During the premarketing evaluations of Effexor XR (for MDD, GAD, SAD, and PD) and Effexor (for MDD), there were twenty reports of acute overdosage with Effexor (6 and 14 reports in Effexor XR and Effexor patients, respectively), either alone or in combination with other drugs and/or alcohol.
Somnolence was the most commonly reported symptom. Among the other reported symptoms were paresthesia of all four limbs, moderate dizziness, nausea, numb hands and feet, and hot-cold spells 5 days after the overdose. In most cases, no signs or symptoms were associated with overdose. The majority of the reports involved ingestion in which the total dose of venlafaxine taken was estimated to be no more than several-fold higher than the usual therapeutic dose. One patient who ingested 2.75 g of venlafaxine was observed to have two generalized convulsions and a prolongation of QTc to 500 msec, compared with 405 msec at baseline. Mild sinus tachycardia was reported in two of the other patients.
Actions taken to treat the overdose included no treatment, hospitalization and symptomatic treatment, and hospitalization plus treatment with activated charcoal. All patients recovered.
In postmarketing experience, overdose with venlafaxine has occurred predominantly in combination with alcohol and/or other drugs. The most commonly reported events in overdosage include tachycardia, changes in level of consciousness (ranging from somnolence to coma), mydriasis, seizures, and vomiting. Electrocardiogram changes (e.g., prolongation of QT interval, bundle branch block, QRS prolongation), ventricular tachycardia, bradycardia, hypotension, rhabdomyolysis, vertigo, liver necrosis, serotonin syndrome, and death have been reported.
Published retrospective studies report that venlafaxine overdosage may be associated with an increased risk of fatal outcomes compared to that observed with SSRI antidepressant products, but lower than that for tricyclic antidepressants. Epidemiological studies have shown that venlafaxine-treated patients have a higher preexisting burden of suicide risk factors than SSRI-treated patients. The extent to which the finding of an increased risk of fatal outcomes can be attributed to the toxicity of venlafaxine in overdosage, as opposed to some characteristic(s) of venlafaxine-treated patients, is not clear. Prescriptions for Effexor XR should be written for the smallest quantity of capsules consistent with good patient management, in order to reduce the risk of overdose.
Management Of OverdosageConsult a Certified Poison Control Center for up-to-date guidance and advice (1-800-222-1222 or www.poison.org). In case of an overdose, provide supportive care, including close medical supervision and monitoring. Treatment should consist of those general measures employed in the management of overdosage with any drug. Consider the possibility of multiple drug overdose. Ensure an adequate airway, oxygenation, and ventilation. Monitor cardiac rhythm and vital signs. Provide supportive and symptomatic measures.
Hypersensitivity to venlafaxine hydrochloride, desvenlafaxine succinate or to any excipients in the formulation
Concomitant Use With Monoamine Oxidase Inhibitors (MAOIs)The use of MAOIs (intended to treat psychiatric disorders) concomitantly with Effexor XR or within 7 days of discontinuing treatment with Effexor XR is contraindicated because of an increased risk of serotonin syndrome. The use of Effexor XR within 14 days of discontinuing treatment with an MAOI (intended to treat psychiatric disorders) is also contraindicated.
Starting Effexor XR in a patient who is being treated with an MAOI such as linezolid or intravenous methylene blue is also contraindicated, because of an increased risk of serotonin syndrome.
The following adverse reactions are discussed in greater detail in other sections of the label:
Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.
Most Common Adverse ReactionsThe most commonly observed adverse reactions in the clinical study database in Effexor XR treated patients in MDD, GAD, SAD, and PD (incidence ≥ 5% and at least twice the rate of placebo) were: nausea (30.0%), somnolence (15.3%), dry mouth (14.8%), sweating (11.4%), abnormal ejaculation (9.9%), anorexia (9.8%), constipation (9.3%), impotence (5.3%) and decreased libido (5.1%).
Adverse Reactions Reported As Reasons For Discontinuation Of TreatmentCombined across short-term, placebo-controlled premarketing studies for all indications, 12% of the 3,558 patients who received Effexor XR (37.5-225 mg) discontinued treatment due to an adverse experience, compared with 4% of the 2,197 placebo-treated patients in those studies.
The most common adverse reactions leading to discontinuation in ≥ 1% of the Effexor XR treated patients in the short-term studies (up to 12 weeks) across indications are shown in Table 7.
Table 7: Incidence (%) of Patients Reporting Adverse Reactions Leading to Discontinuation in
Placebo-controlled Clinical Studies (up to 12 Weeks Duration)
| Body System Adverse Reaction |
Effexor XR n = 3,558 |
Placebo n = 2,197 |
| Body as a whole | ||
| Asthenia | 1.7 | 0.5 |
| Headache | 1.5 | 0.8 |
| Digestive system | ||
| Nausea | 4.3 | 0.4 |
| Nervous system | ||
| Dizziness | 2.2 | 0.8 |
| Insomnia | 2.1 | 0.6 |
| Somnolence | 1.7 | 0.3 |
| Skin and appendages | 1.5 | 0.6 |
| Sweating | 1.0 | 0.2 |
The number of patients receiving multiple doses of Effexor XR during the premarketing assessment for each approved indication is shown in Table 8. The conditions and duration of exposure to venlafaxine in all development programs varied greatly, and included (in overlapping categories) open and double-blind studies, uncontrolled and controlled studies, inpatient (Effexor only) and outpatient studies, fixed-dose, and titration studies.
