Desvenlafaxine
PRISTIQ
Pronunciation: des-ven-la-FAX-een (pris-TEEK)
“Desk faxing dePressed steak”
What it isSNRI and active metabolite of venlafaxine; depression.
Why it mattersIt bypasses CYP2D6 conversion, making exposure less dependent on metabolizer phenotype than venlafaxine.
What it changesBlood pressure and withdrawal symptoms can limit it; renal clearance requires adjustment in impairment.
FDA-approved for
- depression (2008)
Off-label
- menopausal hot flashes
FDA label
Read the full label on DailyMed ↗
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Major depressive disorder | Adult | 50 mg QD | 50 mg QD | 50 mg QD (no added benefit above 50 mg) |
Renal Moderate: max 50 mg/day; severe or ESRD: 25 mg/day or 50 mg every other day; no post-dialysis supplement
Hepatic Moderate-to-severe: max 100 mg/day
Instructions
- Swallow tablets whole; do not divide, crush, chew, or dissolve
- Take at about the same time each day, with or without food
- Taper gradually when discontinuing to minimize discontinuation symptoms
Available strengths
- ER tab 25, 50, 100 mg
Contraindications
- MAOIs (concurrently or within 14 days of stopping MAOI); allow 7 days after stopping desvenlafaxine before starting an MAOI due to risk of serotonin syndrome
Cautions
- Serotonin syndrome (also alone, not only with other serotonergics)
- Elevated blood pressure - control before starting, monitor
- Increased bleeding risk with NSAIDs/aspirin/anticoagulants
- Angle-closure glaucoma
- Activation of mania/hypomania
- Discontinuation syndrome - taper
- Seizure; hyponatremia
- Interstitial lung disease / eosinophilic pneumonia
- Sexual dysfunction
Adverse reactions
- Nausea, dizziness, insomnia, hyperhidrosis, constipation, somnolence, decreased appetite, anxiety, male sexual dysfunction
Pregnancy SNRI exposure near delivery associated with <2-fold increased postpartum hemorrhage risk; third-trimester use may cause neonatal discontinuation syndrome
Lactation Low levels in human milk; no adverse reactions reported in breastfed infants
Cost
Generic entryBy 2023
⚠ BOXED WARNING
- Suicidal thoughts and behaviors in patients under 25
Classes and tags
Clinical profile
Legacy pregnancy categoryC
Defining liabilityHypertension and discontinuation are common concerns; overdose can cause serotonin and cardiovascular toxicity.
Serotonin and MAOI
Provisional washout figures
Elevating mechanismSRI
Non-elevating actionNone recorded
Exposure dependenceTherapeutic exposure; severe toxicity requires meaningful MAO-A inhibition
Washout BEFORE an MAOI7 days
Evidence confidenceHigh
InterpretationClinically significant SRI. A second SRI generally represents therapeutic duplication/additive adverse effects, not the classic life-threatening interaction.
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