affect the pharmacoki¬netics of either citalopram or triazolam.

Ketoconazole \- Combined administration of Citalopram hydrobromide (40 mg) and ketoconazole (200 mg) decreased the Cmax and AUC of keto¬conazole by 21% and 10%, respectively, and did not significantly affect the pharmacokinetics of citalopram.

CYP3A4 and 2C19 Inhibitors \- In vitro studies indicated that CYP3A4 and 2C19 are the primary enzymes involved in the metabolism of citalopram. However, coadministration of citalo¬pram (40 mg) and ketoconazole (200 mg), a potent inhibitor of CYP3A4, did not significantly affect the pharmacokinetics of citalopram. Because citalopram is metabolized by multiple enzyme systems, inhibition of a single enzyme may not apprecia¬bly decrease citalopram clearance.

Metoprolol \- Administration of 40 mg/day Citalopram hydrobromide for 22 days resulted in a two-fold increase in the plasma levels of the beta-¬adrenergic blocker metoprolol. Increased metoprolol plasma lev¬els have been associated with decreased cardioselectivity. Coadministration of Citalopram hydrobromide and metoprolol had no clinically sig¬nificant effects on blood pressure or heart rate.

Imipramine and Other Tricyclic Antidepressants (TCAs) \- In vitro studies suggest that citalopram is a relatively weak inhibitor of CYP2D6. Coadministration of Citalopram hydrobromide (40 mg/day for 10 days) with the TCAimipramine (single dose of 100 mg), a substrate for CYP2D6, did not significantly affect the plasma concentrations of imipramine or citalopram. However, the concentration of the imipramine metabolite desipramine was increased by approxi¬mately 50%. The clinical significance of the desipramine change is unknown. Nevertheless, caution is indicated in the coadminis¬tration of TCAs with Citalopram hydrobromide.

Electroconvulsive Therapy (ECT) \- There are no clinical studies of the combined use of electroconvulsive therapy (ECT) and Citalopram hydrobromide.