Table 8: Patients Receiving Effexor XR in Premarketing Clinical Studies
| Indication | Effexor XR |
| MDD | 705a |
| GAD | 1,381 |
| SAD | 819 |
| PD | 1,314 |
| a In addition, in the premarketing assessment of Effexor, multiple doses were administered to 2,897 patients in studies for MDD. |
The incidences of common adverse reactions (those that occurred in ≥ 2% of Effexor XR treated patients [357 MDD patients, 1,381 GAD patients, 819 SAD patients, and 1,001 PD patients] and more frequently than placebo) in Effexor XR treated patients in short-term, placebo-controlled, fixed-and flexible-dose clinical studies (doses 37.5 to 225 mg per day) are shown in Table 9.
The adverse reaction profile did not differ substantially between the different patient populations.
Table 9: Common Adverse Reactions: Percentage of Patients Reporting Adverse Reactions (≥ 2% and > placebo) in Placebo-controlled Studies (up to 12 Weeks Duration) across All Indications
| Body System Adverse Reaction |
Effexor XR n = 3,558 |
Placebo n = 2,197 |
| Body as a whole | ||
| Asthenia | 12.6 | 7.8 |
| Cardiovascular system | ||
| Hypertension | 3.4 | 2.6 |
| Palpitation | 2.2 | 2.0 |
| Vasodilatation | 3.7 | 1.9 |
| Digestive system | ||
| Anorexia | 9.8 | 2.6 |
| Constipation | 9.3 | 3.4 |
| Diarrhea | 7.7 | 7.2 |
| Dry mouth | 14.8 | 5.3 |
| Nausea | 30.0 | 11.8 |
| Vomiting | 4.3 | 2.7 |
| Nervous system | ||
| Abnormal dreams | 2.9 | 1.4 |
| Dizziness | 15.8 | 9.5 |
| Insomnia | 17.8 | 9.5 |
| Libido decreased | 5.1 | 1.6 |
| Nervousness | 7.1 | 5.0 |
| Paresthesia | 2.4 | 1.4 |
| Somnolence | 15.3 | 7.5 |
| Tremor | 4.7 | 1.6 |
| Respiratory system | ||
| Yawn | 3.7 | 0.2 |
| Skin and appendages | ||
| Sweating (including night sweats) | 11.4 | 2.9 |
| Special senses | ||
| Abnormal vision | 4.2 | 1.6 |
| Urogenital system | ||
| Abnormal ejaculation/orgasm (men)a | 9.9 | 0.5 |
| Anorgasmia (men)a | 3.6 | 0.1 |
| Anorgasmia (women)b | 2.0 | 0.2 |
| Impotence (men)a | 5.3 | 1.0 |
| a Percentages based on the number of men (Effexor XR, n = 1,440; placebo, n = 923) b Percentages based on the number of women (Effexor XR, n = 2,118; placebo, n = 1,274) |
Body as a whole - Photosensitivity reaction, chills
Cardiovascular system - Postural hypotension, syncope, hypotension, tachycardia
Digestive system - Gastrointestinal hemorrhage , bruxism
Hemic/Lymphatic system - Ecchymosis
Metabolic/Nutritional - Hypercholesterolemia, weight gain , weight loss
Nervous system - Seizures , manic reaction , agitation, confusion, akathisia, hallucinations, hypertonia, myoclonus, depersonalization, apathy
Skin and appendages - Urticaria, pruritus, rash, alopecia
Special senses - Mydriasis, abnormality of accommodation, tinnitus, taste perversion
Urogenital system - Urinary retention, urination impaired, urinary incontinence, urinary frequency increased, menstrual disorders associated with increased bleeding or increased irregular bleeding (e.g., menorrhagia, metrorrhagia)
Vital Sign ChangesIn placebo-controlled premarketing studies, there were increases in mean blood pressure (see Table 10). Across most indications, a dose-related increase in mean supine systolic and diastolic blood pressure was evident in patients treated with Effexor XRs. Across all clinical studies in MDD, GAD, SAD and PD, 1.4% of patients in the Effexor XR groups experienced an increase in SDBP of ≥15 mm Hg along with a blood pressure ≥ 105 mm Hg, compared to 0.9% of patients in the placebo groups. Similarly, 1% of patients in the Effexor XR groups experienced an increase in SSBP of ≥ 20 mm Hg with a blood pressure ≥ 180 mm Hg, compared to 0.3% of patients in the placebo groups.
