Venlafaxine
Clinical data | |
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Pronunciation | /ˌvɛnləˈfæksiːn/ VEN-lə-FAK-seen |
Trade names | Effexor, Efexor, Venbysi XR, others[1] |
AHFS/Drugs.com | Monograph |
MedlinePlus | a694020 |
License data |
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Pregnancy category |
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Routes of administration | By mouth |
Drug class | Serotonin–norepinephrine reuptake inhibitor |
ATC code | |
Legal status | |
Legal status | |
Pharmacokinetic data | |
Bioavailability | 42±15%[2] |
Protein binding | 27±2% (parent compound), 30±12% (active metabolite, desvenlafaxine)[6] |
Metabolism | Extensively metabolised by the liver,[2][6] primarily via CYP2D6[8] |
Metabolites | O-desmethylvenlafaxine (ODV), see desvenlafaxine |
Elimination half-life | 5±2 h (parent compound for immediate release preparations), 15±6 h (parent compound for extended release preparations), 11±2 h (active metabolite)[2][6] |
Excretion | Kidney (87%; 5% as unchanged drug; 29% as desvenlafaxine and 53% as other metabolites)[2][6] |
Identifiers | |
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JSmol) | |
Chirality | Racemic mixture |
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Venlafaxine, sold under the brand name Effexor among others, is an antidepressant medication of the serotonin–norepinephrine reuptake inhibitor (SNRI) class.[6][9] It is used to treat major depressive disorder, generalized anxiety disorder, panic disorder, and social anxiety disorder.[9] Studies have shown that venlafaxine improves post-traumatic stress disorder (PTSD).[10] It may also be used for chronic pain.[11] It is taken by mouth.[9] It is also available as the salt venlafaxine besylate in an extended-release formulation (Venbysi XR).[7]
Common side effects include loss of appetite, constipation,
Venlafaxine was approved for medical use in the United States in 1993.
Medical uses
Venlafaxine is used primarily for the treatment of
Venlafaxine has been used off label for the treatment of diabetic neuropathy[15] and migraine prevention.[16] It may work on pain via effects on the opioid receptor.[17] It has also been found to reduce the severity of 'hot flashes' in menopausal women and men on hormonal therapy for the treatment of prostate cancer.[18][19]
Due to its action on both the
Depression
A comparative meta-analysis of 21 major antidepressants found that venlafaxine, agomelatine, amitriptyline, escitalopram, mirtazapine, paroxetine, and vortioxetine were more effective than other antidepressants, although the quality of many comparisons was assessed as low or very low.[24][25]
Venlafaxine was similar in efficacy to the atypical antidepressant bupropion; however, the remission rate was lower for venlafaxine.[26] In a double-blind study, patients who did not respond to an SSRI were switched to either venlafaxine or another SSRI (citalopram); similar improvement was observed in both groups.[27]
Studies have not established its efficacy for use by children.[28] In children and adolescents with depression, venlafaxine increases the risk of suicidal thoughts or attempts.[29][30][31][32][33][34]
Higher doses (e.g. 225 mg and 375 mg per day) of venlafaxine are more effective than lower doses (e.g. 75 mg per day), but also cause more side effects.[35]
Studies have shown that the extended release is superior to the immediate release form of venlafaxine.[36]
A meta-analysis has shown that efficacy of venlafaxine is not correlated with baseline severity of depression.[36]
In other words, regardless of how severe a person's depression is initially, the efficacy of venlafaxine remains consistent and is not influenced by the severity of depression at the start of treatment.
