Milnacipran

FDA label

Read the full label on DailyMed ↗

Titration Per schedule: 12.5 mg Day 1 → 25 mg/day Days 2–3 → 50 mg/day Days 4–7 → 100 mg/day after Day 7

Renal Mild: none; moderate: caution; severe (CrCl 5–29): reduce maintenance 50% to 50 mg/day (may ↑ to 100 mg/day); not recommended in ESRD

Hepatic No adjustment; caution in severe impairment

Doses >200 mg/day have not been studied

Instructions

• Take twice daily with or without food (food may improve tolerability)
• Taper and do not abruptly discontinue after extended use
• ≥14 days between stopping a psychiatric MAOI and starting; ≥5 days after stopping milnacipran before starting an MAOI

Contraindications

• MAOIs (concurrently or within 14 days of stopping MAOI); allow 5 days after stopping milnacipran before starting an MAOI due to risk of serotonin syndrome

Cautions

• Suicidality — monitor for worsening depression/behavior
• Serotonin syndrome (esp. with serotonergic drugs; can occur alone)
• Elevated blood pressure and heart rate — measure at baseline and monitor
• Seizures — caution with seizure history
• Hepatotoxicity — avoid with substantial alcohol use/chronic liver disease
• Discontinuation/withdrawal symptoms — taper gradually
• Increased bleeding risk with NSAIDs/aspirin/anticoagulants
• Genitourinary events in men with obstructive uropathy
• Hyponatremia (elderly)

Adverse reactions

• Nausea
• Headache
• Constipation
• Dizziness
• Insomnia
• Hot flush
• Hyperhidrosis
• Vomiting
• Palpitations
• Heart rate increased
• Dry mouth
• Hypertension

Pregnancy SNRI exposure (esp. month before delivery) associated with <2-fold ↑postpartum hemorrhage; third-trimester exposure linked to neonatal complications; insufficient data on birth defects

Lactation Present in human milk (~5% weight-adjusted maternal dose); monitor infant for agitation, irritability, poor feeding, poor weight gain