Anafranil (clomipramine hydrochloride) is a tricyclic antidepressant (TCA) with potent serotonin reuptake inhibition, approved for the treatment of obsessive-compulsive disorder (OCD). It represents a first-line pharmacological option when selective serotonin reuptake inhibitors (SSRIs) prove insufficient, offering a robust mechanism of action for severe and intrusive symptoms. Its efficacy is well-established in clinical practice, providing a critical therapeutic tool for psychiatrists managing complex anxiety and mood disorders.

Features

• Active ingredient: Clomipramine hydrochloride
• Available in 10 mg, 25 mg, and 50 mg capsules
• Potent inhibitor of serotonin reuptake with secondary noradrenergic effects
• FDA-approved for obsessive-compulsive disorder (OCD)
• Also used off-label for major depressive disorder, panic disorder, and chronic pain
• Requires gradual titration to mitigate anticholinergic and adrenergic side effects

Benefits

• Significantly reduces the frequency and intensity of obsessive thoughts and compulsive behaviors
• Improves overall daily functioning and quality of life in patients with severe OCD
• Provides an alternative for SSRI-resistant cases due to its distinct neurochemical profile
• May alleviate comorbid depressive and anxiety symptoms
• Supported by decades of clinical evidence and long-term safety data
• Available in generic form, improving accessibility and cost-effectiveness

Common use

Anafranil is primarily prescribed for the management of obsessive-compulsive disorder in adults and children aged 10 years and older. Its use extends to treatment-resistant major depression, severe panic disorder, and certain chronic pain syndromes such as neuropathic pain and migraine prophylaxis. In clinical practice, it is often reserved for cases where first-line antidepressants like SSRIs have failed or caused intolerable side effects. Its broad receptor activity makes it particularly useful in complex presentations with overlapping anxiety, mood, and somatic symptoms.

Dosage and direction

Dosage must be individualized and titrated slowly under close medical supervision. For adults with OCD, treatment typically begins with 25 mg daily, gradually increasing by 25 mg every 3–4 days to a target range of 100–250 mg per day, divided into two or three doses. Maximum daily dose should not exceed 250 mg. For elderly patients or those with hepatic impairment, initial doses are lower (10–25 mg/day) with slower titration. Administration with food may reduce gastrointestinal upset. Regular monitoring of blood levels is not routinely required but may be considered in cases of poor response or suspected toxicity.

Precautions

Patients should be advised that sedation and orthostatic hypotension are common during initial treatment; caution is advised when driving or operating machinery. Regular monitoring of blood pressure, heart rate, and ECG is recommended, especially in patients with cardiovascular risk factors. Anafranil may lower seizure threshold; use with caution in patients with epilepsy or those undergoing electroconvulsive therapy. Hyponatremia due to SIADH has been reported, particularly in elderly patients. Abrupt discontinuation should be avoided due to risk of withdrawal symptoms including nausea, headache, and malaise.

Contraindications

Anafranil is contraindicated in patients with known hypersensitivity to clomipramine or other tricyclic antidepressants. It must not be used concomitantly with monoamine oxidase inhibitors (MAOIs) or within 14 days of discontinuing MAOI therapy due to risk of serotonin syndrome. Additional contraindications include recent myocardial infarction, uncompensated heart failure, and certain cardiac arrhythmias. It is contraindicated in patients with narrow-angle glaucoma and significant urinary retention.

Possible side effects

Common adverse reactions include dry mouth, constipation, blurred vision, sedation, dizziness, weight gain, and sweating. Sexual dysfunction including decreased libido, erectile dysfunction, and anorgasmia may occur. Less frequently, patients may experience orthostatic hypotension, tachycardia, urinary retention, or confusion. Serious but rare side effects include seizures, agranulocytosis, and neuroleptic malignant syndrome. Suicidal ideation may emerge particularly in adolescents and young adults, requiring close monitoring especially during initial treatment.

Drug interaction

Anafranil has significant interaction potential due to its metabolism via CYP2D6 and CYP3A4 enzymes and its serotonergic and anticholinergic properties. Concurrent use with SSRIs, SNRIs, triptans, or tramadol increases risk of serotonin syndrome. CYP2D6 inhibitors (e.g., fluoxetine, paroxetine) may increase clomipramine levels. Anticholinergic drugs may exacerbate dry mouth, constipation, and urinary retention. Anafranil may potentiate effects of CNS depressants including alcohol, benzodiazepines, and opioids. It may antagonize antihypertensive effects of guanethidine and similar agents.

Missed dose

If a dose is missed, it should be taken as soon as remembered unless it is close to the time of the next scheduled dose. In that case, the missed dose should be skipped and the regular dosing schedule resumed. Patients should not double the dose to make up for a missed one. Consistent daily administration is important to maintain steady-state plasma concentrations and therapeutic effect.

Overdose

Anafranil overdose is potentially life-threatening and may manifest as drowsiness, stupor, coma, tachycardia, hypotension, respiratory depression, seizures, and cardiac arrhythmias including QT prolongation. Anticholinergic symptoms such as dilated pupils, dry skin, and hyperthermia may be present. Management includes gastric lavage if presented early, activated charcoal, and aggressive supportive care with continuous ECG monitoring. Sodium bicarbonate is indicated for QRS widening. There is no specific antidote; treatment is symptomatic and supportive.

Storage

Store at room temperature (15–30°C or 59–86°F) in a tightly closed container, protected from light and moisture. Keep out of reach of children and pets. Do not use after the expiration date printed on the packaging. Unused medication should be disposed of properly through a medicine take-back program or according to FDA guidelines to prevent accidental ingestion or environmental contamination.

Disclaimer

This information is intended for educational purposes only and does not constitute medical advice. Anafranil is a prescription medication that should be used only under the supervision of a qualified healthcare provider. Dosage, indications, and monitoring requirements should be determined by a physician based on individual patient assessment. Always consult with a healthcare professional before starting, changing, or discontinuing any medication.

Reviews

Clinical studies consistently demonstrate Anafranil’s superiority over placebo in reducing Yale-Brown Obsessive Compulsive Scale (Y-BOCS) scores, with response rates of 40–60% in treatment-resistant OCD. Many psychiatrists report robust efficacy in severe cases where SSRIs have failed, though side effect burden often requires careful management. Long-term users frequently describe significant improvement in quality of life despite initial side effects, with particular appreciation for its effect on intrusive thoughts. The medication maintains a reputation as a powerful option in the psychiatric arsenal, particularly for specialists managing complex anxiety disorders.