Contraindications
Venlafaxine is not recommended in patients hypersensitive to it, nor should it be taken by anyone who is allergic to the inactive ingredients, which include gelatin, cellulose, ethylcellulose, iron oxide, titanium dioxide and hypromellose. It should not be used in conjunction with a monoamine oxidase inhibitor (MAOI), as it can cause potentially fatal serotonin syndrome.[2][6][37] Venlafaxine might interact with tramadol or other opioids, trazodone, so caution is needed while mixing multiple serotonergic agents together.[38]
Adverse effects
Venlafaxine can increase eye pressure, so those with glaucoma may require more frequent eye checks.[6]
A 2017 meta-analysis estimated venlafaxine discontinuation rate to 9.4%.[36]
Suicide
The US
A 2014 meta analysis of 21 clinical trials of venlafaxine for the treatment of depression in adults found that compared to placebo, venlafaxine reduced the risk of suicidal thoughts and behavior.[39]
A study conducted in Finland followed more than 15,000 patients for 3.4 years. Venlafaxine increased suicide risk by 60% (statistically significant), as compared to no treatment. At the same time, fluoxetine (Prozac) halved the suicide risk.[40]
In another study, the data on more than 200,000 cases were obtained from the UK general practice research database. At baseline, patients prescribed venlafaxine had a greater number of risk factors for suicide (such as prior suicide attempts) than patients treated with other anti-depressants. The patients taking venlafaxine had significantly higher risk of suicide than the ones on fluoxetine or citalopram (Celexa). After adjusting for known risk factors, venlafaxine was associated with an increased risk of suicide relative to fluoxetine and dothiepin that was not statistically significant. A statistically significant greater risk for attempted suicide remained after adjustment, but the authors concluded that it could be due to residual confounding. The study was sponsored by Wyeth, which produces and markets venlafaxine.[41]
An analysis of clinical trials by the FDA statisticians showed the incidence of suicidal behaviour among the adults on venlafaxine to be not significantly different from fluoxetine or placebo.[42]
Venlafaxine is contraindicated in children, adolescents and young adults. In children and adolescents with depression, venlafaxine increases the risk of suicidal thoughts or attempts.[29][30][31][32][33][34]
Serotonin syndrome
The development of a potentially life-threatening
Pregnancy
There are few well-controlled studies of venlafaxine in pregnant women. A study released in May 2010 by the Canadian Medical Association Journal suggests use of venlafaxine doubles the risk of
Bipolar disorder
According to the ISBD Task Force report on antidepressant use in bipolar disorder,[54] during the course of treatment for depression with those suffering from bipolar I and II, venlafaxine "appears to carry a particularly high risk of inducing pathologically elevated states of mood and behavior." Because venlafaxine appears to be more likely than SSRIs and bupropion to induce mania and mixed episodes in these patients, provider discretion is advised through "carefully evaluating individual clinical cases and circumstances."
Liver injury
A rare but serious side effect of venlafaxine is liver injury. It appears to affect both male and female patients with a median age of 44. Cessation of venlafaxine is one of the appropriate measures of management. While the mechanism of venlafaxine-related liver injury remains unclear, findings suggest that it may be related to a CYP2D6 polymorphism.[55]
Overdose
Most patients overdosing with venlafaxine develop only mild symptoms. Plasma venlafaxine concentrations in overdose survivors have ranged from 6 to 24 mg/L, while postmortem blood levels in fatalities are often in the 10–90 mg/L range.[56] Published retrospective studies report that venlafaxine overdosage may be associated with an increased risk of fatal outcome compared to that observed with SSRI antidepressant products, but lower than that for tricyclic antidepressants. Healthcare professionals are advised to prescribe Effexor and Effexor XR in the smallest quantity of capsules consistent with good patient management to reduce the risk of overdose.[57] It is usually reserved as a second-line treatment for depression due to a combination of its superior efficacy to the first-line treatments like fluoxetine, paroxetine and citalopram and greater frequency of side effects like nausea, headache, insomnia, drowsiness, dry mouth, constipation, sexual dysfunction, sweating and nervousness.[24][58]
