Clomipramine

About Clomipramine

Clomipramine is a tricyclic antidepressant that strongly blocks the reuptake of serotonin. Its only approved use is the obsessions and compulsions of obsessive-compulsive disorder (OCD) in adults and in children and adolescents aged 10 and older; it is not approved for depression. Treatment starts at 25 mg a day, taken in divided doses with meals to limit stomach upset, and is raised over the first two weeks to about 100 mg a day in adults, then more gradually to a maximum of 250 mg a day. Children start at 25 mg a day and are limited to 3 mg per kilogram or 200 mg a day, whichever is less. Once the dose is settled, the whole daily amount may be taken at bedtime to reduce daytime drowsiness. The full benefit can take several weeks or longer.

The boxed warning says antidepressants increased the risk of suicidal thinking and behavior in children, adolescents and young adults in short-term studies, so anyone starting treatment or changing dose is watched for worsening mood, agitation or unusual behavior. Clomipramine must not be taken with a monoamine oxidase inhibitor or within 14 days of one, must not be started with linezolid or intravenous methylene blue, and is contraindicated during recovery from a heart attack. Seizures are its most important particular risk and appear to rise with dose, which is why the daily maximum exists; it can also trigger mania in people with bipolar illness, cause serotonin syndrome with other serotonergic medicines, and bring on angle-closure glaucoma in people with narrow angles. Dry mouth, drowsiness, tremor, dizziness, constipation, tiredness, sweating and weight gain were the most common side effects in trials, and sexual side effects were frequent in men.

What is distinctive is how carefully it is started, raised and stopped: a drop in blood pressure on standing and a fast heartbeat can occur, so people with heart disease are dosed cautiously, and stopping suddenly can cause dizziness, nausea and irritability, so the dose is tapered. Medicines that block the liver enzyme CYP2D6, including fluoxetine and other SSRIs, quinidine and cimetidine, raise clomipramine levels; the label says enough time must pass after stopping fluoxetine before clomipramine is started, and at least five weeks may be needed. Alcohol and other sedatives add to its drowsiness. There are no adequate studies in pregnancy, withdrawal symptoms have been reported in newborns, and the drug passes into breast milk. Clomipramine is not a controlled substance.

Taking Clomipramine

How to take it

At the start it is usually taken three times a day with meals; once the dose is settled the prescriber may move the whole dose to bedtime. Take it at the same times each day, keep taking it even if you do not feel better yet, and do not stop without talking to the prescriber.

If you miss a dose

Take it as soon as you remember, unless it is almost time for the next dose; then skip the missed dose. Do not take a double dose.

Storage

In the original tightly closed container at room temperature, protected from moisture (not in the bathroom), out of reach of children.

Interactions to know about

Never with a monoamine oxidase inhibitor such as phenelzine, tranylcypromine or selegiline, or within 14 days of one, and not started with linezolid or intravenous methylene blue. Fluoxetine and other SSRIs, quinidine, cimetidine and haloperidol raise its level; barbiturates and phenytoin lower it. Alcohol and other sedatives add to drowsiness, and other serotonergic medicines add to the risk of serotonin syndrome.

This summarizes the official prescribing information. Your prescriber’s and pharmacist’s instructions, and the leaflet that comes with your medicine, take priority.

Why the cash price for Clomipramine differs from pharmacy to pharmacy

Clomipramine is an old generic prescribed far less often than the SSRIs, so not every pharmacy keeps all three strengths, and quotes depend on which maker the pharmacy buys from and whether the drug sits on a flat-price generic list. Doses are built from more than one capsule strength during the climb to the maintenance dose, so the quote changes as the dose changes.

At the usual adult doses a month is several capsules a day, so the count is large and the quote reflects the exact strength and quantity written; a prescription for the Anafranil brand without substitution is priced as a brand and costs far more than the generics.

Ways to pay less for Clomipramine without insurance

• Ask the prescriber to write clomipramine generically and allow substitution.
• Once your dose is settled, ask the prescriber whether it can be written using a single capsule strength, and whether a ninety-day supply suits you.
• Ask the pharmacy to quote the exact strength and count on the prescription, and compare more than one pharmacy, since stocking of the 50 mg and 75 mg capsules varies.
• Ask whether clomipramine is on the pharmacy’s flat-price generic list.
• Upload the prescription to Script Unlock so licensed pharmacies can quote their cash price. You pay the pharmacy directly.

Questions to ask your pharmacist about Clomipramine

1. 1.Should I take my clomipramine with meals, and when can I move the whole dose to bedtime?
2. 2.Which of my other medicines, such as an SSRI, a migraine medicine, cimetidine or a cold remedy, interact with clomipramine?
3. 3.What should I do if I need to stop clomipramine, and how slowly should the dose come down?
4. 4.Which symptoms, such as a seizure, eye pain with blurred vision, or new agitation, mean I should get help right away?

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