Is there an alternative to Clomipramine?

[Wilburis]

Hi

Does anyone know if there is an alternative to Clomipramine and not another TCA?

Many thanks

x

[panic_down_under]

Does anyone know if there is an alternative to Clomipramine and not another TCA?

Sure, SSRIs, SNRIs, even MAOI class antidepressants.

What is the clomipramine for and what is the problem?

[Wilburis]

Hi,

Thank you for replying. Your knowledge has been highly recommended!

I was on Clomipramine for 9 years, for OCD, panic, anxiety, depression and agraphobia.

I have tried many TCAs and SRIs. I cannot tolerate SRIs.

I cannot go back on TCAs as we have Brugada Syndrome in the family and there is a list of medications which should not be taken and of course, this is on the list.

My psychiatrist wanted to put me on Imipramine, but Id already tried this and and it's on the list.

She has put me on Buspar. Ive been on it a week and feel really anxious and have a bad tummy.

Clomipramine worked for me but I cant take it any more.

I wondered if there was an alternative.

Ive also tried Pregabalin and Quetipine (sp).

Thank you xx

---------- Post added at 13:18 ---------- Previous post was at 13:11 ----------

A list of everything Ive tried so far:

Lofepramine
Clomipramine
Amitriptyline
Imipramine
Nortriptyline
Citalopram
Escitalopram
Prozac
Sertraline
Mirtazapine
Quetiapine
Pregabalin

[panic_down_under]

I cannot go back on TCAs as we have Brugada Syndrome in the family

Have you been tested for the Brugada ECG pattern and were you told by a cardiologist to avoid TCAs? If not, I suggest you seek the advice of a cardiologist before doing anything.

She has put me on Buspar. Ive been on it a week and feel really anxious and have a bad tummy.

Buspar (buspirone) is a GAD specific med which works well for some, but not for most. It is rarely effective for OCD, panic disorder and PTSD and is unlikely to help with depression either.

I wondered if there was an alternative.

The SNRIs milnacipran (Savella) and levomilnacipran (Fetzima) are the closest SNRIs to clomipramine in activity though they are more potent noradrenaline, aka norepinephrine, reuptake inhibitors than clomipramine. Neither is listed on the CredibleMeds data base of drugs which prolong heart QTc interval, or trigger Torsades de Pointes (TdP). Periclou A, 2010, tested milnacipran doses to 600mg/day, 3 times the recommended maximum 200mg anxiety/depression dose, and found no evidence it affects cardiac repolarisation even at such overdoses.

Either would be worth a shot, though there are no guarantees they'll work. Note: these are essentially the same med, levomilnacipran contains only the active isomer of milnacipran, whereas milnacipran also contain a mostly inactive form. Levomilnacipran is mostly an exercise in extending the patent in the same way escitalopram (Lexapro) was developed when the citalopram (Celexa) patent expired. As it is still in patent levomilnacipran is likely to be more expensive.

PS: yes, I'm aware that Brugada and prolonged QTc are not the same thing, but QTc probably serves as a good indicator of a med's likely affect on the electrical system of the heart more generally.

[Wilburis]

Hello

Wow! How do you know so much about medication?

Outstanding!

I have had the Ajmaline Test to try to provoke the Brugada ECG pattern, it was negative but my sister and cousin are both positive. My cousin's son had a sudden cardiac arrest but luckily survived. The Ajmaline test is not 100% conclusive.

We are awaiting on gentic testing as there is definitely something going in the family.

I really wouldn't feel confortable taking another TCA.

What does "more potent noradrenaline, aka norepinephrine, reuptake inhibitors than clomipramine" mean?

Im quite upset as I have paid just under £500 to see a top London psychiatrist and she wanted to put me on something I told her I didnt want to take - imipramine and then she gave me buspar. She told me it will have a similar effect to Diazepam after a month.

The only newer med Ive heard of is Effexor.

Thank you so much for your help, I truly appreciate it.

Liz xx

---------- Post added at 15:39 ---------- Previous post was at 15:07 ----------

Hello

Apologies.

I should have included this letter with all the avoid medication listed.

http://www.brugadadrugs.org/upload-d...%20ENGLISH.pdf

Sorry, I don't know how to link it.

xx

[panic_down_under]

Wow! How do you know so much about medication?

I have no life...waaa

I have had the Ajmaline Test to try to provoke the Brugada ECG pattern, it was negative but my sister and cousin are both positive. My cousin's son had a sudden cardiac arrest but luckily survived. The Ajmaline test is not 100% conclusive.

