Levomilnacipran

FDA label

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Titration Increase by 40 mg at intervals of ≥2 days.

Renal Mild (CLcr 60–89): no adjustment; moderate (30–59): max 80 mg QD; severe (15–29): max 40 mg QD; ESRD: not recommended.

Hepatic No adjustment for mild, moderate, or severe.

With strong CYP3A4 inhibitors, max 80 mg QD.

Instructions

• Swallow capsule whole; do not open, chew, or crush.
• Take at about the same time each day, with or without food.
• Taper gradually when discontinuing (discontinuation symptoms).
• With strong CYP3A4 inhibitors: max 80 mg QD.
• Screen for bipolar disorder before starting.
• Allow 14 days after stopping an MAOI before starting; allow 7 days after stopping FETZIMA before starting an MAOI.

Available strengths

• ER cap 20, 40, 80, 120 mg

Contraindications

• MAOIs (concurrently or within 14 days of stopping MAOI); allow 7 days after stopping levomilnacipran before starting an MAOI due to risk of serotonin syndrome

Cautions

• Serotonin syndrome
• Elevated blood pressure and heart rate — control hypertension first, monitor
• Increased bleeding risk with NSAIDs/aspirin/anticoagulants
• Angle-closure glaucoma
• Urinary hesitation/retention
• Activation of mania/hypomania
• Seizures
• Discontinuation syndrome
• Hyponatremia (SIADH)
• Sexual dysfunction

Adverse reactions

• Nausea, constipation, vomiting
• Hyperhidrosis, heart rate increased, tachycardia, palpitations
• Erectile dysfunction, ejaculation disorder, urinary hesitation

Pregnancy Insufficient human data; possible increased postpartum hemorrhage and neonatal complications with third-trimester exposure.

Lactation No levomilnacipran data; racemic milnacipran present in human milk — monitor infant for agitation, poor feeding, poor weight gain.