Aamir Jalal Al-Mosawi
Background: Various medications have been used in the treatment of obsessive-compulsive disorder during the 1960s including imipramine (A tricyclic antidepressant), benzodiazepines including oxazepam, and lithium. However, clomipramine has been increasingly used during the 1970s. (A tricyclic antidepressant). However, more than 20% of patients with obsessive-compulsive disorder continue to represent a therapeutic challenge for the treating physicians.
Selective serotonin reuptake inhibitors have become an integral part of pharmacotherapies for obsessive-compulsive disorder, and the addition of low dose neuroleptic has been increasingly suggested when treating difficult cases.
Patients and Methods: The case of a 24-year old female with obsessive compulsive disorder who didn’t respond to several medication is presented, and the evidence-based therapeutic approach to such case is discussed.
Results: The patient started experiencing the obsessions before about few months during the year 2023, and the obsessions resulted in excessive cleaning as the main compulsion. The illness was complicated with symptoms of anxiety and depression. The patient was treated with multiple medications for only short periods because of intolerance and the development of a variety of unwanted side effects including headaches and tremor. Medications included oral deanxit
(Flupentixol plus melitracen), oral olanzapine, oral clonazepam, imipramine (Tofranil), oral paroxetine, oral Escitalopram, oral levetiracetam. Therefore, the patient was treated according to the available evidence with oral citalopram 20 mg daily plus oral risperidone in an initial dose of 1 mg at night, to be gradually increasing to 2 mg depending on the occurrence of excessive drowsiness. Ondansetron was also given in an initial dose of 4 mg daily in the morning, to be gradually increasing to 8 mg based depending on the occurrence of unwanted gastrointestinal symptoms. Celecoxib was given in an initial dose of 200 mg daily in the morning with possible increase in dose if necessary.
Conclusion: The current evidence-based expert opinion suggests that difficult cases of obsessive-compulsive disorder that are commonly associated with medication intolerance can be treated with relatively low doses of citalopram plus risperidone plus ondansetron plus Celecoxib. If adequate response is not obtained, lamotrigine can be added with gradually withdrawing ondansetron and Celecoxib.