Desvenlafaxine for depression
New SNRI may have more predictable effects and a lower risk of drug-drug interactions.
AEs generally occur during the first week of treatment. In the 8-week trials, the most common AEs were nausea and dizziness (Table 2). In a long-term study (up to 9 months), the most common AE was vomiting. Although the recommended starting dose is 50 mg/d, to avoid AEs consider beginning with every-other-day dosing.
Table 2
Desvenlafaxine trials: Rates of adverse effects
| Desvenlafaxine dose | |||
|---|---|---|---|
| Adverse effect | 50 mg/d | 100 mg/d | Placebo |
| Nausea | 22% | 26% | 10% |
| Dizziness | 13% | 10% | 5% |
| Insomnia | 9% | 12% | 6% |
| Hyperhidrosis | 10% | 11% | 4% |
| Constipation | 9% | 9% | 4% |
| Somnolence | 4% | 9% | 4% |
| Decreased appetite | 5% | 8% | 2% |
| Erectile dysfunction | 3% | 6% | 1% |
| Decreased libido | 4% | 5% | 1% |
| Anxiety | 3% | 5% | 2% |
| Source: Reference 1 | |||
Abruptly discontinuing desvenlafaxine can cause withdrawal symptoms, including dizziness, nausea, headache, irritability, insomnia, diarrhea, anxiety, abnormal dreams, fatigue, and hyperhidrosis. The frequency of withdrawal symptoms is higher with longer treatment duration. Gradually reducing the dose by administering 50 mg of desvenlafaxine less often can reduce withdrawal symptoms.
Clinical issues
All SNRIs and selective serotonin reuptake inhibitors (SSRIs) have a “black-box” warning about the potential for clinical worsening and increased suicidality early in treatment. Closely monitor patients for suicidal ideation/behaviors during the first months of treatment and with dose changes.
When taken in the third trimester of pregnancy, SNRIs and SSRIs can cause serious neonatal complications—including respiratory distress, cyanosis, apnea, and seizures—that may require longer hospitalization, respiratory support, or tube feeding for the infant. Carefully consider risks and benefits of third-trimester antidepressant use.5 Desvenlafaxine is excreted in breast milk and may cause AEs in infants who are breast-fed.
In clinical trials, patients taking desvenlafaxine experienced increased cholesterol, triglycerides, and blood pressure. Monitor these parameters closely in patients taking desvenlafaxine, and use the drug with caution in patients with cerebrovascular and cardiovascular disease.
Other concerns in patients taking desvenlafaxine include:
- Antidepressant medications can trigger hypomania or mania in patients with bipolar disorder.
- Patients—particularly those who are elderly or taking diuretics—may develop hyponatremia as a result of syndrome of in-appropriate antidiuretic hormone.
- Patients with an increased risk of glaucoma need to be monitored because of the drug’s effect on blood pressure.
Drug interactions. Coadministering desvenlafaxine with serotonergic medications— such as triptans, other antidepressants, and tramadol—can cause serotonin syndrome, a potentially life-threatening condition characterized by mental status changes, autonomic instability, neuromuscular aberrations, and gastrointestinal symptoms. Concomitant use of desvenlafaxine and blood-thinning medications such as warfarin, aspirin, and nonsteroidal anti-inflammatory drugs may result in abnormal bleeding. Patients taking a potent CYP 3A4 inhibitor such as ketoconazole may have increased desvenlafaxine concentration.
Contraindications
Do not prescribe desvenlafaxine to patients who are:
- hypersensitive to venlafaxine chloride, desvenlafaxine succinate, or any parts of the desvenlafaxine formulation
- taking a monoamine oxidase inhibitor (MAOI), or have discontinued an MAOI within 14 days.
Patients who stop taking desvenlafaxine should wait 7 days before starting an MAOI.
Drug brand names
- Bupropion • Wellbutrin
- Desvenlafaxine • Pristiq
- Duloxetine • Cymbalta
- Fluoxetine • Prozac
- Ketoconazole • Nizoral
- Paroxetine • Prozac
- Tramadol • Ultram
- Venlafaxine • Effexor
- Warfarin • Coumadin
Disclosures
Dr. Lincoln reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. Preskorn has in the past year received research/ grant support from and served as a speaker for Wyeth Pharmaceuticals. Previously, he has received research/grant support from or served as a speaker for or consultant to Abbott Laboratories, AstraZeneca, Aventis, Biovail, Boehringer Ingleheim, Bristol-Myers Squibb, Eisai, Eli Lilly and Company, GlaxoSmithKline, Hoffman LaRoche, Janssen, L.P., Johnson & Johnson, Lundbeck, Merck, Novartis, Organon, Otsuka, Pfizer Inc., Solvay, Somerset, Sumitomo, and Yamanouchi.
