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Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by seekinginformation on November 4, 2014, at 19:57:20
So, I talked to my PDOC and she would like to add 25 MGs of Clomipramine to help with my OCD and and depression. My current meds are
-25 MGS Clomipramine
-10 MGs Prozac (I read that TCA blood levels can go up when mixed, but I am not concerned because my SSRI and TCA are low dose)
-300 Mgs Gabapentin
-.5 to 1 MG Klonopin
-Occasional Benedryl
I'm really scared about any sort of EPS/Akathisia and increased anxiety. Anyone hear of those issues on Clomipramine (or any others for that matter?) I'm nervous....
Posted by seekinginformation on November 4, 2014, at 20:36:22
In reply to Adding Clomipramine to my meds, posted by seekinginformation on November 4, 2014, at 19:57:20
Whoops, in reading this, I made it appear as though I am already taking clomipramine as a current med... its new, never taken it before.. I'm going to add it. Any thoughts?
> So, I talked to my PDOC and she would like to add 25 MGs of Clomipramine to help with my OCD and and depression. My current meds are
>
> -25 MGS Clomipramine
>
> -10 MGs Prozac (I read that TCA blood levels can go up when mixed, but I am not concerned because my SSRI and TCA are low dose)
>
> -300 Mgs Gabapentin
>
> -.5 to 1 MG Klonopin
>
> -Occasional Benedryl
>
>
> I'm really scared about any sort of EPS/Akathisia and increased anxiety. Anyone hear of those issues on Clomipramine (or any others for that matter?) I'm nervous....
>
Posted by Phillipa on November 4, 2014, at 21:40:09
In reply to Clarification: Adding Clomipramine to my meds, posted by seekinginformation on November 4, 2014, at 20:36:22
If really anxious why not start with half the dose of clomipramine for a few days. I have heard it's pretty intense but having never taken it I don't know. Did you google the archieves. I do remember a few babblers taking this med. Phillipa
Posted by Christ_empowered on November 5, 2014, at 10:50:22
In reply to Adding Clomipramine to my meds, posted by seekinginformation on November 4, 2014, at 19:57:20
could you drop the prozac as you ramp up the anafranil? Just a thought...I've been on a TCA+SRI combo, and it wasn't pleasant.
Posted by seeking information on November 5, 2014, at 13:11:44
In reply to Re: Adding Clomipramine to my meds, posted by Christ_empowered on November 5, 2014, at 10:50:22
Hi there, my pic is adamant about one change at a time. I think she is looking at the clomipramine as an augment strategy because of my ramped up depression, anxiety and OCD. The Prozac alone is not helping. My mom took at celexa clomipramine combo and was zombified and tired, which I don't mind. Im really scared of the anxiety more than anything else. Any other thoughts on this?
could you drop the prozac as you ramp up the anafranil? Just a thought...I've been on a TCA+SRI combo, and it wasn't pleasant.
Posted by phidippus on November 10, 2014, at 20:31:36
In reply to Adding Clomipramine to my meds, posted by seekinginformation on November 4, 2014, at 19:57:20
Once again, your dosing is too low. Adding 25 mgs of clomipramine isn't going to help.
Up your prozac to 60 mg.
Please trust me, I've been doing this for many years.
Eric
Posted by seekinginformation on November 24, 2014, at 18:21:02
In reply to Re: Your dosing is too low. » seekinginformation, posted by phidippus on November 10, 2014, at 20:31:36
Hey Eric,
Thanks for the post. We're working on things. I know this is a cliche, but I tend to be med sensitive.... low and slow for me.I'm actually doing a little better. My goal is to get some of that glutamete action before boosting serotonin.
I am going to talk with my doc about boosting the gabapentin to a much higher dose. I can always boost that clomipramine up too. It'll all work out.
Thanks for the response!
Posted by phidippus on November 26, 2014, at 16:22:08
In reply to Re: Your dosing is too low. » phidippus, posted by seekinginformation on November 24, 2014, at 18:21:02
>low and slow for me.
I'm not saying you won't see results with doses lower than typically used to treat OCD, but right now you're even on the low side for treating depression.
Can I ask why you're going slow and low (except for the the obvious EPS symptoms you seem to be susceptible to)?
>My goal is to get some of that glutamete action before boosting serotonin
Right now the glutamatergic disfunction theory of OCD is in its infancy.
The APA has a cool algorithm for treating OCD and it works kind of like this: serotogenic AD>Atypical Antipsychotic>anti-glutamatergic agent. Boosting an SSRI with Clomipramine is another part of the algorithm. BUT, you're doses need to be adequate. I'd say at least 30 mg on the Prozac and anywhere from 100 mg to 300 mg on the Clomipramine. The Gabapentin can be raised to 2400 mg.
