Clomipramine (Anafranil)

Tricyclic antidepressant (serotonin, norepinephrine reuptake inhibitor)

  • OCD (10+)1
  • Panic2
  • Major Depression3

Features

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Handout

Dosing

Start 25 mg QD, target 150-250 mg QD

Dose by serum level: 70−200 (for clomipramine) 150−300 (for norclomipramine)

INTERACTIONS: Use 1/2 dose and check levels carefully if giving with strong CYP2D6 inhibitors (asenapine, bupropion, cannabidiol, duloxetine, fluoxetine, paroxetine, and sertraline ≥ 150 mg/day)

Management

Most serotonergic TCA and only used in OCD; slightly more effective than SSRIs.

TOLERABILITY: ANTICHOLINERGIC: Constipation (treat docusate 100 mg BID + sennosides 8.6 mg; bethanechol 10-25 mg tid if severe), urinary retention (treat bethanechol 25mg tid), dry mouth (treat spry gum tid, biotene; or pilocarpine swish), blurry vision, confusion.

RISKS: HEART: Orthostatic hypotension (treat elastic abdominal binders or support stockings; if severe, fludrocortisone 0.1-0.2 mg qd or midrodine 0.5 mg tid), falls, cardiac arrhythmias; HEPATOTOXICITY: Extremely rare (4 per 100,000 patient-years).

EMR Text

OCD

Clomipramine use based on FDA approval in obsessive compulsive disorder.

Clomipramine side effects, including cardiac, hypotension, and hepatotoxicity, reviewed with patient.

Depression

Clomipramine use based on controlled trials in major depressive disorder.

Clomipramine side effects, including cardiac, hypotension, and hepatotoxicity, reviewed with patient.

Panic Disorder

Clomipramine use based on controlled trials in panic disorder (Sasson Y et al, Eur Neuropsychopharmacol. 1999;9(3):191-196).

Clomipramine side effects, including cardiac, hypotension, and hepatotoxicity, reviewed with patient.

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