(kloe-MIH-pruh-meen HIGH-droe-KLOR-ide)
Anafranil
Class: Tricyclic antidepressant

 Action Inhibits reuptake of serotonin in CNS.

 Indications Relief of obsessive-compulsive disorder. Unlabeled use(s): Treatment of panic disorder or chronic pain (migraine, chronic tension headache, diabetic neuropathy, tic douloureux, cancer pain, peripheral neuropathy, postherpetic neuralgia, arthritic pain).

 Contraindications Hypersensitivity to any tricyclic antidepressant. Not to be given in combination with or within 14 days of treatment with MAO inhibitor. Not to be given during acute recovery phases of MI.

 Route/Dosage

ADULTS: Initial dose: PO 25 mg/day; gradually increase dose to 100 mg/day during first 2 wk. Dose may then be gradually increased to maximum of 250 mg/day. CHILDREN (£ 10 yr): Initial dose: PO 25 mg/day; gradually increase dose to 3 mg/kg/day or 100 mg/day (whichever is less) during first 2 wk; then slowly increase dose to maximum 3 mg/kg/day or 200 mg/day (whichever is less).

 Interactions

Anticholinergics: Effects may be increased. Barbiturates, charcoal: May increase effects of clomipramine. Cimetidine, fluoxetine, haloperidol, phenothiazine antipsychotics, oral contraceptives: May increase effects of clomipramine. Clonidine: May result in hypertensive crisis. CNS depressants: Depressant effects may be additive. Guanethidine: Antihypertensive effects may be decreased. MAO inhibitors: Sweating, convulsions and death may occur.

 Lab Test Interferences None well documented.

 Adverse Reactions

CV: Orthostatic hypotension; hypertension; tachycardia; palpitations; arrhythmias; ECG changes. CNS: Hyperthermia; confusion; hallucinations; delusions; nervousness; restlessness; agitation; panic; insomnia; nightmares; mania; exacerbation pf psychosis; drowsiness; dizziness; weakness; fatigue; emotional lability; aggressive reaction; seizures. DERM: Rash; pruritus; photosensitivity; dry skin; acne; itching; dermatitis. EENT: Conjunctivitis; blurred vision; dilated pupils; increased intraocular pressure; tinnitus; nasal congestion; peculiar taste in mouth. GI: Nausea; vomiting; anorexia; GI distress; diarrhea; flatulence; dry mouth; constipation. GU: Impotence; sexual dysfunction; ejaculation failure; urinary tract infection; vaginitis; cystitis; dysmenorrhea; amenorrhea; urinary retention or hesitancy. HEMA: Bone marrow depression including agranulocytosis; eosinophilia; purpura; thrombocytopenia; leukopenia; anemia. HEPA: Hepatitis; elevated liver function tests. META: Elevation or depression of glucose levels. RESP: Pharyngitis; rhinitis; sinusitis; laryngitis; cough. OTHER: Numbness; tremors; breast enlargement; nonpuerperal lactation; extrapyramidal symptoms (pseudoparkinsonism, movement disorders, akathisia); vestibular disorder; muscle weakness; significant weight gain; hypothyroidism.

 Precautions

Pregnancy: Category C. Neonatal withdrawal symptoms have been reported. Lactation: Excreted in breast milk. Children: Not recommended for children < 10 yr. Special risk patients: Use with caution in patients with history of seizures, urinary retention, urethral or ureteral spasm, angle-closure glaucoma or increased intraocular pressure, hepatic or renal impairment or cardiovascular disorders; hyperthyroid patients or those receiving thyroid medication and schizophrenic or paranoid patients.

PATIENT CARE CONSIDERATIONS

 Administration/Storage

  • During titration phase administer drug in divided doses daily with meals to lessen GI side effects.
  • After titration, give daily dose at bedtime with large glass of water to minimize daytime sedation.
  • Do not administer drug to patients who have taken MAO inhibitors within past 14 days.
  • Supervise medication intake when prescribed for psychiatric patients.
  • Store at room temperature. Protect from moisture.

 Assessment/Interventions

  • Obtain patient history, including drug history and any known allergies.
  • Assess patient’s physical and psychological condition monthly.
  • Dosage must be gradually decreased before discontinuation.
  • Monitor liver function, ECG, blood sugars (in patients with diabetes) and blood counts (CBC with differential) as needed.
  • Monitor body weight monthly.
  • Watch for anticholinergic effects; flushing, dry mouth, dilated pupils and hyperpyrexia.
  • If there is urinary elimination problem, signs of neuroleptic malignant syndrome or drop in BP of 20 mm Hg, withhold medication and notify physician.
  • If arrhythmia or increase in heart rate develop, notify physician.
  • Discontinue medication immediately if patient demonstrates increased agitation or paranoid delusions.
OVERDOSAGE: SIGNS & SYMPTOMS
  Confusion, hallucinations, agitation, cardiac arrhythmias, dilated pupils, seizures, flushing, dry mouth, fever, tachycardia, cardiac arrest, coma, respiratory depression, cyanosis, hypotension, shock, sweating

 Patient/Family Education

  • Instruct patient to keep weekly record of weight and to decrease caloric intake if necessary.
  • Teach patient how to monitor BP and heart rate.
  • Instruct patient on oral hygiene habits to prevent and treat dry mucous membranes.
  • Advise patient to increase fluid intake.
  • Instruct patient not to discontinue taking drug abruptly.
  • Inform male patients of possible impotence or ejaculation failure.
  • Caution patient to avoid sudden position changes to prevent orthostatic hypotension.
  • Instruct patient to avoid intake of alcoholic beverages or other CNS depressants.
  • Advise patient that drug may cause drowsiness and to use caution while driving or performing other tasks requiring mental alertness.
  • Caution patient to avoid exposure to sunlight and to use sunscreen or wear protective clothing to avoid photosensitivity reaction.
  • Instruct patient not to take otc medications without notifying physician.

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