Citalopram
Summary
Environmental information for citalopram is missing on fass.se (2020-10-12). It is voluntary for manufacturers to provide information about environmental impact on fass.se. This summary information on persistence, bioaccumulation and toxicity is based on previous environmental information in Fass from 2018. For risk, see the environmental assessments from Goodpoint.
Persistence. The potential for persistence of citalopram cannot be excluded, due to lack of data.
Bioaccumulation. Citalopram has low potential for bioaccumulation.
Toxicity. Citalopram has very high acute toxicity.
Risk. See the environmental assessments from Goodpoint below.
Citalopram is a racemate of which one of the enantiomers, escitalopram (S-form), has the pharmacological effect. Therefore, see also the information about escitalopram.
Suggestions on how to reduce emissions of citalopram and escitalopram
Detailed information
Fass environmental information
Fass environmental information for Cipramil (citalopram) from H. Lundbeck AB (downloaded 2018-07-10).
Hazard
Persistence: "The potential for persistence of Citalopram cannot be excluded, due to lack of data."
Bioaccumulation: Log Kow = 1.39.
Acute toxicity: There are data for 2 trophic levels, lowest for algae (Pseudokirchneriella subcapita) 1.6 mg/L.
Risk
Sales data are available for Sweden in the year 2013. PEC/PNEC: "As the base set is not complete, it is not possible to determine the most sensitive specie, and a PNEC cannot be derived." Risk of environmental impact of citalopram cannot be excluded, since there is not sufficient ecotoxicity data available.
Report Goodpoint 2016
Concentrations in the environment in Sweden for several SSRI/SNRIs exceed concentrations with reported effect on the aquatic environment, especially for invertebrates. However, studies with the very lowest effect concentrations are questioned. Levels of citalopram in fish exposed to treated wastewater are equivalent with therapeutic levels in humans.
Citalopram is included in the Region Stockholm's table of pharmaceuticals with a negative environmental impact according to the environmental programme 2017–2021 based on lowest effect concentration, LOEC = 150 ng/L, and concentrations found in the environment. Citalopram has been detected in treated wastewater and surface water in Region Stockholm. The method for analysis does not distinguish between the different enantiomers.
Report Goodpoint 2018
Comparative assessment of environmental risk in the use of citalopram, escitalopram, sertraline, fluoxetine, venlafaxine, paroxetine and clomipramine in Sweden.
Overall, there is a risk profile for the studied antidepressants.
The Wise list
In the Wise list escitalopram is recommended. Environmental classification of pharmaceuticals is taken into consideration, sometimes with other environmental aspects, when selecting pharmaceuticals for the Wise list. When comparable pharmaceuticals are equivalent to medical effects, safety and pharmaceutical efficacy, environmental impact and price are considered.
Suggestions on how to reduce emissions of citalopram and escitalopram
Concrete proposals on how to work to reduce emissions of environmentally harmful pharmaceuticals on the list have been developed in close cooperation with the Stockholm Drug and Therapeutics Committee's expert groups. The action proposals were developed from an environmental perspective. The patient's best always goes first and several pharmaceuticals on the list are also included in the Wise list. However, for such pharmaceuticals, there may be measures that could reduce the environmental impact.
Concrete proposal for citalopram and escitalopram
- In the first place, non pharmacological treatment and/or measures (e.g., CBT and physical activity) alone or in combination with pharmaceuticals for the treatment of depression. Avoid overconsumption of alcohol.
- Citalopram is not recommended in the Wise list. Instead, escitalopram is recommended.
- Avoid randomized prescribing of SSRIs (e.g., escitalopram/citalopram). Evaluate and reconsider the treatment with SSRIs. Can the pharmaceutical be de-prescribed?
- Starter pack for escitalopram is available within the reimbursement system.
References
- Goodpoint. Prioritering av läkemedel med miljörisk inom SLL. Stockholm: Goodpoint; 2016. Rapport LS 2016–0634.
- Provtagningar av läkemedelsrester i vatten, sediment och fisk för Region Stockholm.
- Kellner M, Porseryd T, Porsch-Hällström I, Hansen SH, Olsén KH. Environmentally relevant concentrations of citalopram partially inhibit feeding in the three-spine stickleback (Gasterosteus aculeatus). Aquat Toxicol. 2015;158:165-70.
- Grabicova K, Lindberg RH, Ostman M, Grabic R, Randak T, Larsson DG et al. Tissue-specific bioconcentration of antidepressants in fish exposed to effluent from a municipal sewage treatment plant. Sci Total Environ. 2014;488-489:46-50.
- IVL Swedish Environmental Research Institute Ltd. Fick J, Lindberg RH, Kaj L, Brorström-Lundén E. Results from the Swedish National Screening Programme 2010. Subreport 3. Pharmaceuticals.
- Fick J, Lindberg RH, Tysklind M, Larsson DG. Predicted critical environmental concentrations for 500 pharmaceuticals. Regul Toxicol Pharmacol. 2010;58:516-23.
- Region Stockholm. Förteckning över miljöbelastande läkemedel med åtgärdsförslag framtagen inom ramen för Region Stockholms miljöprogram 2017–2021.
- Goodpoint. Jämförande bedömning av miljörisk vid användning av citalopram, escitalopram, sertralin, fluoxetin, venlafaxin, paroxetin och klomipramin. Stockholm: Goodpoint; 2018.
- Fass.se för vårdpersonal
- Stockholm Drug and Therapeutics Committee. Kloka listan (Wise list).
- Stockholm Drug and Therapeutics Committee. The Wise List 2015.
Author: Health and Medical Care Administration, Region Stockholm