SNRI medications

Question 1

Venlafaxine/Effexor

Answer 1

Use: MDD, GAD, Social anxiety, Panic d/o, PTSD, PMDD
- Good for somatic sx and fibro myalgia
- SSRI resistance
- Tx resistant depression, SSRI failure
- Augment Remeron, mood stabilizers, atypicals (especially in SI)

-Start 37.5 mg, max 225 mg
- Take w/food
- Increase @75mg weekly
- Tabs in 37.5, 75, 150, 225

• XR daily, IR divided
• XR tolerated better

Side effects:
- May need higher dose for effect for SNRI action
- Cross taper with prozac, 50% reduce every 3 days, repeat, then d/c
- 25-50% dose for renal
- NO dialysis
-Hepatic- dose at 50%
- Monitor BP
- Possible weight lose
- CYP450
- Nervousness, nausea sweating, insomnia, dizziness, sweating, SIADH, hyponatremia in elderly

Question 2

Desvenlafaxine/Pristiq

Answer 2

Use: MDD, fibro, GAD, Social anxiety, panic d/o, PTSD
- Helpful after failing SSRI’s
- Good for somatic complaints
- Augment with Remeron, Wellbutrin, nortriptyline, mood stabilizers, atypicals (especially in SI)

• 50mg max 100mg
• ER tab: 25, 50, 100

Side effects
- Taper off
- Renal- 50mg, Hepatic -max 100mg, Caution in cardiac, seizure d/o
- May need higher dose for effect for SNRI action
- False positive PCP and amphetamines
- less that venlafaxine, sexual, sweating, hyponatremia, Hypertension, SIADH

Question 3

Duloxetine/Cymbalta

Answer 3

Use: MDD, Diabetic Peripheral Neuropathic Pain , Fibro, GAD, Chronic musculoskeletal pain, neuropathic pain
- Good for atypical/somatic sx
- Tx resistant/failed SSRI’s

• Start 20-30mg, max 120 mg (BID)
  -Capsules in 20, 30, 60,
• Depression 40-60 mg
• GAD - 60mg

-Side effects
- Taper off
- No dialysis
- No hepatic, no ETOH abuse
- CYP450