Table 10: Final On-therapy Mean Changes From Baseline in Supine Systolic (SSBP) and Diastolic (SDBP) Blood Pressure (mm Hg) in Placebo-controlled Studies
| Indication (Duration) |
Effexor XR | Placebo | ||||
| ≤ 75 mg per day | > 75 mg per day | |||||
| SSBP | SDBP | SSBP | SDBP | SSBP | SDBP | |
| MDD | ||||||
| (8-12 weeks) | -0.28 | 0.37 | 2.93 | 3.56 | -1.08 | -0.10 |
| GAD | ||||||
| (8 weeks) | -0.28 | 0.02 | 2.40 | 1.68 | -1.26 | -0.92 |
| (6 months) | 1.27 | -0.69 | 2.06 | 1.28 | -1.29 | -0.74 |
| SAD | ||||||
| (12 weeks) | -0.29 | -1.26 | 1.18 | 1.34 | -1.96 | -1.22 |
| (6 months) | -0.98 | -0.49 | 2.51 | 1.96 | -1.84 | -0.65 |
| PD | ||||||
| (10-12 weeks) | -1.15 | 0.97 | -0.36 | 0.16 | -1.29 | -0.99 |
Effexor XR treatment was associated with sustained hypertension (defined as treatment-emergent Supine Diastolic Blood Pressure [SDBP] ≥ 90 mm Hg and ≥ 10 mm Hg above baseline for three consecutive on-therapy visits (see Table 11). An insufficient number of patients received mean doses of Effexor XR over 300 mg per day in clinical studies to fully evaluate the incidence of sustained increases in blood pressure at these higher doses.
Table 11: Sustained Elevations in SDBP in Effexor XR
Premarketing Studies
| Indication | Dose Range (mg per day) | Incidence (%) |
| MDD | 75-375 | 19/705 (3) |
| GAD | 37.5-225 | 5/1011 (0.5) |
| SAD | 75-225 | 5/771 (0.6) |
| PD | 75-225 | 9/973 (0.9) |
Effexor XR was associated with mean increases in pulse rate compared with placebo in premarketing placebo-controlled studies (see Table 12).
Table 12: Approximate Mean Final On-therapy Increase in Pulse Rate (beats/min) in Effexor XR Premarketing Placebo-controlled Studies (up to 12 Weeks Duration)
| Indication (Duration) | Effexor XR | Placebo |
| MDD | ||
| (12 weeks) | 2 | 1 |
| GAD | ||
| (8 weeks) | 2 | < 1 |
| SAD | ||
| (12 weeks) | 3 | 1 |
| PD | ||
| (12 weeks) | 1 | < 1 |
Effexor XR was associated with mean final increases in serum cholesterol concentrations compared with mean final decreases for placebo in premarketing MDD, GAD, SAD and PD clinical studies (Table 13).
Table 13: Mean Final On-therapy Changes in Cholesterol Concentrations (mg/dL) in Effexor XR
Premarketing Studies
| Indication (Duration) | Effexor XR | Placebo |
| MDD | ||
| (12 weeks) | +1.5 | -7.4 |
| GAD | ||
| (8 weeks) | +1.0 | -4.9 |
| (6 months) | +2.3 | -7.7 |
| SAD | ||
| (12 weeks) | +7.9 | -2.9 |
| (6 months) | +5.6 | -4.2 |
| PD | ||
| (12 weeks) | 5.8 | -3.7 |
Effexor XR (venlafaxine hydrochloride) extended-release capsules treatment for up to 12 weeks in premarketing placebo-controlled trials for major depressive disorder was associated with a mean final on-therapy increase in serum cholesterol concentration of approximately 1.5 mg/dL compared with a mean final decrease of 7.4 mg/dL for placebo. Effexor XR treatment for up to 8 weeks and up to 6 months in premarketing placebo-controlled GAD trials was associated with mean final on-therapy increases in serum cholesterol concentration of approximately 1.0 mg/dL and 2.3 mg/dL, respectively while placebo subjects experienced mean final decreases of 4.9 mg/dL and 7.7 mg/dL, respectively. Effexor XR treatment for up to 12 weeks and up to 6 months in premarketing placebo-controlled Social Anxiety Disorder trials was associated with mean final on-therapy increases in serum cholesterol concentration of approximately 7.9 mg/dL and 5.6 mg/dL, respectively, compared with mean final decreases of 2.9 and 4.2 mg/dL, respectively, for placebo. Effexor XR treatment for up to 12 weeks in premarketing placebo-controlled panic disorder trials was associated with mean final on-therapy increases in serum cholesterol concentration of approximately 5.8 mg/dL compared with a mean final decrease of 3.7 mg/dL for placebo.
Patients treated with Effexor (immediate release) for at least 3 months in placebo-controlled 12-month extension trials had a mean final on-therapy increase in total cholesterol of 9.1 mg/dL compared with a decrease of 7.1 mg/dL among placebo-treated patients. This increase was duration dependent over the study period and tended to be greater with higher doses. Clinically relevant increases in serum cholesterol, defined as 1) a final on-therapy increase in serum cholesterol ≥50 mg/dL from baseline and to a value ≥261 mg/dL, or 2) an average on-therapy increase in serum cholesterol ≥50 mg/dL from baseline and to a value ≥261 mg/dL, were recorded in 5.3% of venlafaxine-treated patients and 0.0% of placebo-treated patients.
Serum TriglyceridesEffexor XR was associated with mean final on-therapy increases in fasting serum triglycerides compared with placebo in premarketing clinical studies of SAD and PD up to 12 weeks (pooled data) and 6 months duration (Table 14).
Table 14: Mean Final On-therapy Increases in Triglyceride Concentrations (mg/dL) in Effexor
XR Premarketing Studies
| Indication (Duration) | Effexor XR | Placebo |
| SAD | 8.2 | 0.4 |
| (12 weeks) | ||
| SAD | 11.8 | 1.8 |
| (6 months) | ||
| PD | 5.9 | 0.9 |
| (12 weeks) | ||
| PD | 9.3 | 0.3 |
| (6 months) |
In general, the adverse reaction profile of venlafaxine (in placebo-controlled clinical studies) in children and adolescents (ages 6 to 17) was similar to that seen for adults. As with adults, decreased appetite, weight loss, increased blood pressure, and increased serum cholesterol were observed.
