What is Clomipramine (tricyclic antidepressant) typically prescribed for?

Clomipramine: Primary Use and Indications

Clomipramine is primarily prescribed for obsessive-compulsive disorder (OCD) as a first-line pharmacological treatment when SSRIs have failed or as an augmentation strategy. 1

Primary Indications

• Clomipramine was the first agent to show efficacy in OCD and remains a cornerstone treatment for this condition 1
• As a non-selective serotonin reuptake inhibitor (SRI), it has particularly strong effects on the serotonergic system, which is implicated in OCD pathophysiology 1
• Meta-analyses have suggested clomipramine may be more efficacious than SSRIs for OCD, though head-to-head trials indicate equivalent efficacy 1

Dosing and Administration for OCD

• Starting dose typically 25-50 mg/day, gradually titrated up as needed 1
• Therapeutic dose range for OCD is typically 150-250 mg/day 1
• Treatment guidelines indicate 8-12 weeks is the optimal duration to determine efficacy 1
• Maintenance treatment should continue for a minimum of 12-24 months after achieving remission 1

Secondary Indications

• Premature ejaculation - used at doses of 25-50 mg/day or 25 mg 4-24 hours before intercourse 1
• Treatment-resistant depression - particularly when combined with SSRIs 1
• Panic disorder with or without agoraphobia - reduces frequency and severity of panic attacks 2
• Chronic pain syndromes - may provide analgesic effects 3

Important Safety Considerations

• Clomipramine carries a black box warning regarding increased risk of suicidality, particularly in children, adolescents, and young adults 4
• Risk of serotonin syndrome when combined with other serotonergic medications 4
• May lower seizure threshold, with dose-related risk (0.64% at 90 days with doses up to 300 mg/day) 4
• Common side effects include dry mouth, visual disturbances, constipation, sexual dysfunction, somnolence, tremors, and dizziness 5
• Potential for cardiotoxicity, particularly conduction abnormalities and orthostatic hypotension 5

Comparative Efficacy and Place in Therapy

• SSRIs are generally preferred as first-line agents for OCD due to better tolerability and safety profile 1
• Clomipramine is often reserved for SSRI-resistant cases or used as an augmentation strategy 1
• When used as augmentation to SSRIs in treatment-resistant OCD, careful monitoring is required due to potential drug interactions and increased risk of serotonin syndrome 1

Common Pitfalls and Caveats

• Abrupt discontinuation should be avoided as it may precipitate withdrawal syndrome 1
• Should be avoided in patients with a history of bipolar disorder due to risk of mania 1
• Careful medical supervision is required due to significant overdose risk 5
• Higher doses are typically required for OCD than for depression, but this increases risk of adverse effects 1
• Patients often need reassurance about taking a medication labeled as an "antidepressant" for conditions other than depression 1

Clomipramine represents an important treatment option for OCD, with decades of evidence supporting its efficacy, though its side effect profile necessitates careful patient selection and monitoring.