Citalopram 40mg/ml Oral Drops, Solution

• Keep this leaflet. You may need to read it again.
• If you have any further questions, ask your doctor or pharmacist.
• This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours.
• If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. See section 4.

The name of your medicine is Citalopram 40mg/ml Oral Drops, Solution but it will be referred to as Citalopram throughout this leaflet.

1. What Citalopram is and what it is used for
2. What you need to know before you take Citalopram
3. How to take Citalopram
4. Possible side effects
5. How to store Citalopram
6. Contents of the pack and other information

Citalopram is a Selective Serotonin Reuptake Inhibitor (SSRI) and belongs to a group of medicines known as antidepressants.

These medicines help to correct certain chemical imbalances in the brain that are causing the symptoms of your illness.

Citalopram is used for the treatment of depression and, when you feel better, to help prevent these symptoms recurring. Citalopram is also used for long-term treatment to prevent the occurrence of new episodes of depression or if you have recurrent depression.

Citalopram is also beneficial in relieving symptoms if you tend to suffer from panic attacks.

Ask your doctor if you have any questions about why Citalopram has been prescribed for you.

• if you are allergic to citalopram, or any of the other ingredients of this medicine (listed in section 6).
  Consult your doctor if you think you might be
• at the same time as taking medication known as monoamine oxidase inhibitors (MAOIs). MAOIs include medicines such as phenelzine, iproniazid, isocarboxazid, nialamide, tranylcypromine and moclobemide (used for the treatment of depression), selegiline (used in the treatment of Parkinson’s disease) and linezolid (an antibiotic). Even if you have finished taking one of the following MAOIs: phenelzine, iproniazid, isocarboxazid, nialamide or tranylcypromine you will need to wait 2 weeks before you start taking Citalopram. One day must elapse after you have finished taking moclobemide. After stopping Citalopram you must allow 1 week before taking any MAOI
• if you are born with or have had an episode of abnormal heart rhythm (seen at ECG; an examination to evaluate how the heart is functioning)
• if you take medicines for heart rhythm problems or that may affect the heart’s rhythm (see Other medicines and Citalopram below).

Please tell your doctor if you have any medical problems, especially if you have:

• liver disease
• kidney disease
• diabetes (you may need an adjustment of your anti-diabetic therapy)
• epilepsy or a history of seizures or fits. Citalopram should be stopped if seizures occur or if there is an increase in the seizure frequency (see also section 4 “Possible side effects")
• a bleeding disorder or have ever suffered from bleeding in the stomach or intestine or if you are pregnant (see ‘Pregnancy’)
• mania or panic disorder
• low blood levels of sodium
• ECT (electroconvulsive therapy)
• suffered or suffer from heart problems or have recently had a heart attack
• a low resting heart-rate and/or you know that you may have salt depletion as a result of prolonged severe diarrhoea and vomiting (being sick) or usage of diuretics (water tablets)
• experienced a fast or irregular heartbeat, fainting, collapse or dizziness on standing up which may indicate abnormal functioning of the heart rate
• if you have a problem with dilatation of the pupil of the eye (mydriasis)
• or if you have or have previously had eye problems, such as certain kinds of glaucoma (increased pressure in the eye)
• if you have so-called psychosis with depressive episodes. Citalopram might make your psychotic symptoms worse.

Please consult your doctor, even if these statements were applicable to you at any time in the past.

Please note:

Some patients with manic-depressive illness may enter into a manic phase. This is characterised by unusual and rapidly changing ideas, inappropriate happiness and excessive physical activity. If you experience this, contact your doctor.

Symptoms such as restlessness or difficulty in sitting or standing still can also occur during the first weeks of the treatment. Tell your doctor immediately if you experience these symptoms.

As with other medicines used to treat depression or related diseases, the improvement is not achieved immediately.

After the start of Citalopram treatment it may take several weeks before you experience any improvement. In the treatment of panic disorder it usually takes 2-4 weeks before any improvement is seen. In the beginning of the treatment certain patients may experience increased anxiety, which will disappear during continued treatment. Therefore, it is very important that you follow exactly your doctor’s orders and do not stop the treatment or change the dose without consulting your doctor.

