Drug therapy for OCD

• seek specialist advice
• choice of drug treatment
  • selective serotonin reuptake inhibitors (SSRIs)
    • for adults with OCD, the initial pharmacological treatment should be one of the following SSRIs: fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram
    • for adults with body dysmorphic disorder (BDD) (including those with beliefs of delusional intensity), the initial pharmacological treatment should be fluoxetine because there is more evidence for its effectiveness in BDD than there is for other SSRIs
    • if an adult with OCD or BDD develops marked and/or prolonged akathisia, restlessness or agitation while taking an SSRI, the use of the drug should be reviewed. If the patient prefers, the drug should be changed to a different SSRI
    • for adults with OCD or BDD, if there has not been an adequate response to a standard dose of an SSRI, and there are no significant side effects after 4-6 weeks, a gradual increase in dose should be considered in line with the schedule suggested by the Summary of Product Characteristics
    • for adults with OCD or BDD, the rate at which the dose of an SSRI should be increased should take into account therapeutic response, adverse effects and patient preference. Patients should be warned about, and monitored for, the emergence of side effects during dose increases
    • if treatment for OCD or BDD with an SSRI is effective, it should be continued for at least 12 months to prevent relapse and allow for further improvements
    • for adults with OCD or BDD, to minimise discontinuation/withdrawal symptoms when reducing or stopping SSRIs, the dose should be tapered gradually over several weeks according to the person's need
      • rate of reduction should take into account the starting dose, the drug half-life and particular profiles of adverse effects
    • other drugs
      • the following drugs should not normally be used to treat OCD or BDD without comorbidity:
        • tricyclic antidepressants other than clomipramine
        • tricyclic-related antidepressants
        • serotonin and noradrenaline re-uptake inhibitors (SNRIs), including venlafaxine
        • monoamine oxidase inhibitors (MAOIs) · anxiolytics (except cautiously for short periods to counter the early activation of SSRIs)
      • antipsychotics as a monotherapy should not normally be used for treating OCD
      • antipsychotics as a monotherapy should not normally be used for treating BDD (including beliefs of delusional intensity)

Notes:

• how to use clomipramine in adults
  • for adults with OCD or BDD who are at a significant risk of suicide, healthcare professionals should only prescribe small amounts of clomipramine at a time because of its toxicity in overdose . The patient should be monitored regularly until the risk of suicide has subsided
  • an electrocardiogram (ECG) should be carried out and a blood pressure measurement taken before prescribing clomipramine for adults with OCD or BDD at significant risk of cardiovascular disease
  • for adults with OCD or BDD, if there has not been an adequate response to the standard dose of clomipramine, and there are no significant side effects, a gradual increase in dose should be considered in line with the schedule suggested by the Summary of Product Characteristics
  • for adults with OCD or BDD, treatment with clomipramine should be continued for at least 12 months if it appears to be effective and because there may be further improvement.
  • for adults with OCD or BDD, when discontinuing clomipramine, doses should be reduced gradually in order to minimise potential discontinuation/withdrawal symptoms. C

Reference:

1. NICE (2005).Obsessive-compulsive disorder