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Clomipramine (brand-name Anafranil®) is a tricyclic
antidepressant. It was developed in the 1960s by the
Swiss drug manufacturer Geigy (now known as Novartis)
and has been in clinical use worldwide for decades.
* Depression with lack of energy or mild agitation
* Obsessive compulsive disorder (OCD)
* Panic attacks with or without agoraphobia
* Narcolepsy
* Premature Ejaculation
* Chronic pain with or without organic disease, particular
headache of the tension type
* enuresis (involuntary nightly urinating in sleep)
in children and adolescents
* Off label: sometimes antidepressants of this type
have been found helpful in reducing relapses in cocaine
addicts and to help repair cocaine-caused neurotransmitter
imbalances and early brain damage. Further studies are
needed for clomipramine in this regard.
It may take 2 to 3 weeks before the full effects of
this medication are noticed in all indications.
Along with SSRIs, clomipramine is a frequently prescribed
drug for the treatment of OCD. As is typical with the
older tricyclic antidepressants, it has more side effects
than SSRIs, so some authorities regard it as a second-line
treatment to be used if treatment with SSRIs fails.
However, disregarding side effects, it may be slightly
more effective in combatting the symptoms of OCD. It
is not commonly used for treating depression, and usually
another tricyclic (or drug from a different class) would
be used. Clomipramine and the SSRIs (specifically Paroxetine)
have also been used to treat premature ejaculation.
Contraindications
* Concomitant therapy with an (irreversible) MAO inhibitor
(e.g. tranylcypromine, phenelzine)
* Acute intoxication with central depressants (alcohol,
psychoactive drugs, narcotics)
* States of confusion (caution), absolutely contraindicated
in patients with coma and delirium tremens
* Patients with severe agitation or anxiety (give sedative
drugs concomitantly)
* Hypersensitivity/allergy against clomipramine or other
related tricyclic compounds
* Hypertrophy of the prostate with urine retention (=difficulty
in urinating)
* Caution: hypertrophy of the prostate without urine
retention
* Preexisting closed angle glaucoma
* Epilepsy and other conditions which lower the seizure
threshold (alcohol-withdrawal, active brain tumors)
* Serious liver disease (elimination is decreased),
if clomipramine is given consider dose reduction
* Serious kidney disease (elimination is decreased),
if clomipramine is given consider dose reduction
* Severe hypotension, shock, serious cardiovascular
dysfunction (postinfarctous states, heart insufficience,
arrhythmias), avoid high oral doses or injections/infusions
* Preexisting bone marrow depression (leukopenia, thrombocytopenia,
anemia, pancytopenia), can be worsened by clomipramine
* Hyperthyroidism (overfunction of the thyroid gland)
makes the patient more sensitive to side effects of
clomipramine. Cautious doses should be used and the
overfunction should be treated.
* Caution should be exerted when treating pediatric
patients under 18 years of age
Side effects
Clomipramine may have a broad range of side effects:
* central nervous system: Often, fatigue, dizziness,
lightheadedness, headaches, confusion, agitation, insomnia,
nightmares, increased anxiety, seizures (0,5% to 2%,
see above), rarely hypomania or induction of schizophrenia
(immediate termination of therapy required), and extrapyramidal
side-effects (pseudoparkinsonism, dyskinesia, rarely
tardive dyskinesia) are noted.
* Anticholinergic side effects in different grades of
severity are quite common: dry mouth, constipation,
rarely ileus (paralysis of the large intestine, life-threatening),
difficulties in urinating, sweating, precipitation of
glaucoma (may lead to permanent eye-damage or even blindness,
if untreated). The incidence of dental caries may be
increased due to dry mouth.
* antiadrenergic side effects occur very frequently
due to strong central and peripheral blockage of alpha
receptors: hypotension, postural collapse (when patient
is rising too fast from lying or sitting position to
standing), arrhythmias (sinus tachycardia, bradycardia,
AV block, rarely other forms of cardiac problems). Preexisting
heart insufficiency can be worsened.
Most of these side-effects are dose related and/or
tolerance will develop with continued use.
* Allergic/toxic: skin reactions and photosensitivity
with increased frequency of sunburns are seen in a few
percentage of cases. Rarely liver damage of the cholostatic
type, hepatitis, and leukopenia or other forms of blood
dyskrasia are seen, also severe acute allergy including
difficulties in breathing, skin reaction, chest pain
etc.
* Other side effects may include heartburn, weight gain,
but also nausea and bruxism - teeth-grinding while asleep
- (the latter due to the strong inhibition of reuptake
of serotonin).
* The drug often causes sexual problems in men (e.g.
impotence, ejaculation difficulties). In about 5% of
patients, it can instead cause inadvertent orgasms when
yawning.[2]
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