What is the starting dose for Clomipramine (Tricyclic Antidepressant)?

Starting Dose for Clomipramine

The recommended starting dose for clomipramine is 25 mg daily, which should be gradually increased as tolerated to approximately 100 mg during the first 2 weeks. 1

Initial Dosing Recommendations

• Treatment with clomipramine should be initiated at 25 mg daily and gradually increased to minimize side effects 1
• During initial titration, clomipramine should be given in divided doses with meals to reduce gastrointestinal side effects 1
• After the initial 2-week titration period, the dosage may be increased gradually over the next several weeks, up to a maximum of 250 mg daily 1
• After titration, the total daily dose may be given once daily at bedtime to minimize daytime sedation 1

Dosing Considerations for Special Populations

• For children and adolescents, the starting dose is also 25 mg daily, gradually increased during the first 2 weeks up to a daily maximum of 3 mg/kg or 100 mg, whichever is smaller 1
• In older or frail patients, consider lower starting dosages (10-25 mg) and slower titration to minimize side effects 2
• Patients with hepatic or renal impairment may require dose adjustments 2

Pharmacokinetic Considerations

• Clomipramine and its active metabolite, desmethylclomipramine, have long elimination half-lives (mean elimination half-life is 39 hours) 3
• Steady-state plasma levels may not be achieved until 2-3 weeks after dosage changes 1
• After initial titration, it is appropriate to wait 2-3 weeks between further dosage adjustments 1

Common Side Effects and Management

• The most common adverse effects are anticholinergic in nature 3
• Other common side effects include:
  • Nausea and gastrointestinal disturbances 3
  • Sedation 1
  • Sexual dysfunction 3
• Starting at a low dose and gradually titrating helps develop tolerance to side effects 1

Important Precautions

• Never combine clomipramine with monoamine oxidase inhibitors (MAOIs) - at least 14 days should elapse between discontinuing an MAOI and starting clomipramine 1
• Monitor for seizures, which are dose-related (occurring in 0.48% of patients receiving ≤250 mg/day and 2.1% of patients receiving ≥300 mg/day) 4
• For patients with panic disorder, starting at an even lower dose (10 mg/day) may improve tolerability and compliance 5

Maintenance Treatment

• After achieving therapeutic response, maintain the patient on the lowest effective dosage 1
• Patients should be periodically reassessed to determine the need for continued treatment 1
• During maintenance, the total daily dose may be given once daily at bedtime 1

Alternative Administration Methods

• For treatment-resistant cases, intravenous pulse loading of clomipramine has shown rapid benefit in obsessive-compulsive disorder, but this is not a standard first-line approach 6, 7