Fluvoxamine
Clinical data | |
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Trade names | Luvox, others |
AHFS/Drugs.com | Monograph |
MedlinePlus | a695004 |
License data |
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Routes of administration | By mouth |
Drug class | Selective serotonin reuptake inhibitor (SSRI) |
ATC code | |
Legal status | |
Legal status | |
Pharmacokinetic data | |
Bioavailability | 53% (90% confidence interval: 44–62%)[3] |
Protein binding | 77–80%[3][4] |
Metabolism | Liver (primarily O-demethylation) Major: CYP1A2 Minor: CYP3A4 Minor: CYP2C19[3] |
Elimination half-life | 12–13 hours (single dose), 22 hours (repeated dosing)[3] |
Excretion | Kidney (98%; 94% as metabolites, 4% as unchanged drug)[3] |
Identifiers | |
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Fluvoxamine, sold under the brand name Luvox among others, is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class.[6] It is primarily used to treat major depressive disorder and obsessive–compulsive disorder (OCD),[7] but is also used to treat anxiety disorders[8] such as panic disorder, social anxiety disorder, and post-traumatic stress disorder.[9][10][11]
Fluvoxamine's side-effect profile is very similar to other SSRIs:
Although the many drug-drug interactions of fluvoxamine can be problematic (and may temper enthusiasm for its prescribing, advocation and usage to some), its tolerance-profile itself is actually superior in some respects to other SSRIs (particularly with respect to cardiovascular complications), despite its age.[13] Compared to escitalopram and sertraline, indeed, fluvoxamine's gastrointestinal profile may be less intense,[14] often being limited to nausea.[15] Mosapride has demonstrated efficacy in treating fluvoxamine-induced nausea.[16] It is also advised practice to divide total daily doses of fluvoxamine greater than 100 milligrams, with the higher fraction being taken at bedtime (e.g., 50 mg at the beginning of the waking day and 200 mg at bedtime). In any case, high starting daily doses of fluvoxamine rather than the recommended gradual titration (starting at 50 milligrams and gradually titrating, up to 300 if necessary) may predispose to nauseous discomfort.[17]
It is on the World Health Organization's List of Essential Medicines.[18]
Medical uses
In many countries (e.g., Australia,
There is evidence that fluvoxamine is effective for
Fluvoxamine is also effective for treating a range of anxiety disorders in children and adolescents, including generalized anxiety disorder, social anxiety disorder, panic disorder and separation anxiety disorder.[34][35][36]
The drug works long-term, and retains its therapeutic efficacy for at least one year.[37] It has also been found to possess some analgesic properties in line with other SSRIs and tricyclic antidepressants.[38][39][40]
The average therapeutic dose for fluvoxamine is 100 to 300 mg/day, with 300 mg being the upper daily limit normally recommended.
Adverse effects
Fluvoxamine's side-effect profile is very similar to other SSRIs, with
Common
Common side effects occurring with 1–10% incidence:
- Abdominal pain
- Agitation
- Anxiety
- Asthenia(weakness)
- Constipation
- Diarrhea
- Dizziness
- Dyspepsia(indigestion)
- Headache
- Hyperhidrosis (excess sweating)
- Insomnia
- Loss of appetite
- Malaise
- Nausea
- Nervousness
- Palpitations
- Restlessness
- Sexual dysfunction (including delayed ejaculation, erectile dysfunction, decreased libido, etc.)
- Somnolence (drowsiness)
- Tachycardia (high heart rate)
- Tremor
- Vomiting
- Weight loss
- Xerostomia (dry mouth)
- Yawning
Uncommon
Uncommon side effects occurring with 0.1–1% incidence:
- Arthralgia
- Confusional state
- Cutaneous hypersensitivity reactions (e.g. oedema [buildup of fluid in the tissues], rash, pruritus)
- Extrapyramidal side effects (e.g. dystonia, parkinsonism, tremor, etc.)
- Hallucination
- Orthostatic hypotension
Rare
Rare side effecs occurring with 0.01–0.1% incidence:
- Abnormal hepatic (liver) function
- Galactorrhoea (expulsion of breast milk unrelated to pregnancy or breastfeeding)
- Mania
- Photosensitivity (being abnormally sensitive to light)
- Seizures
Unknown frequency
- Akathisia – a sense of inner restlessness that presents itself with the inability to stay still
- Bed-wetting
- Bone fractures
- Dysgeusia
- Ecchymoses
- Glaucoma
- Haemorrhage
- Hyperprolactinaemia (elevated plasma prolactin levels leading to galactorrhoea, amenorrhoea [cessation of menstrual cycles], etc.)
- Hyponatraemia
- Mydriasis
- Neuroleptic malignant syndrome – practically identical presentation to serotonin syndrome except with a more prolonged onset
- Paraesthesia
- Serotonin syndrome – a potentially fatal condition characterised by abrupt onset muscle rigidity, hyperthermia (elevated body temperature), rhabdomyolysis, mental status changes (e.g. coma, hallucinations, agitation), etc.
- Suicidal ideation and behaviour
- Syndrome of inappropriate antidiuretic hormone secretion
- Urinary incontinence
- Urinary retention
- Violence towards others[47]
- Weight changes
- Withdrawal symptoms
Interactions
Fluvoxamine inhibits the following cytochrome P450 enzymes:[48][49][50][51][52][53][54][55][56][excessive citations]
- CYP1A2 (strongly) which metabolizes agomelatine, amitriptyline, caffeine, clomipramine, clozapine, duloxetine, haloperidol, imipramine, phenacetin, tacrine, tamoxifen, theophylline, olanzapine, etc.