We are awaiting on gentic testing as there is definitely something going in the family.

The odds are good that you're not affected, Liz. Even 'identical twins' aren't completely identical. Also being female helps as males are at far greater risk of sudden heart failure.

What does "more potent noradrenaline, aka norepinephrine, reuptake inhibitors than clomipramine" mean?

Clomipramine and the milnacipran/levomilnacipran inhibit both serotonin (5-HT) and noradrenaline (NA) reuptake. Clomiporamine does in a 5-HT:NA ratio of about 2:1, the two SNRIs are about 1:1 and 1:2 respectively, which may seem like a huge variation, but isn't in antidepressant terms and is about as close as you can get with single meds. As a comparison, the only other SNRI worth considering, duloxetine (Cymbalta), inhibits 5-HT:NA in a ratio of about 10:1. If you can't get milnacipran/levomilnacipran then duloxetine would be the next closest.

She told me it will have a similar effect to Diazepam after a month.

If you had only GAD it might be worth persisting with though even for that it is more likely to not work than be effective. But I doubt it will help you given the OCD, panic and depression.

The only newer med Ive heard of is Effexor.

While technically a SNRI, it is only really a SSRI having only a very weak affect on NA reuptake. The SSRIs fluoxetine, fluvoxamine, paroxetine, sertraline and vortioxetine are all far more potent NA reuptake inhibitors. So if you can't tolerate SSRIs you probably won't Effexor (venlafaxine) either. Same goes for its metabolite desvenlafaxine marketed as Pristiq.

[Wilburis]

Hello

Thank you again.

Oh my, you are amazing! You know so much.

May I ask what medication you are on?

xx

[panic_down_under]

May I ask what medication you are on?

225mg dosulepin, aka dothiepin, (Prothiaden, Dothep) for 20 years. This used to be the UKs most popular antidepressant with nearly 75% of the market at one stage until it was found to be very cardio toxic. I understand it has been removed from the British National Formulary and only specialist-care prescribers can now prescribe it for new patients. Amitriptyline is the closest med in terms of potency.

Ironically I switch from 350mg of imipramine (Tofranil) because the understanding then was dosulepin was the safer drug.

[MyNameIsTerry]

We still have people on Dosulepin, Ian.

NICE recommend not to use it in their depression guidelines due to evidence of tolerability vs. the cardio issues being outweighed by the latter. It has been used for things like fibro & neuropathic pain off label but the evidence is considered weak and therefore not recommended. The BNF have it marked "less suitable for prescribing" from what I understand.

It's one for psychiatrists in that respect. Looking at one local trust alone reporting on it in 2016, they noticed prescribing rates we still "high", stating In the South West area, Dorset CCG was the highest prescriber of dosulepin for the 2015/16 financial year (3.238% of all antidepressant items). Of the 209 CCGs in the UK, Dorset is the fourteenth highest prescriber of dosulepin, and well above the national average of 2.111%.

So, there is the possibility that these are cases where psychiatrists have assessed and prescribed or recommended to your GP's where referred. GP's will usually support a psychiatrist. In the UK, if you reach Level 4 on the NICE Stepped Care Model (above takes you into the hospital levels) then you are with the traditional Community Mental Health Teams (CMHT) which can mean they take over your prescribing and then hand you back to your GP for maintenance prescribing later. But you can be with a CMHT and still have the GP managing you too, it depends what treatment is taking place e.g. a CMHT review might just determine you need support from a nurse in the community or other support worker.

Therefore, I wonder if our average represents psychiatrist decisions handed back to GP's as well? There may be internal guidelines to limit or phase it out where they can but perhaps there are still ways for people like the OP?

Googling "dosulepin BNF" will pull you back the evidence searches and local trust guidance docs, if you ever needed them.

Whilst NICE issue guidance on excellence, it's not always the case that's what doctors are doing. Many of us on here will likely have found that at some point, I've posted many a reply showing the guidance opposes a GP view.

[panic_down_under]

We still have people on Dosulepin, Ian.

Yes, I know the restricts are for new patients. But I understand the amount of drug that can be prescribed is now restricted to only 2 weeks supply of 75mg tablets. Fortunately, news of the potential problems with dosulepin have not yet made it down-under (those convict ships are slow ) so we can still get a month's supply. GPs do need to get authorisation from the federal health dept for each script, but this is the case for many antidepressants.

But it isn't widely prescribed. According to my chemist I'm the only one on it in my town of around 12,000 people.