Clomipramine (Anafranil and generics®) belong to a group of medications called “antiobsessional” medications.

What is this medication used for?

Clomipramine is approved by Health Canada for treatment of obsessive compulsive disorder (OCD) in children and adolescents ages 10 years and older.

Clomipramine is also known as a tricyclic antidepressant (TCA). While it is not approved by Health Canada for other uses in children and adolescents, clomipramine may help treat depression, anxiety disorders and severe repetitive behaviours.

When potential benefits outweigh risks, clomipramine may be “off- label.” Learn more about off-label medication use: http://bit.ly/KMH-off-label-use

Tell your doctor or pharmacist if you:

• Have allergies or bad reactions to a medication
• Take (or plan to take) other prescription or non- prescription medications, including natural medicines Some medications interact with clomipramine. Your doctor may adjust medication doses or monitor for side effects
• Have a history (or family history) of heart, kidney, liver or thyroid disease, seizures, arrhythmias, sleep apnea, glaucoma or bipolar disorder
• Miss a menstrual period, are pregnant, breast-feeding or planning a pregnancy
• Use alcohol or drugs. Taking clomipramine together with certain substances may cause a bad reaction. Learn more at www.DrugCocktails.ca

When will the medication start to work?

When used to treat OCD, you (or your family members) may notice improvements after 6 to 12 weeks. However, full beneficial effects may take up to 4 to 6 months.

Since clomipramine takes time to work, it is important that you continue taking it as prescribed, even if you are feeling better or there are no improvements in the first few weeks.

Talk with your doctor if you feel that this medication has not been helpful or if side effects are too bothersome. Your doctor may recommend switching you to a different medication.

This medication is not addictive. Do not stop taking it before talking to your doctor.

How do I take this medication?

Clomipramine is usually taken once nightly, with or without food, at the same time each night. However, sometimes it may be taken up to 2-3 times daily based on your symptoms. Usually, you will start with a low dose and slowly increase this dose over several days to weeks, based on how you tolerate it.

Avoid eating grapefruit or drinking grapefruit juice while taking clomipramine as this can lead to excessive drowsiness and increased side effects.

Possible common or serious side effects:

Side effects may be more common when starting a medication or after a dose increase. Talk to your doctor, nurse or pharmacist if any side effect concerns you.

• Dizziness, drowsiness or headache
• Agitation, anxious thoughts or abnormal dreams
• Memory problems or confusion
• Blurred vision, dry eyes or dry mouth
• Nausea, stomach ache or constipation
• Increased appetite or weight gain
• Muscle stiffness or muscle spasm
• In adolescents/adults: changes in sexual performance or interest

Contact your doctor immediately if you experience:

• Thoughts of hurting yourself, hostility or suicide
• Change in mood to an unusual state of excitement, irritability or happiness
• Uncomfortable sense of inner restlessness or agitation
• Uncomfortable awareness of your own heartbeat, or sudden and brief loss of consciousness
• Unexpected rash, seizure, fever or excessive sweating
• Unusual bruising or bleeding

What precautions should my doctor and I be aware of when taking this medication?

• While taking clomipramine, if you feel dizzy, drowsy or slowed down, do not drive a car or operate heavy machinery. Alcohol could make this worse. Try to avoid alcohol while taking clomipramine.
• Clomipramine (and medications like it) can cause a rare side effect called “serotonin syndrome,” especially when used in combination with other serotonergic drugs such as MAO-inhibitors and most other antidepressants. Symptoms include diarrhea, sweating, increased heart rate, tremors, severe muscle stiffness and increased agitation.
• Do not stop taking clomipramine suddenly. This can cause “antidepressant discontinuation syndrome” that involves flu-like symptoms, trouble sleeping, nausea, irritability, headache and abnormal sensations that feel like electric shocks, burning, tingling or numbness. If stopping or changing medications, your dose should be reduced slowly.

What special instructions should I follow while using this medication?

• Keep all appointments with your doctor and the lab.
• Your doctor may want to talk to you within 1-2 weeks after starting clomipramine, and meet with you over time to make sure it is working well for you and monitor for side effects.
• Do not allow anyone else to use your medication.

What should I do if I forget to take a dose of this medication?

If you take clomipramine only at night and forget to take a dose, skip the missed dose and continue regularly with your next scheduled dose.

If you take clomipramine more than once a day and forget to take a dose, take the missed dose as soon as you remember. Take any remaining doses for that day at evenly spaced intervals. However, if it is close to your next scheduled dose, skip the missed dose and continue with your regular schedule. DO NOT double your next dose to try to ‘catch up’.

How do I store this medication?

Keep clomipramine in the original container, stored at room temperature away from moisture and heat and protected from light. Keep clomipramine out of reach and sight of children.

How does this medication work?

Like other TCAs, clomipramine increases levels of various brain chemicals, mainly serotonin and norepinephrine. These brain chemicals are not functioning properly in people who have depression or anxiety. The exact way that clomipramine improves symptoms of OCD is not known but is likely related to increasing serotonin levels in the brain.

How well does the medication work in children and adolescents?

Clomipramine has been studied in children and adolescents with OCD and may reduce both obsessions (recurrent, intrusive, inappropriate or unwelcome thoughts and images, which cause great anxiety or distress) and compulsions (repetitive behaviours or mental acts done to reduce distress or prevent a feared event). Clomipramine was found to be effective in about 75% of children and adolescents ages 10 to 17 with OCD. Even if you respond well to clomipramine, some of your symptoms may continue. However, clomipramine may help you better resist those obsessions or compulsions, spend less time engaging in obsessive or compulsive behaviours, and may prevent symptoms from returning in the future. Clomipramine has not been well studied in children under 10 years of age.

How long should I take the medication for?

This depends on the symptoms you have, how frequently they occur and how long you have had them. Most people need to take clomipramine for several months. This allows time for symptoms to stabilize and for function to improve. After 3 to 6 months, you and your doctor can discuss the benefits and risks of continuing treatment.

Depending on your symptoms and whether you tolerate clomipramine well, you may be asked to take clomipramine on an ongoing basis. Continuing treatment will significantly decrease the chance of your OCD symptoms returning.

Do not increase, decrease or stop taking clomipramine without discussing it with your doctor, even if you are feeling better. If you stop taking clomipramine suddenly, it is possible that your symptoms may return or you may have a bad reaction.

TIP: Use the Kelty Mental Health Antidepressant Monitoring Form for Children and Adolescents to help measure your progress on this medication.