- CYP3A4 (moderately) which metabolizes alprazolam, aripiprazole, clozapine, haloperidol, quetiapine, pimozide, ziprasidone, etc.[57]
- CYP2D6 (weakly) which metabolizes aripiprazole, chlorpromazine, clozapine, codeine, fluoxetine, haloperidol, olanzapine, oxycodone, paroxetine, perphenazine, pethidine, risperidone, sertraline, thioridazine, zuclopenthixol, etc.[58]
- sulfonylureas, etc.
- CYP2C19 (strongly) which metabolizes clonazepam, diazepam, phenytoin, etc.
- CYP2B6 (weakly) which metabolizes bupropion, cyclophosphamide, sertraline, tamoxifen, valproate, etc.
By so doing, fluvoxamine can increase serum concentration of the substrates of these enzymes.[48]
Fluvoxamine may also elevate plasma levels of olanzapine by approximately two times.[59] Combined olanzapine and fluvoxamine, which may cause increased sedation,[60] should be used cautiously and controlled clinically and by therapeutic drug monitoring to avoid olanzapine induced adverse effects and/or intoxication.[61][62]
The plasma levels of oxidatively metabolized benzodiazepines (e.g., triazolam, midazolam, alprazolam and diazepam) are likely to be increased when co-administered with fluvoxamine. However, the clearance of benzodiazepines metabolized by glucuronidation (e.g., lorazepam; oxazepam, which is coincidentally a metabolite of diazepam;[63] temazepam)[64][65] are not affected by fluvoxamine and may be safely taken alongside fluvoxamine should concurrent treatment with a benzodiazepine be necessary.[66] Additionally, it appears that benzodiazepines metabolized by nitro-reduction (clonazepam, nitrazepam) may also, in a somewhat similar vein, be unlikely to be affected by fluvoxamine.[67][68]
Using fluvoxamine and alprazolam together can increase alprazolam plasma concentrations.[69] If alprazolam is coadministered with fluvoxamine, the initial alprazolam dose should be reduced to the lowest effective dose.[70][71]
Fluvoxamine and ramelteon coadministration is not indicated.[72][73]
Fluvoxamine has been observed to increase serum concentrations of mirtazapine, which is mainly metabolized by CYP1A2, CYP2D6, and CYP3A4, by three- to four-fold in humans.[74] Caution and adjustment of dosage as necessary are warranted when combining fluvoxamine and mirtazapine.[74]
Fluvoxamine seriously affects the pharmacokinetics of tizanidine and increases the intensity and duration of its effects. Because of the potentially hazardous consequences, the concomitant use of tizanidine with fluvoxamine, or other potent inhibitors of CYP1A2, should be avoided.[75]
When a beta-blocker is required, atenolol,[76] pindolol[77][78][79] and, possibly, metoprolol[80][81][57][82] may be safer choices than propranolol, as the latter's metabolism is seriously, potentially dangerously, inhibited by fluvoxamine.[83] Indeed, fluvoxamine may increase propranolol blood-levels by five-fold.[84]
Clomipramine increases fluvoxamine levels and, conversely-likewise, fluvoxamine increases clomipramine levels (thereby its serotoninergic potential) and inhibits its metabolism to its strongly-noradrenergic metabolite, norclomipramine.[85][86]
Pharmacology
Site | Ki (nM) |
---|---|
SERT | 2.5 |
NET | 1,427 |
5-HT2C | 5,786 |
α1-adrenergic | 1,288 |
σ1 | 36 |
Fluvoxamine is a potent selective serotonin reuptake inhibitor with around 100-fold affinity for the serotonin transporter over the norepinephrine transporter.[49] It has negligible affinity for the dopamine transporter or any other site, with the sole exception of the σ1 receptor.[90][13] It behaves as a potent agonist at this receptor and has the highest affinity (36 nM) of any SSRI for doing so.[90] This may contribute to its antidepressant and anxiolytic effects and may also afford it some efficacy in treating the cognitive symptoms of depression.[91] Unlike some other SSRIs, fluvoxamine's metabolites are pharmacologically neutral.[92]
History
Fluvoxamine was developed by Kali-Duphar,
Research directions
While early studies have suggested potential benefits for fluvoxamine as an anti-inflammatory agent and a possible impact on reducing cytokine storms, further studies did not confirm this expected benefit on COVID-19 patients.[105][106] A cytokine storm refers to an excessive immune response characterized by a release of large amounts of pro-inflammatory cytokines.[107]
In May 2022, based on a review of available scientific evidence, the U.S.
A large double-blind randomized controlled trial called ACTIV-6, published in 2023 in JAMA, revealed that taking 200 mg of fluvoxamine every day for about two weeks was not significantly better than placebo at shortening the duration of mild or moderate COVID-19 symptoms.[110][medical citation needed]
There is tentative evidence that fluvoxamine may reduce the overall morbidity of COVID-19 and complications thereof.[111][112]
Environment
Fluvoxamine is a common finding in waters near human settlement.[113] Christensen et al. 2007 finds it is "very toxic to aquatic organisms" by European Union standards.[113]
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