Occasionally, the symptoms of depression or panic disorder may include thoughts of suicide or self-harm. It is possible that these symptoms continue or get worse until the full antidepressant effect of the medicine becomes apparent. This is more likely to occur if you are a young adult, i.e. under 25 years of age and you have not used antidepressive medicines before.

Sometimes you may be unaware of the above-mentioned symptoms and therefore you may find it helpful to ask a friend or relative to help you to observe the possible signs of change in your behavior.

Tell your doctor immediately or contact the nearest hospital if you have disturbing thoughts or experiences or if any of the above-mentioned symptoms occurs during the treatment.

If you are depressed and/or have anxiety disorders you can sometimes have thoughts of harming or killing yourself.

These may be increased when first starting antidepressants, since these medicines all take time to work, usually about two weeks but sometimes longer.

You may be more likely to think like this if:

• you have previously had thoughts about killing or harming yourself
• you are a young adult. Information from clinical trials has shown an increased risk of suicidal behaviour in adults aged less than 25 years with psychiatric conditions who were treated with an antidepressant.

If you have thoughts of harming or killing yourself at any time, contact your doctor or go to a hospital straight away.

You may find it helpful to tell a relative or close friend that you are depressed or have an anxiety disorder, and ask them to read this leaflet. You might ask them to tell you if they think your depression or anxiety is getting worse, or if they are worried about changes in your behaviour.

Medicines like Citalopram (so called SSRIs/SNRIs) may cause symptoms of sexual dysfunction (see section 4). In some cases, these symptoms have continued after stopping treatment.

Citalopram should normally not be used for children and adolescents under 18 years. Also, you should know that patients under 18 have an increased risk of side-effects such as suicide attempt, suicidal thoughts and hostility (predominantly aggression, oppositional behaviour and anger) when they take this class of medicines. Despite this, your doctor may prescribe Citalopram for patients under 18 because he/she decides that this is in their best interests. If your doctor has prescribed Citalopram for a patient under 18 and you want to discuss this, please go back to your doctor. You should inform your doctor if any of the symptoms listed above develop or worsen when patients under 18 are taking Citalopram. Also, the long-term safety effects concerning growth, maturation and cognitive and behavioural development of Citalopram in this age group have not yet been demonstrated.

Medicines may affect the action of other medicines and this can sometimes cause serious adverse reactions.

Please tell your doctor or pharmacist if you are taking, have taken or might take any other medicines. This includes other medicines for depression (see Do not take Citalopram above), medicines that you buy without a prescription and herbal medicines.

• the herbal remedy St John's wort (Hypericum perforatum). This should not be taken at the same time as Citalopram
• monoamine oxidase inhibitors (MAOIs). These should not be taken at the same time as Citalopram (see Do not take Citalopram above).

Tell your doctor if you are taking any of the following medicines:

• linezolid (an antibiotic)
• Sumatriptan and similar medicines (used to treat migraine) and tramadol and similar medicines (opioids, used against severe pain); these increase the risk of side effects; if you get any unusual symptoms when using this combination you should see your doctor.
• lithium (used to prevent and treat mania) and tryptophan (an antidepressant)
• pimozide (a neuroleptic). This should not be taken at the same time as Citalopram
• imipramine and desipramine (used to treat depression)
• medicines containing selegiline (used to treat Parkinson’s disease)
• cimetidine, lansoprazole and omeprazole (used to treat stomach ulcers), fluconazole (used to treat fungal infections), fluvoxamine (antidepressant) and ticlopidine (used to reduce the risk of stroke). These may cause increased blood levels of citalopram
• mefloquine (used to treat malaria)
• bupropion (used to treat depression)
• medicines known to affect the blood platelets (e.g. anticoagulant drugs used to treat or prevent blood clots; aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and diclofenac used as painkillers; and some antipsychotic drugs and tricyclic antidepressants)
• metoprolol, a beta blocker used to treat migraine, some heart conditions and high blood pressure. The effects of either drug could be increased, decreased or altered
• neuroleptics (used in the treatment of schizophrenia) and antidepressants (SSRIs) due to a possible risk of a lowered threshold for seizures
• Medicines that decrease blood levels of potassium or magnesium as these conditions increase the risk of life-threatening heart rhythm disorder.