In pediatric clinical studies, the adverse reaction, suicidal ideation, was observed.
Particularly, the following adverse reactions were observed in pediatric patients: abdominal pain, agitation, dyspepsia, ecchymosis, epistaxis, and myalgia.
Adverse Reactions Identified During Postapproval UseThe following adverse reactions have been identified during postapproval use of Effexor XR. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure:
Body as a whole - Anaphylaxis, angioedema
Cardiovascular system - QT prolongation, ventricular fibrillation, ventricular tachycardia (including torsade de pointes)
Digestive system - Pancreatitis
Hemic/Lymphatic system - Mucous membrane bleeding , blood dyscrasias (including agranulocytosis, aplastic anemia, neutropenia and pancytopenia), prolonged bleeding time, thrombocytopenia
Metabolic/Nutritional - Hyponatremia , Syndrome of Inappropriate Antidiuretic Hormone (SIADH) secretion , abnormal liver function tests, hepatitis, prolactin increased
Musculoskeletal - Rhabdomyolysis
Nervous system - Neuroleptic Malignant Syndrome (NMS) , serotonergic syndrome , delirium, extrapyramidal reactions (including dystonia and dyskinesia), impaired coordination and balance, tardive dyskinesia
Respiratory system - Dyspnea, interstitial lung disease, pulmonary eosinophilia
Skin and appendages - Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme
Special senses - Angle-closure glaucoma
Effexor XR (venlafaxine hydrochloride) extended-release capsules are indicated for the treatment of major depressive disorder (MDD). Efficacy was established in three short-term (4, 8, and 12 weeks) and two long-term, maintenance trials.
Generalized Anxiety DisorderEffexor XR is indicated for the treatment of Generalized Anxiety Disorder (GAD). Efficacy was established in two 8-week and two 26-week placebo-controlled trials.
Social Anxiety DisorderEffexor XR is indicated for the treatment of Social Anxiety Disorder (SAD), also known as social phobia. Efficacy was established in four 12-week and one 26-week, placebo-controlled trials.
Panic DisorderEffexor XR is indicated for the treatment of Panic Disorder (PD), with or without agoraphobia. Efficacy was established in two 12-week placebo-controlled trials.
Venlafaxine and ODV have no significant affinity for muscarinic-cholinergic, H1 -histaminergic, or α1 adrenergic receptors in vitro. Pharmacologic activity at these receptors is hypothesized to be associated with the various anticholinergic, sedative, and cardiovascular effects seen with other psychotropic drugs. Venlafaxine and ODV do not possess monoamine oxidase (MAO) inhibitory activity.
Steady-state concentrations of venlafaxine and ODV in plasma are attained within 3 days of oral multiple-dose therapy. Venlafaxine and ODV exhibited linear kinetics over the dose range of 75 to 450 mg per day. Mean±SD steady-state plasma clearance of venlafaxine and ODV is 1.3±0.6 and 0.4±0.2 L/h/kg, respectively; apparent elimination half-life is 5±2 and 11±2 hours, respectively; and apparent (steadystate) volume of distribution is 7.5±3.7 and 5.7±1.8 L/kg, respectively. Venlafaxine and ODV are minimally bound at therapeutic concentrations to plasma proteins (27% and 30%, respectively).
Absorption And DistributionVenlafaxine is well absorbed and extensively metabolized in the liver. ODV is the major active metabolite. On the basis of mass balance studies, at least 92% of a single oral dose of venlafaxine is absorbed. The absolute bioavailability of venlafaxine is approximately 45%.
Administration of Effexor XR (150 mg once daily) generally resulted in lower Cmax and later Tmax values than for Effexor (immediate release) administered twice daily (Table 16). When equal daily doses of venlafaxine were administered as either an immediate-release tablet or the extended-release capsule, the exposure to both venlafaxine and ODV was similar for the two treatments, and the fluctuation in plasma concentrations was slightly lower with the Effexor XR capsule. Therefore, Effexor XR provides a slower rate of absorption, but the same extent of absorption compared with the immediate-release tablet.
Table 16: Comparison of Cmax and Tmax Values for Venlafaxine and ODV Following Oral
Administration of Effexor XR and Effexor (Immediate Release)
| Venlafaxine | ODV | |||
| Cmax (ng/mL) |
Tmax (h) |
Cmax (ng/mL) |
Tmax (h) |
|
| Effexor XR (150 mg once daily) | 150 | 5.5 | 260 | 9 |
| Effexor (75 mg twice daily) | 225 | 2 | 290 | 3 |
Food did not affect the bioavailability of venlafaxine or its active metabolite, ODV. Time of administration (AM versus PM) did not affect the pharmacokinetics of venlafaxine and ODV from the 75 mg Effexor XR capsule.
Venlafaxine is not highly bound to plasma proteins; therefore, administration of Effexor XR to a patient taking another drug that is highly protein-bound should not cause increased free concentrations of the other drug.