There is no specific
Withdrawal syndrome
People stopping venlafaxine commonly experience SSRI withdrawal symptoms such as dysphoria, headaches, nausea, irritability, emotional lability, sensation of electric shocks (commonly called "brain zaps"[60][61]), and sleep disturbance.[62] Venlafaxine has a higher rate of moderate to severe withdrawal symptoms relative to other antidepressants (similar to the SSRI paroxetine).[63]
The higher risk and increased severity of withdrawal symptoms relative to other antidepressants may be related to the short half-life of venlafaxine and its active metabolite.[64] After stopping venlafaxine, the levels of both serotonin and norepinephrine decrease, leading to the hypothesis that the withdrawal symptoms could result from an overly rapid reduction of neurotransmitter levels.[65]
Other
In rare cases, drug-induced akathisia can occur after use in some people.[66]
Venlafaxine should be used with caution in hypertensive patients. Venlafaxine must be discontinued if significant hypertension persists.[67][68][69] It can also have undesirable cardiovascular effects.[70]
Pharmacology
Transporter | Ki [nM][71] | IC50 [nM][72] |
---|---|---|
SERT | 82 | 27 |
NET | 2480 | 535 |
DAT | 7647 | ND |
Receptor | Ki [nM] [73][74] | Species |
---|---|---|
5-HT2A | 2230 | Human |
5-HT2C | 2004 | Human |
5-HT6 | 2792 | Human |
α1A | >1000 | Human |
Pharmacodynamics
Venlafaxine is usually categorized as a
Venlafaxine selectively inhibits the serotonin transporter at lower doses, but at a dose of 225 mg per day it additionally blocks the norepinephrine transporter.[82] However, others studies find that there is no significant norepinephrine inhibition.[83][84]
Venlafaxine indirectly affects opioid receptors as well as the α2-adrenergic receptor, and was shown to increase pain threshold in mice. These benefits with respect to pain were reversed with naloxone, an opioid antagonist, thus supporting an opioid mechanism.[85][86]
Pharmacokinetics
Venlafaxine is well absorbed, with at least 92% of an oral dose being absorbed into systemic circulation. It is extensively metabolized in the liver via the
Venlafaxine is a substrate of
Chemistry
The
Venlafaxine extended release is chemically the same as normal venlafaxine. The extended release (controlled release) version distributes the release of the drug into the gastrointestinal tract over a longer period than normal venlafaxine. This results in a lower peak plasma concentration. Studies have shown that the extended release formula has a lower incidence of nausea as a side effect, resulting in better compliance.[94]
Interactions
Venlafaxine should be taken with caution when using St John's wort.[95] Venlafaxine may lower the seizure threshold, and coadministration with other drugs that lower the seizure threshold such as bupropion and tramadol should be done with caution and at low doses.[96]
Recreational use
Venlafaxine can be abused as recreational drug, with damages that can manifest within a month.[97] Hard data regarding prevalence of abuse are not easy to find. Abusers reported usage of extremely high dosage, 5 to 10 times of acceptable clinical dosage. The adverse side effects were strong cases of the listed side effects. As standard measure treatment is to be supervised by a doctor with relevant education, such as neurologist or psychiatrist.
Society and culture
Venlafaxine was originally marketed as Effexor in most of the world; generic venlafaxine has been available since around 2008 and extended release venlafaxine has been available since around 2010.[98]