Do not take Citalopram if you take medicines for heart rhythm problems or medicines that may affect the heart’s rhythm, e.g. such as Class IA and III antiarrhythmics, antipsychotics (e.g. phenothiazine derivatives, pimozide, haloperidol), tricyclic antidepressants, certain antimicrobial agents (e.g. sparfloxacin, moxifloxacin, erythromycin IV, pentamidine, anti-malarial treatment particularly halofantrine), certain antihistamines (astemizole, mizolastine). If you have any further questions about this you should speak to your doctor.

Citalopram can be taken with or without food (see section 3 “How to take Citalopram”).

As with all antidepressants, it is sensible to avoid drinking alcohol whilst receiving treatment although Citalopram has not been shown to increase the effects of alcohol.

Ask your doctor or pharmacist for advice before taking any medicine. If you are pregnant, think you might be pregnant, or are trying to become pregnant, tell your doctor. Do not take Citalopram if you are pregnant unless you and your doctor have discussed the risks and benefits involved.

If you take Citalopram near the end of your pregnancy there may be an increased risk of heavy vaginal bleeding shortly after birth, especially if you have a history of bleeding disorders. Your doctor or midwife should be aware that you are taking Citalopram so they can advise you.

Make sure your midwife and/or doctor know you are on Citalopram. When taken during pregnancy, particularly in the last 3 months of pregnancy, medicines like Citalopram may increase the risk of a serious condition in babies, called persistent pulmonary hypertension of the newborn (PPHN), making the baby breathe faster and appear bluish. These symptoms usually begin during the first 24 hours after the baby is born. If this happens to your baby you should contact your midwife and/or doctor immediately. Also, if you take Citalopram during the last 3 months of your pregnancy and until the date of birth you should be aware that the following effects may be seen in your newborn: trouble with breathing, blue-ish skin, fits, being too hot or cold, feeding difficulties, vomiting, low blood sugar, stiff or floppy muscles, overactive reflexes, tremor, jitteriness, irritability, lethargy, constant crying, sleepiness or sleeping difficulties. If your newborn baby gets any of these symptoms please contact your midwife and/or doctor immediately.

Ask your doctor or pharmacist for advice before taking any medicine. If you are breast-feeding, ask your doctor for advice. You should not breast-feed your baby when taking Citalopram because small amounts of the medicine can pass into the breast milk.

Citalopram has been shown to reduce the quality of sperm in animal studies. Theoretically, this could affect fertility, but impact on human fertility has not been observed as yet.

Citalopram does not usually affect the ability to carry out normal daily activities. However, if you feel dizzy or sleepy when you start to take this medicine, you should be careful when driving, operating machinery or performing jobs that need you to be alert until these effects wear off.

This product contains methyl parahydroxybenzoate (E218) and ethyl parahydroxybenzoate (E214), which may cause allergic reactions (possibly delayed).

Always take this medicine exactly as your doctor or pharmacist has told you. Check with your doctor or pharmacist if you are not sure.

Adults

Depression

The usual dose is 16mg (8 drops) per day. This may be increased by your doctor to a maximum of 32mg (16 drops) per day.

Panic disorder

The starting dose is 8mg (4 drops) per day for the first week before increasing the dose to between 16 -24mg (8 to 12 drops) per day. The dose may be increased by your doctor to a maximum of 32mg (16 drops) per day.

Elderly patients (above 65 years of age)

The starting dose should be decreased to half of the recommended dose, e.g. 8-16mg per day.

Elderly patients should not usually receive more than 16mg (8 drops) per day.

Children and adolescents (less than 18 years of age)

Citalopram should not be given to children or adolescents under 18 years of age. For further information, please see section 2, “What you need to know before you take Citalopram”.

Patients with special risks

Patients with liver complaints should not receive more than 16mg (8 drops) per day.

Count the required number of drops into your drink (water, orange juice or apple juice), stir it briefly and then drink all of it.