Metabolism And EliminationFollowing absorption, venlafaxine undergoes extensive presystemic metabolism in the liver, primarily to ODV, but also to N-desmethylvenlafaxine, N,O-didesmethylvenlafaxine, and other minor metabolites. In vitro studies indicate that the formation of ODV is catalyzed by CYP2D6; this has been confirmed in a clinical study showing that patients with low CYP2D6 levels (poor metabolizers) had increased levels of venlafaxine and reduced levels of ODV compared to people with normal CYP2D6 levels (extensive metabolizers).
Approximately 87% of a venlafaxine dose is recovered in the urine within 48 hours as unchanged venlafaxine (5%), unconjugated ODV (29%), conjugated ODV (26%), or other minor inactive metabolites (27%). Renal elimination of venlafaxine and its metabolites is thus the primary route of excretion.
Venlafaxine did not cause malformations in offspring of rats or rabbits given doses up to 2.5 times (rat) or 4 times (rabbit) the maximum recommended human daily dose on a mg/m2 basis. However, in rats, there was a decrease in pup weight, an increase in stillborn pups, and an increase in pup deaths during the first 5 days of lactation, when dosing began during pregnancy and continued until weaning. The cause of these deaths is not known. These effects occurred at 2.5 times (mg/m2) the maximum human daily dose. The no effect dose for rat pup mortality was 0.25 times the human dose on a mg/m2 basis. In reproductive developmental studies in rats and rabbits with O-desmethylvenlafaxine (ODV), the major human metabolite of venlafaxine, evidence of teratogenicity was not observed at exposure margins of 13 in rats and 0.3 in rabbits. There are no adequate and well-controlled studies in pregnant women. Effexor XR should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.
Non-Teratogenic EffectsNeonates exposed to Effexor XR, other SNRIs, or SSRIs, late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. Such complications can arise immediately upon delivery. Reported clinical findings have included respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying. These features are consistent with either a direct toxic effect of SSRIs and SNRIs, or possibly a drug discontinuation syndrome. It should be noted, that in some cases the clinical picture is consistent with serotonin syndrome. When treating a pregnant woman with Effexor XR during the third trimester, the physician should carefully consider the potential risks and benefits of treatment.
Effexor XR® (venlafaxine hydrochloride) extended-release capsules are available in the following strengths:
Effexor XR® (venlafaxine hydrochloride) extended-release capsules are available as follows:
Store at controlled room temperature, 20° to 25°C (68° to 77°F).
The unit-of-use package is intended to be dispensed as a unit.
Distributed by: Pfizer, Wyeth Pharmaceuticals Inc, A subsidiary of Pfizer Inc, Philadelphia, PA 19101. Revised: March 2017
Included as part of the "PRECAUTIONS" Section
PRECAUTIONS Suicidal Thoughts And Behaviors In Children, Adolescents, And Young AdultsPatients with major depressive disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. Suicide is a known risk of depression and certain other psychiatric disorders, and these disorders themselves are the strongest predictors of suicide. There has been a long-standing concern, however, that antidepressants may have a role in inducing worsening of depression and the emergence of suicidality in certain patients during the early phases of treatment. Pooled analyses of short-term placebo-controlled studies of antidepressant drugs (SSRIs and others) showed that these drugs increase the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults (ages 18-24) with MDD and other psychiatric disorders. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was a reduction with antidepressants compared to placebo in adults aged 65 and older.
The pooled analyses of placebo-controlled studies in children and adolescents with MDD, Obsessive Compulsive Disorder (OCD), or other psychiatric disorders included a total of 24 short-term studies of 9 antidepressant drugs in over 4,400 patients. The pooled analyses of placebo-controlled studies in adults with MDD or other psychiatric disorders included a total of 295 short-term studies (median duration of 2 months) of 11 antidepressant drugs in over 77,000 patients. There was considerable variation in risk of suicidality among drugs, but a tendency toward an increase in the younger patients for almost all drugs studied. There were differences in absolute risk of suicidality across the different indications, with the highest incidence in MDD. The risk differences (drug versus placebo), however, were relatively stable within age strata and across indications. These risk differences (drug-placebo difference in the number of cases of suicidality per 1,000 patients treated) are provided in Table 1.
Table 1: Difference in the Number of Cases of Suicidality per 1,000 Patients Treated versus
Placebo
| Age Range | |
| Increases Compared to Placebo | |
| < 18 | 14 additional cases |
| 18-24 | 5 additional cases |
| Decreases Compared to Placebo | |
| 25-64 | 1 fewer case |
| ≥ 65 | 6 fewer cases |
No suicides occurred in any of the pediatric studies. There were suicides in the adult studies, but the number was not sufficient to reach any conclusion about drug effect on suicide.
It is unknown whether the suicidality risk extends to longer term use, i.e., beyond several months. However, there is substantial evidence from placebo-controlled maintenance studies in adults with depression that the use of antidepressants can delay the recurrence of depression.
All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases.
The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for MDD, as well as for other indications, both psychiatric and nonpsychiatric. Although a causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality.
Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality, especially if these symptoms are severe, abrupt in onset, or were not part of the patient's presenting symptoms.
If the decision has been made to discontinue treatment, medication should be tapered, as rapidly as is feasible, but with recognition that abrupt discontinuation can be associated with certain symptoms.