Have you thought of adding an atypical anytypsychotic?
Dopamine tends to be raised in certain areas of the brain of people with ocd, in particular the nucleus accumbens.
BUT, I wouldn't add it until your ADs were at the right dose.
Eric
Posted by ed_uk2010 on November 27, 2014, at 12:02:51
In reply to Adding Clomipramine to my meds, posted by seekinginformation on November 4, 2014, at 19:57:20
>-25 MGS Clomipramine
-10 MGs Prozac (I read that TCA blood levels can go up when mixed, but I am not concerned because my SSRI and TCA are low dose)....That's correct, fluoxetine (Prozac) can affect the metabolism of clomipramine. Some SSRIs, such as citalopram (Celexa) affect clomipramine levels to a far lesser extent, but there is a still some risk of interactions. It's usual to try a variety of SSRIs and clomipramine alone before combining the two. If you start to respond to clomipramine your doctor may consider withdrawing fluoxetine. Bear in mind, fluoxetine is extremely long acting and the interaction persists for several weeks after it's been stopped.
Fluoxetine is a potent inhibitor of CYP 2D6, one of the liver enzymes which is required for the body to metabolise clomipramine. Fluoxetine also has a weaker inhibitory effect of various other drug-metabolising enzymes.
As a result, caution is needed when using these two drugs in combination. The initial dose of clomipramine should be low (eg. 25mg) and increased very gradually in small steps, eg. 25mg every few weeks, if necessary. For sure, do not increase fluoxetine and clomipramine doses at the same time. For most people, the maximum safe dose of clomipramine is likely to be reduced when taken in combination with fluoxetine. There are reports of a few patients who have tolerated high/full doses of clomipramine while on fluoxetine, but in general lower doses have been used. It has been suggested that the daily dose of clomipramine should not exceed 75mg when combined with fluoxetine, unless blood levels of clomipramine (and its metabolites, esp. desmethylclomipramine) are being closely monitored (as well as the EKG). In the absence of blood level monitoring, the EKG should still be checked at intervals, paying particular attention to the QTc interval.
***Clomipramine augmentation of SSRIs may improve treatment response in obsessive-compulsive disorder patients in whom response to SSRI monotherapy is inadequate.
***Clomipramine can raise the blood levels and hence the adverse effects of most SSRIs. More importantly, fluoxetine (Prozac), fluvoxamine, and possibly high doses of the other SSRIs can raise the blood levels and hence the adverse effects of clomipramine, resulting in treatment-limiting adverse effects, as well as life-threatening problems such as QTc prolongation and seizures.
***When combining fluoxetine (Prozac) or fluvoxamine with clomipramine, it is best to use low doses of each drug. In particular, doses of clomipramine should not exceed 75 mg/d unless the blood clomipramine level is monitored. Electrocardiographic (EKG) monitoring of the QTc interval is also desirable (to assess the risk of abnormal heart rhythms).
The potency of clomipramine at the serotonin transporter is very high. I think it's important not to overdo the dose early on during treatment.
A mere 10mg of clomipramine was enough to occupy 80% of serotonin transporters in a brain scan study. This level of occupancy was similar to a low/standard dose of an SSRI (fluvoxamine, Luvox, 50mg).
Posted by ed_uk2010 on November 27, 2014, at 12:05:57
In reply to Re: Your dosing is too low. » phidippus, posted by seekinginformation on November 24, 2014, at 18:21:02
>I know this is a cliche, but I tend to be med sensitive.... low and slow for me.
Absolutely, you need to stay safe.
> I'm actually doing a little better. My goal is to get some of that glutamate action before boosting serotonin.
Your improvement may or may not have anything to do with glutamate, but an improvement on your current dose is very possible, and you will already be boosting serotonin.
Posted by seekinginformation on November 29, 2014, at 19:07:27
In reply to Re: Your dosing is too low. » seekinginformation, posted by ed_uk2010 on November 27, 2014, at 12:05:57
Thanks for response Ed!
I've actually had some major life stresses this week, and experienced quite a setback. I have more of the "Pure-O" OCD, and the flare up has been intense, especially these past few months.... lots of hyper arousal, ruminating thoughts, and anxiety. I really hope that the clomipramine kicks in and starts to ease it.