As of January 2020, venlafaxine is marketed under many brand names worldwide, many with alternative extended release forms (not shown): Adefaxin, Alenthus, Altven, Alventa, Amfax, Anapresin, Ansifix, Arafaxina, Argofan, Arrow Venlafaxine, Axone, Axyven, Benolaxe, Blossom, Calmdown, Dalium, Defaxine, Depefex, Depretaxer, Deprevix, Deprexor, Deprixol, Depurol, Desinax, Dislaven, Dobupal, Duofaxin, Easyfor, Ectien, Eduxon, Efastad, Efaxin, Efaxine, Efectin, Efegen, Efevelon, Efevelone, Efexiva, Efexor, Effegad, Effexine, Effexor, Elafax, Elaxine, Elify, Enpress, Enlafax, Envelaf, Falven, Faxigen, Faxine, Faxiprol, Faxiven, Faxolet, Flavix, Flaxen, Fobiless, Ganavax, Idixor, Idoxen, Intefred, Illovex, Lafactin, Lafaxin, Lanvexin, Laroxin, Levest, Limbic, Linexel, Maxibral, Mazda, Melocin, Memomax, Mezine, Neoxacina, Neoxacina, Nervix, Norafexine, Norezor, Norpilen, Noviser, Nulev, Odiven, Olwexya, Oriven, Paxifar, Politid, Pracet, Prefaxine, Psiseven, Quilarex, Rafax, Senexon, Sentidol, Sentosa, Serosmine, Seroxine, Sesaren, Subelan, Sulinex, Sunveniz, Sunvex, Symfaxin, Tedema, Tifaxin, Tonpular, Trevilor, Tudor, Vafexin, Valosine, Vandral, Velaf, Velafax, Velahibin, Velaxin, Velaxor, Velept, Velpine, Venax, Venaxin, Venaxx, Vencarm, Vencontrol, Vendep, Venegis, Venex, Venexor, Venfalex, Venfax, Ven-Fax, Venfaxine, Venforin, Venforspine, Veniba, Veniz, Venjoy, Venla, Venlabax, Venlablue, Venlabrain, Venladep, Venladex, Venladoz, Venlaf, Venlafab, Venlafaxin, Venlafaxina, Venlafaxine, Venlagamma, Venlalic, Venlamax, Venlamylan, Venlaneo, Venlapine, Venla-Q, Venlasand, Venlatrin, Venlavitae, Venlax, Venlaxin, Venlaxine, Venlaxor, Venlazid, Venlectine, Venlifax, Venlift, Venlix, Venlobax, Venlofex, Venlor, Venorion, Venozap, Vensate, Ventab, Venxin, Venxor, Vextor, Venzip, Vexamode, Vfax, Viepax, ViePax, Voxafen, Zacalen, Zanfexa, Zaredrop, Zarelis, Zarelix, and Zenexor.[1]
The
Veterinary effects
Veterinary overdose in dogs is very well treated by Cyproheptadine HCl.[99]: 1371
Venlafaxine is highly toxic to
References
- ^ a b "Venlafaxine". Drugs.com. Dallas, Texas: Drugsite Trust. January 2020. Brand Names. Archived from the original on 6 September 2020. Retrieved 24 January 2020.
- ^ a b c d e f g "Efexor-XR (venlafaxine hydrochloride)" (PDF). TGA eBS. Archived from the original on 12 May 2021. Retrieved 11 May 2021.
- FDA. Retrieved 22 October 2023.
- ^ Anvisa (31 March 2023). "RDC Nº 784 - Listas de Substâncias Entorpecentes, Psicotrópicas, Precursoras e Outras sob Controle Especial" [Collegiate Board Resolution No. 784 - Lists of Narcotic, Psychotropic, Precursor, and Other Substances under Special Control] (in Brazilian Portuguese). Diário Oficial da União (published 4 April 2023). Archived from the original on 3 August 2023. Retrieved 16 August 2023.
- ^ "Efexor XL 75 mg hard prolonged release capsules - Summary of Product Characteristics (SmPC)". (emc). 16 March 2020. Archived from the original on 7 October 2020. Retrieved 15 April 2020.
- ^ a b c d e f g h i j "Effexor XR- venlafaxine hydrochloride capsule, extended release". DailyMed. Archived from the original on 12 May 2021. Retrieved 11 May 2021.
- ^ a b "Venlafaxine tablet, extended release". DailyMed. 30 June 2022. Retrieved 7 January 2023.
- from the original on 29 November 2017. Retrieved 28 December 2018.
- ^ a b c d e f g h i j "Venlafaxine Hydrochloride Monograph for Professionals". Drugs.com. AHFS. Archived from the original on 27 November 2020. Retrieved 24 December 2018.
- PMID 30204376. Archived from the original on 10 July 2018. Retrieved 29 July 2023.)
{{cite report}}
: CS1 maint: DOI inactive as of March 2024 (link - ^ "Antidepressants: Another weapon against chronic pain". Mayo Clinic. Archived from the original on 26 October 2021. Retrieved 25 January 2020.
- ^ "The Top 300 of 2021". ClinCalc. Archived from the original on 15 January 2024. Retrieved 14 January 2024.
- ^ "Venlafaxine - Drug Usage Statistics". ClinCalc. Retrieved 14 January 2024.
- ^ "venlafaxine-hydrochloride". The American Society of Health-System Pharmacists. Archived from the original on 27 November 2020. Retrieved 3 April 2011.
- S2CID 28187627.
- PMID 30570984.
- ISBN 978-0-444-64168-7. Archivedfrom the original on 27 August 2021. Retrieved 9 May 2020.
- ^ Mayo Clinic staff (2005). "Beyond hormone therapy: Other medicines may help". Hot flashes: Ease the discomfort of menopause. Mayo Clinic. Archived from the original on 25 February 2005. Retrieved 19 August 2005.
- S2CID 45334784.
- ^ "Medications". Stanford University School of Medicine, Center for Narcolepsy. 7 February 2003. Archived from the original on 21 August 2007. Retrieved 3 September 2007.
