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).
poster:ed_uk2010
thread:1073199
URL: http://www.dr-bob.org/babble/20141120/msgs/1073796.html