Nurses Compass
Drug Guide
Clomipramine Hydrochloride
Classification
Therapeutic: Antidepressant, Tricyclic Antidepressant (TCA)
Pharmacological: Serotonin and Norepinephrine Reuptake Inhibitor (SNRI)
FDA Approved Indications
- Obsessive-Compulsive Disorder (OCD)
- Depression
- Panic Disorder
- Nosocomial and other repetitive behaviors in children with OCD
Mechanism of Action
Inhibits reuptake of serotonin and norepinephrine at presynaptic neuronal membranes, increasing their levels in the synaptic cleft, resulting in antidepressant and anxiolytic effects.
Dosage and Administration
Adult: Initially 25 mg daily, gradually increased based on response and tolerability, typical dose range 100-250 mg/day.
Pediatric: Not approved for children under 10; dosage must be individualized.
Geriatric: Start at lower doses due to increased risk of side effects and pharmacokinetic changes; close monitoring recommended.
Renal Impairment: Use with caution; dose adjustments may be necessary.
Hepatic Impairment: Start with lower doses; hepatic function should be evaluated prior to initiation.
Pharmacokinetics
Absorption: Well absorbed orally.
Distribution: Widely distributed in body tissues; crosses the blood-brain barrier.
Metabolism: Extensively metabolized by the liver via demethylation and hydroxylation.
Excretion: Excreted primarily in urine as metabolites; some in feces.
Half Life: Approximately 24 hours, but can range from 8-37 hours depending on individual metabolism.
Contraindications
- Known hypersensitivity to clomipramine or other TCAs.
- Recent myocardial infarction.
- Use concomitantly with MAO inhibitors.
Precautions
- History of seizure disorder, urinary retention, glaucoma, or significant cardiac disease. Use cautiously in elderly, suicidal patients, or those with a history of mania.
Adverse Reactions - Common
- Dry mouth (Common)
- Drowsiness (Common)
- Constipation (Common)
- Dizziness (Common)
Adverse Reactions - Serious
- Cardiac arrhythmias (Serious (rare))
- Suicidal thoughts (Serious (black box warning))
- Serotonin Syndrome (Serious (rare, especially with polypharmacy))
Drug-Drug Interactions
- MAO inhibitors (risk of serotonin syndrome),
- Other serotonergic drugs (e.g., SSRIs, SNRIs, triptans)
- CNS depressants.
- Anticholinergic agents.
Drug-Food Interactions
- Avoid alcohol due to additive CNS depressant effects.
Drug-Herb Interactions
- Potential interactions with herbal serotonergic supplements like St. John's Wort.
Nursing Implications
Assessment: Assess mental status, suicidality, and adherence; monitor ECG in patients with cardiac history; evaluate for anticholinergic effects.
Diagnoses:
- Risk for suicide, Ineffective coping, Risk for falls.
Implementation: Administer with food to decrease gastrointestinal upset; monitor for therapeutic response and adverse effects.
Evaluation: Regularly assess for symptom improvement and side effects; adjust dosage as needed.
Patient/Family Teaching
- Take medication exactly as prescribed.
- Do not stop abruptly to prevent withdrawal syndrome.
- Report worsening depression, suicidal thoughts, or unusual changes in mood.
- Caution about drowsiness and operating machinery.
- Avoid alcohol and OTC medications without consulting a healthcare provider.
Special Considerations
Black Box Warnings:
- Risk of suicidal thoughts and behaviors in children, adolescents, and young adults.
Genetic Factors: CYP2D6 poor metabolizers may experience increased plasma levels.
Lab Test Interference: None significant; routine labs as per clinical indication.
Overdose Management
Signs/Symptoms: Confusion, hallucinations, seizures, arrhythmias, hypotension, coma.
Treatment: Supportive care; gastric decontamination (activated charcoal), cardiac monitoring, and management of arrhythmias; specific antidote not available.
Storage and Handling
Storage: Store at room temperature 20-25°C (68-77°F), away from moisture and light.
Stability: Stable under recommended storage conditions.