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February 26, 2014
Citalopram Reduces Alzheimer’s Agitation, but Side Effects Limit Usage
Rochester, NY—A widely used antidepressant reduced agitation in Alzheimer’s disease patients, but researchers said they couldn’t generally recommend the drug at the dosage tested because of unacceptable side effects. With 30 mg a day of citalopram, patients experienced mild cognitive and cardiac adverse effects, according to the research published recently in the Journal of the American Medical Association. Background in the article notes that agitation is persistent, difficult to treat, costly, and associated with severe adverse consequences for patients and caregivers, yet current pharmacologic therapies have proven inadequate. Although widely used for the condition, antipsychotic drugs raise both serious safety concerns, including increased risk of death, and uncertain effectiveness, according to the article. The study, led by researchers from the University of Rochester, sought to test the efficacy and safety of citalopram, which is frequently used in older patients to treat depression. For the investigation, 186 patients with probable Alzheimer disease without major depression and clinically significant agitation were randomized to receive citalopram or placebo for 9 weeks. Both groups, drawn from medical centers in the United States and Canada, received psychological counseling and assistance. Treatment with citalopram at 30 mg per day significantly reduced agitations: By one measure, 40% of citalopram-treated participants were judged to be much or very much improved versus 26% those receiving a placebo. Researchers found in the intervention group, however, a worsening of cognition and higher risks of ECG changes that could predispose to an abnormal heart rhythm. Citalopram “cannot be generally recommended as an alternative treatment option at that dose,” they conclude. “An assessment of individual patient circumstances, including symptom severity, value of improvement, cognitive function and change, cardiac conduction, vulnerability to adverse effects, and effectiveness of behavioral interventions can help guide appropriate medication use in patients with marked agitation or aggression,” the authors recommend. An accompanying commentary from Gary Small, MD, of the University of California, Los Angeles, suggests that nonpharmacologic strategies be used for agitation and that clinicians remain cautious about prescribing medications until more information is available. “In addition to educating caregivers and family members about the potential risks and benefits of particular medications, physicians should carefully document their treatment plans and aim for short-term treatment to minimize the possible added risks of long-term use,” Small writes. “As demonstrated by the results of this study of citalopram, when behavioral interventions fail to improve agitation, multiple factors need consideration for selecting the best medication for an individual patient, including cardiac safety issues and evidence of efficacy from randomized controlled trials. Until more definitive treatments are available, the careful selection and monitoring of pharmacologic agents may help optimize the level of functioning and quality of life for some patients with dementia.” Study coauthor Constantine Lyketsos, MD, of Johns Hopkins Medicine, pointed out that the cognition declines with citalopram were “not huge, but measureable,” adding “That introduces a tradeoff.” “If the agitation is not responding to non-medication treatments and your patient’s agitation isn’t improving, there are no great options,” Lyketsos added. “But here’s another medication choice that might be safer than other medications and seems to be just as effective.” |
U.S. Pharmacist Social Connect
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