I know that my PDOC definitely will not exceed 10 MGS of prozac (which is reassuring as far as toxicity issues go). I am also fairly sure that my PDOC will check blood levels, but I will be sure to ask about that if it's not brought up.I've considered asking to up my Gabapentin (I'm on a tiny dose of 300 MGS total a day) but am wondering if that would really be beneficial at all. My biggest goal right now is to ease the anxiety and clear my mind of all the ruminations and other nonesense. If that can happen and things can cool down, I am hopeful that the clomipramine will have a chance to kick in and ease some of the OCD issues.
Sorry for the long, rambling post :)
> >I know this is a cliche, but I tend to be med sensitive.... low and slow for me.
>
> Absolutely, you need to stay safe.
>
> > I'm actually doing a little better. My goal is to get some of that glutamate action before boosting serotonin.
>
> Your improvement may or may not have anything to do with glutamate, but an improvement on your current dose is very possible, and you will already be boosting serotonin.
>
>
>
>
>
Posted by ed_uk2010 on December 2, 2014, at 5:47:55
In reply to Re: Your dosing is too low. » ed_uk2010, posted by seekinginformation on November 29, 2014, at 19:07:27
Sorry to hear about your setback.
> Thanks for response Ed!
You're welcome.
>I've actually had some major life stresses this week, and experienced quite a setback. I have more of the "Pure-O" OCD, and the flare up has been intense, especially these past few months.... lots of hyper arousal, ruminating thoughts, and anxiety. I really hope that the clomipramine kicks in and starts to ease it.
Horrible isn't it...
>I know that my PDOC definitely will not exceed 10 MGS of prozac (which is reassuring as far as toxicity issues go).
That's good. You should not need a full dose of Prozac because clomipramine is a potent serotonergic drug in its own right.
>I am also fairly sure that my PDOC will check blood levels, but I will be sure to ask about that if it's not brought up.
Checking blood levels is not usual practice for clomipramine except in very specific circumstances. Taking it with fluoxetine or paroxetine (Paxil) is a special circumstance. It's valuable to check its major metabolite (desmethylclomipramine) and not just clomipramine itself. Clomipramine's major metabolite is active. Checking the clomipramine level alone is not very useful.
Doing an EKG (12-lead electrocardiogram) is standard for this type of combination. Have you had one? It takes about 5 minutes. The major purpose is to check that the various 'intervals' are normal, especially QTc. This is to ensure that the medication is not interfering excessively with normal cardiac conduction.
>I've considered asking to up my Gabapentin (I'm on a tiny dose of 300 MGS total a day) but am wondering if that would really be beneficial at all.
Gabapentin is probably more useful for generalised and social anxiety than OCD, but you could ask to try a higher dose because it works quickly and does not interact with any of your other medication. The fast-acting nature of gabapentin allows you to avoid spending a long time on a higher dose if it clearly isn't helping. Gabapentin generally needs to be taken in divided doses for anxiety, usually three, and not a single daily dose. Except for the elderly, the minimum effective dose is probably about 300mg three times a day for most people, but much more can be taken - and is often necessary. Gradual withdrawal is needed if you stay on a high dose for a while and then decide to reduce.
>I am hopeful that the clomipramine will have a chance to kick in and ease some of the OCD issues.
Annoyingly, clomipramine is not a fast-acting drug for OCD (neither are the SSRIs). Benefit usually occurs gradually but can take over 12 weeks to become maximal at any particular dose. In the mean time, other drugs such as benzos (eg. clonazepam, often around 0.25mg-0.5mg twice a day) and gabapentin may offer a little relief but the waiting game is still difficult. Have you had any CBT for your OCD?
Unless you believe that 10mg fluoxetine is highly beneficial, you could ask your pdoc about stopping it (you can stop 10mg abruptly, especially while on another serotonergic drug). Because it's very long-acting, you'd still need to be very cautious with the clomipramine dose for around a month after stopping. Fluoxetine's metabolite persists for several weeks and has the same drug interactions as fluoxetine itself. There are a few people who do better on an SSRI + clomipramine but most can take one or the other, and safety issues are less of a concern.
Take care. I sympathise with your situation very much.
Posted by SLS on December 2, 2014, at 8:53:12
In reply to Re: Clomipramine etc. » seekinginformation, posted by ed_uk2010 on December 2, 2014, at 5:47:55
I agree with Ed. First of all, the dosage of fluoxetine necessary to treat OCD can be as high as 60 mg/day. 10 mg/day is unlikely to do anything other than to increase the blood concentration of clomipramine and its active metabolite. Fortunately, many blood tests for clomipramine are actually tests for total TCA, so the metabolite would be assayed along with the parent drug.
It might be better to discontinue the fluoxetine now so that you can establish a more predictable titration of clomipramine according to its known therapeutic dosages.
- Scott
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