- PMID 23157376.
- S2CID 25215502.
- S2CID 30973410.
- ^ S2CID 35858125.
- PMID 29477251.
- S2CID 276619.
- S2CID 34986490.
- PMID 15453105.
- ^ S2CID 253347210.
- ^ PMID 32563306.
- ^ PMID 34029378.
- ^ PMID 32394557.
- ^ PMID 32982805.
- ^ PMID 34002501.
- PMID 9541154.
- ^ S2CID 4394404.
- ISBN 978-0-470-97948-8.
- from the original on 6 April 2022. Retrieved 6 April 2022.
- PMID 22309973.
- PMID 17146010.
- PMID 17164297.
- ^ "Overview for December 13 Meeting of Psychopharmacologic Drugs Advisory Committee" (PDF). Food and Drug Administration: Center for Drug Evaluation and Research. 16 November 2006. Archived (PDF) from the original on 16 March 2007. Retrieved 20 June 2007.
- PMID 12925718.
- PMID 9279702.
- ^ Ebert D, et al. "Hallucinations as a side effect of venlafaxine treatment". Psychiatry On-line. Archived from the original on 21 May 2008. Retrieved 17 June 2008.
- PMID 12549949.
- S2CID 28153571.
- PMID 20513781.
- PMID 23281074.
- S2CID 24798891.
- PMID 12892015.
- S2CID 27443298.
- S2CID 30284439.
- PMID 24030475.
- PMID 23073329.
- ISBN 978-0-9626523-7-0.
- ^ "Wyeth Letter to Health Care Providers". Wyeth Pharmaceuticals Inc. 2006. Archived from the original on 27 August 2009. Retrieved 6 August 2009.
- PMID 24167687.
- from the original on 4 March 2016. Retrieved 6 November 2013.
- S2CID 58577252.
- PMID 32077900.
- PMID 22295261.
- PMID 21286371.
- S2CID 26897797.
- PMID 16369248.
- ^ "Venlafaxine Side Effects in Detail". Archived from the original on 3 October 2020. Retrieved 3 January 2018.
- PMID 14656626.
- PMID 9818630.
- PMID 25763307.
- PMID 16943176.
- PMID 11750180.
- PMID 20378347.
- PMID 11750180.
- PMID 16712488.
- ^ Clinical trial number NCT00001483 for "Acute Effectiveness of Additional Drugs to the Standard Treatment of Depression" at ClinicalTrials.gov
- PMID 11516890.
- ^ "venlafaxine". National Cancer Institute. Archived from the original on 24 January 2022.
- from the original on 30 June 2022. Retrieved 24 January 2022.
- S2CID 26795121.
- ^ "Stahl's Essential Psychopharmacology – Cambridge University Press". Stahlonline.cambridge.org. Archived from the original on 27 February 2012. Retrieved 21 November 2013.
- PMID 10703757.[full citation needed]
- PMID 34958348.
- PMID 16690005.
- S2CID 2633719.
- ISBN 978-0-323-29507-9. Archivedfrom the original on 27 August 2021. Retrieved 9 May 2020.
- ISBN 978-0-444-64168-7. Archivedfrom the original on 27 August 2021. Retrieved 9 May 2020.
- S2CID 33558428.
- S2CID 22236102.
- from the original on 26 October 2020. Retrieved 7 February 2020.
- S2CID 34824025.
- ^ "Rs2032583 -SNPedia". Snpedia.com. Archived from the original on 11 December 2013. Retrieved 21 November 2013.
- S2CID 6772775.
- PMID 12702786.
- PMID 14700450.
- ISBN 978-1-58255-436-5.
- PMID 18072153.
- S2CID 73496502.
- ^ Staton T (13 June 2012). "Drugstores accuse Pfizer, Teva of blocking Effexor generics". FiercePharma. Archived from the original on 26 November 2020. Retrieved 22 June 2017.
- OCLC 794491298.
- S2CID 232419482.
- ^ "The Top 5 Cat Toxins". Pet Health Network. Retrieved 3 May 2023.
Further reading
- Dean L (July 2015). "Venlafaxine Therapy and CYP2D6 Genotype". In Pratt VM, McLeod HL, Rubinstein WS, et al. (eds.). Medical Genetics Summaries. PMID 28520361.