Prescribing
Forms: 20, 40, 80, 120mg extended-release capsuleDose Range: 40-120 mg/day
Starting: 20 mg qd x2 days, then 40 mg qd; may ↑ by 40 mg/day q2 days.
Stopping: A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible
Precautions
Contraindications: Concomitant use of MAOIs; uncontrolled narrow angle glaucomaSerious Side Effects: Serotonin syndrome; ↑ risk of SI in children and young adults; may impair platelet aggregation; SIADH; HTN (~3mmHg ↑ in both systolic & diastolic), ↑ HR
Side Effects: urinary retention, hyponatremia, nausea, constipation, vomiting, palpitations, erectile dysfunction, anorgasmia, hyperhidrosis
Pharmacokinetics
t½: 12° TMAX: 6-8°Substrate of: 3A4
Inhibits: ∅ ; Induces: ∅
Active Metabolites: ∅
DDIs
- - DO NOT CO-PRESCRIBE WITH MAOIs (need a 14-day washout period)
- - few known DDIs
- - 3A4 inhibitors can ↑ levels; likewise, 3A4 inducers can ↓ levels
Misc
- - the more pharmacologically active isomer derived from the racemic compound milnacipran (Savella)
- - Levomilnacipran is the most noradrenergically active of the SNRIs
- - from most to least noradrenergic: levomilnacipran (1:2, 5HT:NE ratio) >> duloxetine (10:1) > desvenlafaxine (12:1) > venlafaxine (30:1)
Special Populations
Category C—Based on animal data, may cause fetal harm.
There are no clinical data regarding the effect on lactation and nursing
No dosage adjustment necessary
Renal elimination has been reported to account for 58% of clearance, so adjust accordingly. CrCl 30-59: max 80 mg/day; CrCl 15-29: max 40 mg/day; ESRD: avoid use
Hepatic elimination is low. Dose adjustment is not recommended.
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