Families and caregivers of patients being treated with antidepressants for MDD or other indications, both psychiatric and nonpsychiatric, should be alerted about the need to monitor patients for the emergence of agitation, irritability, unusual changes in behavior, and the other symptoms described above, as well as the emergence of suicidality, and to report such symptoms immediately to healthcare providers. Such monitoring should include daily observation by families and caregivers. Prescriptions for Effexor XR should be written for the smallest quantity of capsules consistent with good patient management, in order to reduce the risk of overdose.
Screening Patients For Bipolar DisorderA major depressive episode may be the initial presentation of bipolar disorder. It is generally believed (though not established in controlled studies) that treating such an episode with an antidepressant alone may increase the likelihood of precipitation of a mixed/manic episode in patients at risk for bipolar disorder. Whether any of the symptoms described above represent such a conversion is unknown. However, prior to initiating treatment with an antidepressant, patients with depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. It should be noted that Effexor XR is not approved for use in treating bipolar depression.
Serotonin SyndromeThe development of a potentially life-threatening serotonin syndrome has been reported with SNRIs and SSRIs, including Effexor XR alone, but particularly with concomitant use of other serotonergic drugs (including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. John’s wort) and with drugs that impair metabolism of serotonin in particular, MAOIs, both those intended to treat psychiatric disorders and others, such as linezolid or intravenous methylene blue). Serotonin syndrome symptoms may include mental status changes (e.g., agitation, hallucinations, delirium, coma) autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia, diaphoresis, flushing, and dizziness), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination); seizures and gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Patients should be monitored for the emergence of serotonin syndrome.
The concomitant use of Effexor XR with MAOIs (intended to treat psychiatric disorders) is contraindicated. Effexor XR should also not be started in a patient who is being treated with MAOIs such as linezolid or intravenous methylene blue. All reports with methylene blue that provided information on the route of administration involved intravenous administration in the dose range of 1 mg/kg to 8 mg/kg. No reports involved the administration of methylene blue by other routes (such as oral tablets or local tissue injection) or at lower doses. There may be circumstances when it is necessary to initiate treatment with a MAOI such as linezolid or intravenous methylene blue in a patient taking Effexor XR. Effexor XR should be discontinued before initiating treatment with the MAOI.
If concomitant use of Effexor XR with other serotonergic drugs (e.g., triptans, tricyclic antidepressants, mirtazapine, fentanyl, lithium, tramadol, buspirone, amphetamines, tryptophan, or St. John's wort) is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases. Patients should be made aware of the potential risk of serotonin syndrome. Treatment with Effexor XR and any concomitant serotonergic agents should be discontinued immediately if the above events occur, and supportive symptomatic treatment should be initiated.
Elevations In Blood PressureIn controlled trials, there were dose-related increases in systolic and diastolic blood pressure, as well as cases of sustained hypertension.
Monitor blood pressure before initiating treatment with Effexor XR and regularly during treatment. Control pre-existing hypertension before initiating treatment with Effexor XR. Use caution in treating patients with pre-existing hypertension or cardiovascular or cerebrovascular conditions that might be compromised by increases in blood pressure. Sustained blood pressure elevation can lead to adverse outcomes. Cases of elevated blood pressure requiring immediate treatment have been reported with Effexor XR. Consider dose reduction or discontinuation of treatment for patients who experience a sustained increase in blood pressure.
Across all clinical studies with Effexor, 1.4% of patients in the Effexor XR treated groups experienced a ≥15 mm Hg increase in supine diastolic blood pressure (SDBP ) ≥ 105 mm Hg, compared to 0.9% of patients in the placebo groups. Similarly, 1% of patients in the Effexor XR treated groups experienced a ≥ 20 mm Hg increase in supine systolic blood pressure (SSBP) with blood pressure ≥ 180 mm Hg, compared to 0.3% of patients in the placebo groups. Effexor XR treatment was associated with sustained hypertension (defined as treatment-emergent SDBP ≥ 90 mm Hg and ≥ 10 mm Hg above baseline for three consecutive on-therapy visits. An insufficient number of patients received mean doses of Effexor XR over 300 mg per day in clinical studies to fully evaluate the incidence of sustained increases in blood pressure at these higher doses.
Abnormal BleedingSSRIs and SNRIs, including Effexor XR, may increase the risk of bleeding events, ranging from ecchymoses, hematomas, epistaxis, petechiae, and gastrointestinal hemorrhage to life-threatening hemorrhage. Concomitant use of aspirin, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), warfarin, and other anti-coagulants or other drugs known to affect platelet function may add to this risk. Case reports and epidemiological studies (case-control and cohort design) have demonstrated an association between use of drugs that interfere with serotonin reuptake and the occurrence of gastrointestinal bleeding. Caution patients about the risk of bleeding associated with the concomitant use of Effexor XR and NSAIDs, aspirin, or other drugs that affect coagulation.
Angle-Closure GlaucomaThe pupillary dilation that occurs following use of many antidepressant drugs including Effexor XR may trigger an angle closure attack in a patient with anatomically narrow angles who does not have a patent iridectomy.
Activation Of Mania/HypomaniaMania or hypomania was reported in Effexor XR treated patients in the premarketing studies in MDD, SAD, and PD (see Table 2). Mania/hypomania has also been reported in a small proportion of patients with mood disorders who were treated with other marketed drugs to treat MDD. Effexor XR should be used cautiously in patients with a history of mania or hypomania.
