Venlafaxine XR

EFFEXOR XR

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What it isVenlafaxine extended-release (EFFEXOR XR, 1997) inhibits serotonin and norepinephrine reuptake; depression and several anxiety disorders.

Why this oneUnlike the IR tablets, its label includes GAD, SAD, panic—more approved anxiety indications than most antidepressants.

What limits itAbrupt interruption causes prominent discontinuation symptoms; monitor blood pressure and avoid stacking serotonergic drugs.

FDA-approved for

depression (1997)
generalized anxiety disorder (1999)
social anxiety disorder (2003)
panic disorder (2005)

FDA label

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BOXED WARNING Increased risk of suicidal thoughts and behavior in pediatric and young adult patients; monitor closely. Not approved for pediatric patients.

FDA dosing	Population	Start	Target	Max
Major Depressive Disorder (MDD)	Adults	37.5-75 mg QD	75 mg QD	225 mg QD
Generalized Anxiety Disorder (GAD)	Adults	37.5-75 mg QD	75 mg QD	225 mg QD
Social Anxiety Disorder (SAD)	Adults	75 mg QD	75 mg QD	75 mg QD
Panic Disorder (PD)	Adults	37.5 mg QD	75 mg QD	225 mg QD

Titration Increase in increments up to 75 mg/day at intervals of not less than 4 days (not less than 7 days for panic disorder)

Renal Reduce total daily dose 25-50% (mild-moderate); 50% or more for severe impairment or hemodialysis

Hepatic Reduce total daily dose 50% (mild-moderate); more than 50% for severe impairment or cirrhosis

Instructions

Take once daily with food at approximately the same time each day
Swallow capsules whole; do not divide, crush, chew, or dissolve (or sprinkle contents on applesauce and swallow immediately without chewing)
Taper gradually when discontinuing (reduce ~75 mg at 1-week intervals) — do not stop abruptly
Allow ≥14 days after stopping an MAOI before starting, and ≥7 days after stopping before starting an MAOI

Contraindications

Concomitant use of MAOIs, or within 14 days of stopping an MAOI, because of the risk of serotonin syndrome
Life-threatening serotonin syndrome requires combination with an MAOI; SRI overdose or SRI+SRI combination causes non-life-threatening serotonin toxicity.

Cautions

Serotonin syndrome (increased with other serotonergic drugs; can occur alone)
Elevated blood pressure — control hypertension before starting; monitor
Increased bleeding risk with NSAIDs/aspirin/anticoagulants
Angle-closure glaucoma; activation of mania/hypomania (screen for bipolar disorder)
Discontinuation syndrome; seizures; hyponatremia/SIADH; interstitial lung disease/eosinophilic pneumonia; sexual dysfunction

Adverse reactions

Nausea
Somnolence
Dry mouth
Sweating
Abnormal ejaculation
Anorexia
Constipation
Dizziness
Insomnia

Pregnancy No established increased risk of major birth defects; possible increased preeclampsia and postpartum hemorrhage; monitor neonates for poor adaptation/discontinuation syndrome (third-trimester exposure)

Lactation Venlafaxine and active metabolite present in human milk; no adverse reactions seen in breastfed infants in studies

⚠ BOXED WARNING