If you have previously taken citalopram tablets, you will find that the dose of your medicine in mg given as drops is a bit lower than that of tablets. This is because your body more easily absorbs the drops than the tablets, so you do not need as many mg to have the same effect.

The doses of tablets correspond to doses of drops as follows:

Tablets / dose Equivalent Drops

10mg 8mg (4 drops)

20mg 16mg (8 drops)

30mg 24mg (12 drops)

40mg 32mg (16 drops)

The drops are for oral use and can be taken in a drink of water, or orange or apple juice.

Citalopram is taken every day as one dose at any time of the day.

Like other medicines for depression and panic disorder these drops may take a few weeks before you feel any improvement. Continue to take Citalopram even if it takes some time before you feel any improvement in your condition.

The duration of treatment is individual, usually at least 6 months. Continue to take the drops for as long as your doctor recommends. Do not stop taking them even if you begin to feel better, unless you are told to do so by your doctor. The underlying illness may persist for a long time and if you stop your treatment too soon your symptoms may return.

Patients who have recurrent depression benefit from continued treatment, sometimes for several years, to prevent the occurrence of new depressive episodes.

Never change the dose of the medicine without talking to your doctor first.

If you think that you or anyone else may have taken too many Citalopram drops, contact your doctor or nearest hospital emergency department immediately. Do this even if there are no signs of discomfort or poisoning. Take the Citalopram box/container with you if you go to a doctor or hospital, this is so the doctor knows what you have taken. Some of the signs of an overdosage could be life-threatening.

Symptoms of overdosage may include:

• irregular heart beat
• seizures
• changes in heart rhythm
• feeling sick (nausea)
• vomiting
• sweating
• drowsiness
• unconsciousness
• fast heart beats
• tremor
• changes in blood pressure
• serotonin syndrome (see section 4)
• agitation
• dizziness
• enlarged eye pupils
• bluish skin
• breathing too quickly.

Do not take a double dose to make up for a forgotten dose. If you forget to take a dose, and you remember before you go to bed, take it straight away. Carry on as usual the next day. If you only remember during the night, or the next day, leave out the missed dose and carry on as usual.

Do not stop taking citalopram until your doctor tells you to do so. When you have completed your course of treatment, it is generally advised that the dose of citalopram is gradually reduced over a number of weeks.

Stopping this medicine quickly may cause symptoms such as dizziness, nausea and numbness or tingling in hands or feet, sleep disturbances (vivid dreams, nightmares, inability to sleep), feeling anxious, headaches, feeling or being sick, sweating, feeling restless or agitated, tremor, feeling confused or disorientated, feeling emotional or irritable, diarrhoea (loose stools), visual disturbances, fluttering or pounding heartbeat (palpitations). These are usually non-serious and disappear within a few days. When you have completed your course of treatment, the dose of Citalopram is usually reduced gradually over a couple of weeks.

Stop taking Citalopram and seek medical advice immediately if you have any of the following symptoms:

Rare (may affect up to 1 in 1,000 people):

• Hyponatraemia: abnormally low blood levels of sodium which can cause tiredness, confusion, and muscle twitching.

Not known (frequency cannot be estimated from the available data):

• High fever, agitation, confusion, trembling and abrupt contractions of muscles; these may be signs of a rare condition called serotonin syndrome which has been reported with the combined use of antidepressants.
• Swelling of skin, throat, tongue, lips, or face, feeling dizzy or having difficulties breathing or swallowing (serious allergic reaction).
• Unusual bleeds, including gastrointestinal bleeds.
• Fast, irregular heartbeat, fainting, which could be symptoms of a life-threatening condition known as Torsade de Pointes.

If you notice any of the following you should contact your doctor immediately as your dose may need to be reduced or stopped:

• you start having fits for the first time or fits that you have suffered from in the past before become more frequent
• your behaviour changes because you feel elated or over excited
• you experience high fever, agitation, confusion, and trembling or abrupt contractions of muscles. These may be signs of a rare condition called serotonin syndrome
• tiredness, confusion and twitching of your muscles. These may be signs of a low blood level of sodium (hyponatraemia).

