Tips for tapering off clomipramine (Anafranil)

[Altostrata]

Clomipramine is an older tricyclic antidepressant like amitriptyline and nortriptyline. It is a chemical derivative or analog of another TCA, imipramine. Of the TCAs, imipramine and clomipramine are the most potent serotonin reuptake inhibitors.

 

About clomipramine, from official US FDA information at dailymed.nlm.nih.gov:

 

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Initial Treatment/Dose Adjustment (Adults)

Treatment with clomipramine HCl capsules, USP should be initiated at a dosage of 25 mg daily and gradually increased, as tolerated, to approximately 100 mg during the first 2 weeks. During initial titration, clomipramine HCl capsules, USP should be given in divided doses with meals to reduce gastrointestinal side effects. Thereafter, the dosage may be increased gradually over the next several weeks, up to a maximum of 250 mg daily. After titration, the total daily dose may be given once daily at bedtime to minimize daytime sedation.

 

Initial Treatment/Dose Adjustment (Adults)

Treatment with clomipramine HCl capsules, USP should be initiated at a dosage of 25 mg daily and gradually increased, as tolerated, to approximately 100 mg during the first 2 weeks. During initial titration, clomipramine HCl capsules, USP should be given in divided doses with meals to reduce gastrointestinal side effects. Thereafter, the dosage may be increased gradually over the next several weeks, up to a maximum of 250 mg daily. After titration, the total daily dose may be given once daily at bedtime to minimize daytime sedation.

....

Withdrawal Symptoms

A variety of withdrawal symptoms have been reported in association with abrupt discontinuation of clomipramine HCl, including dizziness, nausea, vomiting, headache, malaise, sleep disturbance, hyperthermia, and irritability. In addition, such patients may experience a worsening of psychiatric status. While the withdrawal effects of clomipramine HCl have not been systematically evaluated in controlled trials, they are well known with closely related tricyclic antidepressants, and it is recommended that the dosage be tapered gradually and the patient monitored carefully during discontinuation.

 

Clomipramine is metabolized via liver enzymes P450 CYP2D6 and 3A4 (it is a CYP1A2 inhibitor) ; it may conflict with other drugs utilizing those liver enzymes.

 

With its active metabolite, desmethylclomipramine (DMI) or norclomipramine, clomipramine has a long half-life of about 54-77 hours.

 

From US FDA information at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b1739aa5-69d8-4a69-be58-6d789ea2a516

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Because both CMI and its active metabolite, DMI, have long elimination half-lives, the prescriber should take into consideration the fact that steady-state plasma levels may not be achieved until 2 to 3 weeks after dosage change.... Therefore, after initial titration, it may be appropriate to wait 2 to 3 weeks between further dosage adjustments.

 

Brand-name Anafranil and generic clomipramine are supplied in 25 mg, 50 mg, 75 mg capsules. Generics may also be available in 10mg, 25mg, 50mg tablets. Clomipramine is freely soluble in water.

 

Reduce by 10% per month to start

The 10% rule holds for clomipramine, just like other psychiatric drugs: Reduce by 10% per month, calculated on the last dosage. (The amount of the reduction gets progressively smaller.)

 

See Why taper by 10% of my dosage?

 

Use a combination of clomipramine dosages to taper

If you are taking, for example, 150mg, you may wish to get 50mg of your prescription in 10mg tablets (if available). This will enable you to decrease by 10mg at a time.

 

(To justify a prescription comprised of various dosage capsules or tablets for insurance coverage, your doctor may need to indicate split dosing -- taking the drug more than once a day.)

 

When you are down to 100mg, you may wish to have your prescription filled with 50mg capsules or tablets plus 10mg tablets and carefully split the tablets until you are down to 50mg.

 

The smallest decrease you can make with available tablet sizes would be 2.5mg -- 1/4 of a 10mg tablet. Accurately cutting a tablet into quarters can be difficult. When you need to make a decrease smaller than 5mg (half a 10mg tablet), you may wish to to cut up tablets, weigh the powder (from the capsules), get a prescription for the liquid, or make a liquid to continue a 10% taper.

 

At 50mg and lower, you may wish to combine whole 25mg capsules or tablets with partial tablets or powder from the capsule weighed for accuracy, or a liquid to fill out the rest of your daily dose.

 

Use a digital scale to weigh tablet fragments or powder

For small amounts of the drug, weighing tablet fragments or powder from the If you wish to weigh the powder, see Using a digital scale to measure doses

 

You will probably find using a liquid to be much more convenient when tapering by amounts smaller than 10mg.

 

Make a clomipramine liquid yourself from tablets or capsules

Clomipramine is soluble in water. See How to make a liquid from tablets or capsules

 

Use an oral syringe to precisely measure out doses as small as .01mg.

 

Have a compounding pharmacy make custom capsules or a liquid
Compounding pharmacies can make capsules with custom dosages or a liquid from the powder. You will need a prescription written for any  compounding. The only drawback is insurance may not cover it; it can be quite expensive.