Table 2: Incidence (%) of Mania or Hypomania Reported in Effexor XR Treated Patients in the
Premarketing Studies
| Indication | Effexor XR | Placebo |
| MDD | 0.3 | 0.0 |
| GAD | 0.0 | 0.2 |
| SAD | 0.2 | 0.0 |
| PD | 0.1 | 0.0 |
Discontinuation symptoms have been systematically evaluated in patients taking venlafaxine, including prospective analyses of clinical studies in GAD and retrospective surveys of studies in MDD and SAD. Abrupt discontinuation or dose reduction of venlafaxine at various doses has been found to be associated with the appearance of new symptoms, the frequency of which increased with increased dose level and with longer duration of treatment. Reported symptoms include agitation, anorexia, anxiety, confusion, impaired coordination and balance, diarrhea, dizziness, dry mouth, dysphoric mood, fasciculation, fatigue, flu-like symptoms, headaches, hypomania, insomnia, nausea, nervousness, nightmares, sensory disturbances (including shock-like electrical sensations), somnolence, sweating, tremor, vertigo, and vomiting.
During marketing of Effexor XR, other SNRIs, and SSRIs, there have been spontaneous reports of adverse events occurring upon discontinuation of these drugs, particularly when abrupt, including the following: dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesia, such as electric shock sensations), anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania, tinnitus, and seizures. While these events are generally self-limiting, there have been reports of serious discontinuation symptoms.
Patients should be monitored for these symptoms when discontinuing treatment with Effexor XR. A gradual reduction in the dose, rather than abrupt cessation, is recommended whenever possible. If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose, but at a more gradual rate.
SeizuresSeizures have occurred with venlafaxine therapy. Effexor XR, like many antidepressants, should be used cautiously in patients with a history of seizures and should be discontinued in any patient who develops seizures. [Must mitigate the risk: Risk factors, concomitant meds that lower the seizure threshold.]
HyponatremiaHyponatremia can occur as a result of treatment with SSRIs and SNRIs, including Effexor XR. In many cases, the hyponatremia appears to be the result of the Syndrome of Inappropriate Antidiuretic Hormone (SIADH) secretion. Cases with serum sodium lower than 110 mmol/L have been reported. Elderly patients may be at greater risk of developing hyponatremia with SSRIs and SNRIs. Also, patients taking diuretics, or those who are otherwise volume-depleted, may be at greater risk. Consider discontinuation of Effexor XR in patients with symptomatic hyponatremia, and institute appropriate medical intervention.
Signs and symptoms of hyponatremia include headache, difficulty concentrating, memory impairment, confusion, weakness, and unsteadiness, which may lead to falls. Signs and symptoms associated with more severe and/or acute cases have included hallucination, syncope, seizure, coma, respiratory arrest, and death.
Weight And Height Changes In Pediatric Patients Weight ChangesThe average change in body weight and incidence of weight loss (percentage of patients who lost 3.5% or more) in the placebo-controlled pediatric studies in MDD, GAD, and SAD are shown in Tables 3 and 4.
Table 3: Average Change in Body Weight (kg) From Beginning of Treatment in Pediatric
Patients in Double-blind, Placebo-controlled Studies of Effexor XR
| Indication (Duration) | Effexor XR | Placebo |
| MDD and GAD | ||
| (4 pooled studies, 8 weeks) | -0.45 (n = 333) | +0.77 (n = 333) |
| SAD | ||
| (16 weeks) | -0.75 (n = 137) | +0.76 (n = 148) |
Table 4: Incidence (%) of Pediatric Patients Experiencing Weight Loss (3.5% or more) in
Double-blind, Placebo-controlled Studies of Effexor XR
| Indication (Duration) |
Effexor XR | Placebo |
| MDD and GAD | ||
| (4 pooled studies, 8 weeks) | 18a (n = 333) | 3.6 (n = 333) |
| SAD | ||
| (16 weeks) | 47a (n = 137) | 14 (n = 148) |
| a p < 0.001 versus placebo |
Weight loss was not limited to patients with treatment-emergent anorexia.
The risks associated with longer term Effexor XR use were assessed in an open-label MDD study of children and adolescents who received Effexor XR for up to six months. The children and adolescents in the study had increases in weight that were less than expected, based on data from age-and sex-matched peers. The difference between observed weight gain and expected weight gain was larger for children (< 12 years old) than for adolescents (≥ 12 years old).
Height Changes Table 5 shows the average height increase in pediatric patients in the short-term, placebo-controlled MDD, GAD, and SAD studies. The differences in height increases in GAD and MDD studies were most notable in patients younger than twelve.
Table 5: Average Height Increases (cm) in Pediatric Patients in Placebo-controlled Studies of
Effexor XR
| Indication (Duration) |
Effexor XR | Placebo |
| MDD | ||
| (8 weeks) | 0.8 (n = 146) | 0.7 (n = 147) |
| GAD | ||
| (8 weeks) | 0.3a (n = 122) | 1.0 (n = 132) |
| SAD | ||
| (16 weeks) | 1.0 (n = 109) | 1.0 (n = 112) |
| a p = 0.041 |
In the six-month, open-label MDD study, children and adolescents had height increases that were less than expected, based on data from age-and sex-matched peers. The difference between observed and expected growth rates was larger for children (< 12 years old) than for adolescents (≥ 12 years old).
