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Draw blood before next scheduled dose.
Centrifuge and remove serum from cells within 2 hours of collection.
Test interpretation requires knowledge of which enantiomers (R, S- or S-) are prescribed; this assay does not distinguish the enantiomers. Flagging is based off of the racemic R,S-enantiomeric citalopram reference range, not the S-enantiomer escitalopram reference range.
Specimens that are obtained from gel tubes are not acceptable.
Citalopram (Celexa) and S-citalopram (escitalopram, Lexapro) are approved for treatment of depression. Celexa is a racemic mixture containing equal amounts of R- and S-enantiomer. Metabolites of citalopram (N-desmethylcitalopram) are less active than citalopram and do not accumulate in serum to clinically significant concentration.
Citalopram metabolism is carried out by cytochrome P450 (CYP) 2C19 and 3A4-5. CYP 2D6 may play a minor role in citalopram metabolism. Citalopram is known to reduce CYP 2D6 activity. Citalopram clearance is significantly affected by reduced hepatic function, but only slightly by reduced renal function.
A typical Celexa dose administered to an adult is 40-mg per day. A typical Lexapro dose is 20-mg per day. Citalopram is 80% protein bound, and the apparent volume of distribution is 12 L/Kg. Bioavailability is 80% and protein binding is 56% for either form of the drug. Time to peak serum concentration is 4 hours, and the elimination half-life is 35 hours. Half-life is increased in the elderly. Dosage reductions may be necessary for patients who are elderly or have reduced hepatic function.
Steady-state serum concentrations associated with optimal response to citalopram are in the range of 50 to 100 ng/mL when the patient is administered the R,S-enantiomeric mixture (Celexa).
The most common toxicities associated with excessive serum concentration are fatigue, impotence, insomnia, and anticholinergic effects. The toxic range for citalopram is greater than 220 ng/mL.