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Porsteinsson AP, Drye LT, Pollock BG, Devanand DP, Frangakis C, Ismail Z, Marano C, Meinert CL, Mintzer JE, Munro CA, Pelton G, Rabins PV, Rosenberg PB, Schneider LS, Shade DM, Weintraub D, Yesavage J, Lyketsos CG, CitAD Research Group. Effect of citalopram on agitation in Alzheimer disease: the CitAD randomized clinical trial. JAMA. 2014 Feb 19;311(7):682-91. PubMed.
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King's College London
This is an important study, well-conducted by a “dream team” of U.S. researchers in the area. I expect that it will have a major impact upon practice in the field. Having said this, citalopram is clearly not a magic bullet for the treatment of agitation in AD. It joins a list of agents that have shown statistically significant superiority over placebo in the treatment of behavioral symptoms in dementia. But, as for the other agents, the benefits compared with placebo only just scraped over the margins of what might be considered a clinically significant difference. The field still needs to look for treatments that convincingly improve these distressing symptoms in a way that impacts positively on the experience of patients and their caregivers. Agitation is such a compound symptom that it is unlikely that there will be a pharmacological solution. Excellent trained nursing care remains the most effective and least harmful treatment course.
As regards safety, we only discovered the risks associated with the use of atypical antipsychotics in this indication from trial databases that were an order of magnitude larger than what is available from this study, so I think it is too early to comment on safety. The significance of the prolonged QT interval seen in 1 of 8 treated patients isn’t yet apparent. I suspect that the cognition difficulty may have more to do with the placebo patients improving their MMSE score (change over nine weeks 14.4 to 15.33), rather than citalopram patients worsening their score (17.0 to 16.83). I’d be relaxed about this.
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