Depression with lack of energy or mild agitation
Obsessive Compulsive Disorders (OCD)
Panic attacks with or without Agoraphobia
Narcolepsy
chronic pain with or without organic disease, particular headache of the tension type
Enuresis (involuntary nightly urinating in sleep) in children / adolescents
Off label, sometimes antidepressants of this type have been found helpful in reducing relapses in cocaine addicts and to help repair cocaine-caused neurotransmitter imbalances and early brain damage. Further studies are needed for Clomipramine in this regard.

It may take 2 to 3 weeks before the full effects of this medication are noticed in all indications.

Contraindications

Concomitant therapy with an (irreversible) MAO-Inhibitor (e.g. Tranylcypromin, Phenelzin)
Acute intoxication with central depressants (alcohol, psychoactive drugs, narcotics)
States of confusion (caution), absolutely contraindicated in patients with coma and Delirium tremens
Patients with massive agitation or anxiety (give sedative drugs concomittantly)
Hypersensitivity/Allergy against Clomipramine or other related tricyclic compounds
Hypertrophy of the Prostate with urine retention (=difficulty in urinating)
Caution : Hypertrophy of the Prostate without urine retention
Preexisting closed angle glaucoma
Epilepsy and other conditions which lower the seizure-threshold (alcohol-withdrawal, active brain tumors)
Serious liver disease (elimination is decreased), if Clomipramine is given consider dose reduction
Serious kidney disease (elimination is decresed), if Clomipramine is given consider dose reduction
Severe hypotension, shock, serious cardiovascular dysfunction (postinfarctous states, heart insufficience, arrhythmias), avoid high oral doses or injections/infusions
Preexisting bone marrow depression (leukopenia, thrombopenia, anemia, pancytopenia), can be worsened by Clomipramine
Overfunction of the thyreoid gland makes the patient more sensitive to side-effects of Clomipramine. Cautious doses should be used and the overfunction should be treated.
Caution should be exerted when treating pediatric patients under 18 yrs. of age

Pharmacology

Clomipramine is the 3-chloro derivative of Imipramine. Clomipramine is a strong, but not completely selective Serotonic-Reuptake-Inhibitor (SRI), as the active main metabolite Desmethyclomipramine acts preferably as inhibitor of Noradrenaline-Reuptake. Other hydroxy-metabolites are also active. Alpha-1-Receptor blockage and beta-down-regulation as well as postsynaptic antagonism on H1 (histaminergic)-receptors have been noted. A blockade of Sodium-channels and NDMA-receptors might, as with other tricyclics, account for its effect in chronic pain, particular of the neuropathic type.

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Clinical Quiz - continuing medical education
From American Family Physician, 10/1/02

Clinical Quiz questions are based on selected articles in this issue. Answers appear in this issue.

American Family Physician has been approved by the American Academy of Family Physicians as having educational content acceptable for Prescribed credit hours. Term of approval covers issues published within one year from the beginning distribution date of January 2002. This issue has been reviewed and is acceptable for up to 4.5 Prescribed credit hours. One half hour of these credit hours conforms to AAFP criteria for evidence-based CME clinical content. Credit may be claimed for one year from the date of this issue. When reporting CME credit hours, AAFP members should report total Prescribed credit hours earned for this activity. It is not necessary for members to label credit hours as evidence-based or Prescribed for CME reporting purposes.

The American Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The AAFP designates this educational activity for a maximum of 4.5 hours in Category 1 credit toward the American Medical Association Physician's Recognition Award. Each physician should claim only those hours of credit that he or she actually spent in the educational activity.

AAFP Credit

Each copy of AFP contains a Clinical Quiz answer card. AAFP members may use this card to obtain the designated number of Prescribed credit hours for the year in which the card is postmarked.

AMA/PRA Category 1 Credit

AAFP members who satisfy the Academy's continuing medical education requirements are automatically eligible for the AMA/PRA.

Physicians who are not members of the AAFP are eligible to receive the designated number of credit hours in Category 1 of the AMA/PRA on completion and return of the Clinical Quiz answer card. AFP keeps a record of AMA/PRA Category 1 credit hours for nonmember physicians. This record will be provided on request; however, nonmembers are responsible for reporting their own Category 1 CME credits when applying for the AMA/PRA or other certificates or credentials.

For health care professionals who are not physicians and are AFP subscribers, a record of CME credit is kept by AAFP and will be provided to you on written request. You are responsible for reporting CME hours to your professional organization.

NOTE: The full text of AFP is available online (www.aafp.org/afp), including each issue's Clinical Quiz. The table of contents for each online issue will link you to the Clinical Quiz. Just follow the online directions to take the quiz and, if you're an AAFP member, you can submit your answers for CME credit.

INSTRUCTIONS

(1) Read each article, answer all questions on the quiz pages, and transfer your answers to the Clinical Quiz answer card (bound into your copy of AFP). This will help you avoid errors and permit you to check your answers against the correct answers.

(2) Mail the Clinical Quiz answer card within one year (by October 31, 2003). The bar code on the answer card contains your identification for CME credit hours.

Before beginning the test, please note:

Each Clinical Quiz includes two types of questions: Type A and Type X.

Type A questions have only one correct answer and may have four or five choices. Here is a typical Type A question:

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