General
Pronunciation
kloe-MIP-ra-meen
Trade Name(s)
Anafranil
Pregnancy CategoryCategory CTher. class.antiobsessive agents
Pharm. class.tricyclic antidepressants
Indications
Obsessive-Compulsive Disorder (OCD)
Unlabelled Use(s):
Depression, neuropathic pain/chronic pain.
Action
Potentiates the effect of serotonin (antiobsessional effect) and norepinephrine in the CNS. Has moderate anticholinergic effects
Therapeutic Effect(s):
Diminished obsessive-compulsive behavior
Pharmacokinetics
Absorption: Well absorbed from the GI tract
Distribution: Widely distributed, enters breast milk
Protein Binding: >=90%
Metabolism and Excretion: Extensively metabolized by the liver. Some conversion to a pharmacologically active metabolite (desmethylclomipramine). Undergoes enterohepatic recirculation and secretion into gastric juices
Half-life: 2131 hr
TIME/ACTION PROFILE
| ROUTE | ONSET | PEAK | DURATION |
| PO | 16 wk | unknown | unknown |
Contraindication/Precautions
Contraindicated in:
Hypersensitivity
Angle-closure glaucoma
Recent myocardial infarction
History of QTc prolongation
Cardiac arrythmias
Heart failure
Concurrent MAO inhibitor or clonidine use (avoid if possible)
OB: Potential for fetal harm or neonatal withdrawal syndrome
Lactation: Discontinue drug or bottle feed
Use Cautiously in: History of seizures (threshold may be lowered)
Patients with pre-existing cardiovascular disease
Older men with prostatic hyperplasia (may be more susceptible to urinary retention)
Hyperthyroidism (increased risk of arrhythmias)
May
risk of suicide attempt/ideation especially during dose early treatment or dose adjustment; risk may be greater in children or adolescents
Pedi: Safety not established in children <10 yr
Geri:
risk of arrhythmias
Adverse Reactions/Side Effects
CNS: SEIZURES, lethargy, sedation, weakness, aggressive behavior.
EENT: blurred vision, dry eyes, dry mouth, vestibular disorder.
CV: ARRHYTHMIAS, ECG changes, orthostatic hypotension.
GI: constipation, nausea, vomiting, weight gain, eructation.
GU: male sexual dysfunction, urinary retention.
Derm: dry skin, photosensitivity.
Endo: gynecomastia.
Hemat: anemia.
MS: muscle weakness.
Neuro: extrapyramidal reactions.
Misc: hyperthermia.
*CAPITALS indicates life-threatening.
*italic indicates most frequent.
Interactions
Drug-Drug
May cause hypotension and tachycardia when used with MAO inhibitors (concurrent use not recommended)
Wait 2 wks before initiating clomipramine after MAO Inhibitors are stopped
Wait 2 wks before initiating MAO Inhibitors after clomipramine is stopped
May prevent the therapeutic response to antihypertensives
Use with clonidine may result in hypertensive crisis (avoid concurrent use)
CNS depression with other CNS depressants including alcohol, antihistamines, opioids, and sedative/hypnotics
Adrenergic and anticholinergic side effects may be
with other agents having adrenergic/anticholinergic properties
Effects and toxicity may be
by concurrent use with SSRI antidepressants (wait several weeks after stopping SSRIs to start clomipiramine; up to 5 weeks for fluoxetine), phenothiazines, cimetidine, or oral contraceptives
Nicotine may
metabolism and
effectiveness
Transient delirium may occur with disulfiram
Drug-Natural Products Increased risk of serotonergic side effects including serotonin syndrome with St. John's wort and SAMe
Kava, valerian, or chamomile can increase CNS depression
Drug-FoodGrapefruit juice

serum levels and effect
Route/Dosage
PO (Adults):
Antiobsessive25 mg/day, increased over 2-wk period to 100 mg/day in divided doses. May be further increased over several weeks up to 250300 mg/day in divided doses. Once stabilizing dose is reached, entire daily dose may be given at bedtime.
Antidepressant25 mg 3 times daily, may be increased as needed (unlabeled).
PO (Geriatric Patients): 2030 mg/day initially, may be increased as needed.
PO (Children >1017 yr): 25 mg/day initially, increased over 2-wk period to 3 mg/kg/day or 100 mg/day (whichever is smaller) in divided doses. May be further increased to 3 mg/kg/day or 200 mg/day (whichever is smaller) in divided doses. Once stabilizing dose is reached, entire daily dose may be given at bedtime.
Availability
Capsules: 10 mg, 25 mg, 50 mg, 75 mg
Assessment
Monitor mental status (orientation, mood, behanior) frequently. Assess patient for frequency of OCD. Note degree to which these thoughts and behaviors interfere with daily functioning
Monitor blood pressure and pulse before and during initial therapy. Notify physician or other health care professional of decreases in blood pressure (1020 mmHg) or sudden increase in pulse rate. Patients taking high doses or with a history of cardiovascular disease should have ECG monitored before and periodically during therapy
Assess weight and BMI initially and throughout treatment. Assess FBS and cholesterol levels in obese individuals. Refer as appropriate for nutritional/weight management and medical management
Observe for onset of extrapyramidal parkinsonian side effects (difficulty speaking or swallowing, loss of balance control, pill rolling with hands, mask-like face, shuffling gait, rigidity, tremors). Notify physician or other health care professional if these symptoms occur; reduction in dose or discontinuation of medication may be necessary. Trihexyphenidyl or diphenhydramine may be used to control these symptoms
Lab Test Considerations Serum glucose may be
or 
» Monitor CBC and differential during chronic therapy. May rarely cause bone marrow suppression
» In chronic therapy, periodically monitor hepatic and renal function
Potential Nursing Diagnoses
Ineffective coping (obsessive-compulsive behaviors), related to repressed anxiety (Indications)
Risk for injury (Side Effects)
Chronic pain (Indications)
Implementation
Do not confuse clomipramine with clomiphene or desipramine
PO: Administer medication with or immediately after a meal to minimize gastric irritation. After titration of dose, total daily dose may be given at bedtime
Patient/Family Teaching
Instruct patient to take medication exactly as directed. Abrupt discontinuation may cause nausea, headache, and malaise
May cause drowsiness and blurred vision. Caution patient to avoid driving and other activities requiring alertness until response to drug is known
Orthostatic hypotension, sedation, and confusion are common during early therapy, especially in geriatric patients. Protect patient from falls and advise patient to change positions slowly
Advise patient to avoid alcohol or other CNS depressant drugs during course of therapy and for 37 days after cessation of therapy
Instruct patient to notify health care professional if dry mouth or constipation persists or if urinary retention, uncontrolled movements, or rigidity occurs. Sugarless candy or gum may diminish dry mouth, and an increase in fluid intake or bulk may prevent constipation. If these symptoms persist, dosage reduction or discontinuation may be necessary. Consult health care professional if dry mouth persists for more than 2 wk
Advise patient to inform health care professional if sexual dysfunction occurs. Inform male patients that sexual dysfunction is common with this medication
Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions
Inform patient of need to monitor dietary intake because possible increase in appetite may lead to undesired weight gain
Advise patient to notify health care professional of medication regimen before treatment or surgery
Emphasize the importance of follow-up exams to monitor effectiveness and side effects and to improve coping skills
Inform patients taking high doses (250300 mg/day) that risk of seizures is increased
Refer patient to local OCD group
Evaluation/Desired Outcomes
Diminished obsessive compulsive behavior
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