If you have thoughts of harming or killing yourself at any time, contact your doctor or go to a hospital straight away.

The following side effects are often mild and usually disappear after a few days’ treatment.

Very common (may affect more than 1 in 10 people)

• sleepiness
• difficulty in sleeping
• headache
• increased sweating
• dry mouth (a dry mouth increases the risk of tooth decay, so be sure to clean your teeth more often than usual)
• feeling sick (nausea).

Common (may affect up to 1 in 10 people)

• decreased appetite
• agitation
• decreased sex drive
• anxiety
• nervousness
• confusion
• abnormal dreams
• tremor
• tingling or numbness in the hands or feet
• dizziness
• problems concentrating
• ringing in the ears (tinnitus)
• yawning
• diarrhoea
• vomiting
• constipation
• itching
• pain in muscles and joints
• for men, problems with ejaculation and erection
• for women, failing to reach an orgasm
• fatigue
• fever
• prickling of the skin
• loss of weight.

Uncommon (may affect up to 1 in 100 people)

• Purpura: red or purple patches/spots (smaller than 1cm) of the skin caused by bleeding underneath
• increased appetite
• aggression
• depersonalisation (feeling detached from yourself)
• hallucinations
• mania (feeling excessively elated, impulsive, irritable, or irrational)
• fainting
• large pupils (the dark centre of the eye)
• fast heart beat
• slow heart beat
• nettle rash
• loss of hair
• rash
• sensitivity to sunlight
• difficulties urinating
• excessive menstrual bleeding
• swelling of the arms or legs
• increased weight.

Rare (may affect up to 1 in 1000 people)

• convulsions
• involuntary movements
• taste disturbances
• bleeding
• hepatitis

Some patients have reported (frequency not known)

• thoughts of harming or killing themselves, see also section 2. “What you need to know before you take Citalopram”
• an increase in bleeding or bruising caused by a decrease in blood platelets (thrombocytopenia)
• rash (hypersensitivity)
• disruption to the hormones affecting urine production
• low potassium levels in the blood (hypokalaemia), which can cause muscle weakness, twitching or abnormal heart rhythms
• panic attack
• grinding teeth
• restlessness
• unusual muscle movements or stiffness
• involuntary movements of the muscles (akathisia)
• visual disturbance
• low blood pressure
• nosebleed
• bleeding disorders including skin and mucosal bleeding (ecchymosis)
• sudden swelling of skin or mucosa
• in men, painful erections
• increased blood levels of the hormone prolactin
• flow of breast milk in men or in women who are not breast-feeding (galactorrhoea)
• irregular menstrual periods
• abnormal liver function tests
• an increased risk of bone fractures has been observed in patients taking this type of medicines
• alteration of the heart rhythm (called “prolongation of QT interval”, seen on ECG, a trace of the electrical activity of the heart).
• heavy vaginal bleeding shortly after birth (postpartum haemorrhage), see Pregnancy in section 2 for more information

SSRIs can, very rarely, increase the risk of bleeding, including stomach or intestinal bleeding. Let your doctor know if you vomit blood or develop black or blood stained stools.

Also let your doctor know if you continue to have other symptoms associated with your depression. This might include hallucinations, anxiety, mania or confusion.

Any side effects that do occur will usually disappear after a few days. If they are troublesome or persistent, or if you develop any other unusual side effects while taking Citalopram, please tell your doctor.

If you get any side effects please talk to your doctor or pharmacist. This includes any possible side-effects not mentioned in this leaflet.

Reporting of side effects:

If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via the Yellow Card Scheme Website at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

By reporting side effects you can help provide more information on the safety of this medicine.

The active substance is citalopram (as hydrochloride).

Each ml of the solution contains 40mg citalopram (as hydrochloride).

Each ml of the solution contains 20 drops.

Each drop contains 2mg citalopram.

The other ingredients are methyl parahydroxybenzoate (E218), ethyl parahydroxybenzoate (E214), hydroxyethylcellulose and purified water.

Citalopram is a clear, colourless solution supplied in an amber glass bottle containing 15ml solution fitted with polyethylene dropper with tamper evident, child resistant plastic cap.

Citalopram is sugar free.