Question from a Member:
For a patient on 150 mg per day of clomipramine, the clomipramine level was 157 (normal 50-250) and the total was 514 (normal 200-600), but the desmethylclomipramine level is high at 357 (normal 50-350). My quick literature review revealed that lower desmethylclomipramine levels are associated with improved outcomes. What are your thoughts? How would you handle this situation?
The significance of the desmethylclomipramine level
In addition to potentially toxic levels, the levels of clomipramine and desmethylclomipramine are also related to response to the medication.
It has been suggested that improvement in OCD is related to serum levels of clomipramine (Mavissakalian et al., 1990; Stern et al., 1980), while improvement in depression may be related to serum levels of desmethylclomipramine (Stern et al., 1980).
Patients who responded to treatment of OCD with clomipramine had a trend toward lower desmethylclomipramine/clomipramine ratios (Mavissakalian et al., 1990).
This was also found in a more recent study. Patients who had a greater improvment in OCD with clomipramine treatment were found to have a lower desmethylclomipramine/clomipramine ratio (Marcourakis et al., 2015). The authors concluded that hese data suggest that a lower demethylation rate correlates with better clinical outcome.
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