Appetite Changes In Pediatric PatientsDecreased appetite (reported as treatment-emergent anorexia) was more commonly observed in Effexor XR treated patients versus placebo-treated patients in the premarketing evaluation of Effexor XR for MDD, GAD, and SAD (see Table 6).
Table 6: Incidence (%) of Decreased Appetite and Associated Discontinuation Ratesa (%) in
Pediatric Patients in Placebo-controlled Studies of Effexor XR
| Indication (Duration) | Effexor XR Incidence | Discontinuation | Placebo Incidence | Discontinuation |
| MDD and GAD | ||||
| (pooled, 8 weeks) | 10 | 0.0 | 3 | - |
| SAD | ||||
| (16 weeks) | 22 | 0.7 | 3 | 0.0 |
| a The discontinuation rates for weight loss were 0.7% for patients receiving either Effexor XR or placebo. | ||||
Interstitial lung disease and eosinophilic pneumonia associated with venlafaxine therapy have been rarely reported. The possibility of these adverse events should be considered in venlafaxine-treated patients who present with progressive dyspnea, cough or chest discomfort. Such patients should undergo a prompt medical evaluation, and discontinuation of venlafaxine therapy should be considered.
Patient Counseling InformationSee FDA-approved patient labeling (PATIENT INFORMATION).
Prescribers or other healthcare professionals should inform patients, their families, and their caregivers about the benefits and risks associated with treatment with Effexor XR and should counsel them in its appropriate use. A patient Medication Guide about “Antidepressant Medicines, Depression and Other Serious Mental Illnesses, and Suicidal Thoughts or Actions” is available for Effexor XR. The prescriber or healthcare professional should instruct patients, their families, and their caregivers to read the Medication Guide and should assist them in understanding its contents. Patients should be given the opportunity to discuss the contents of the Medication Guide and to obtain answers to any questions they may have. The complete text of the Medication Guide is reprinted at the end of this document. Patients should be advised of the following issues and should be asked to alert their prescriber if these occur while taking Effexor XR.
Suicidal Thoughts And BehaviorsAdvise patients, their families and caregivers to look for the emergence of suicidality, worsening of depression, and other psychiatric symptoms (anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, psychomotor restlessness, hypomania, mania, other unusual changes in behavior), especially early during treatment and when the dose is adjusted up or down. Such symptoms should be reported to the patient's prescriber or health professional, especially if they are severe, abrupt in onset, or were not part of the patient's presenting symptoms. Symptoms such as these may be associated with an increased risk for suicidal thinking and behavior and indicate a need for very close monitoring.
Concomitant MedicationAdvise patients taking Effexor XR not to use concomitantly other products containing venlafaxine or desvenlafaxine. Healthcare professionals should instruct patients not to take Effexor XR with an MAOI or within 14 days of stopping an MAOI and to allow 7 days after stopping Effexor XR before starting an MAOI.
Serotonin SyndromePatients should be cautioned about the risk of serotonin syndrome, with the concomitant use of Effexor XR and triptans, tramadol, amphetamines, tryptophan supplements, with antipsychotics or other dopamine antagonists, or other serotonergic agents.
Elevated Blood PressureAdvise patients that they should have regular monitoring of blood pressure when taking Effexor XR.
Abnormal BleedingPatients should be cautioned about the concomitant use of Effexor XR and NSAIDs, aspirin, warfarin, or other drugs that affect coagulation since combined use of psychotropic drugs that interfere with serotonin reuptake and these agents has been associated with an increased risk of bleeding.
Angle Closure GlaucomaPatients should be advised that taking Effexor XR can cause mild pupillary dilation, which in susceptible individuals, can lead to an episode of angle closure glaucoma. Pre-existing glaucoma is almost always open-angle glaucoma because angle closure glaucoma, when diagnosed, can be treated definitively with iridectomy. Open-angle glaucoma is not a risk factor for angle closure glaucoma. Patients may wish to be examined to determine whether they are susceptible to angle closure, and have a prophylactic procedure (e.g., iridectomy), if they are susceptible.
Activation Of Mania/HypomaniaAdvise patients, their families and caregivers to observe for signs of activation of mania/hypomania.
Cardiovascular/Cerebrovascular DiseaseCaution is advised in administering Effexor XR to patients with cardiovascular, cerebrovascular, or lipid metabolism disorders.
Serum Cholesterol And Triglyceride ElevationAdvise patients that elevations in total cholesterol, LDL and triglycerides may occur and that measurement of serum lipids may be considered.
Discontinuation [Symptoms]Advise patients not to stop taking Effexor XR without talking first with their healthcare professional. Patients should be aware that discontinuation effects may occur when stopping Effexor XR.
Interference With Cognitive And Motor PerformanceCaution patients about operating hazardous machinery, including automobiles, until they are reasonably certain that Effexor XR therapy does not adversely affect their ability to engage in such activities.
AlcoholAdvise patients to avoid alcohol while taking Effexor XR.
Allergic ReactionsAdvise patients to notify their physician if they develop allergic phenomena such as rash, hives, swelling, or difficulty breathing.
PregnancyAdvise patients to notify their physician if they become pregnant or intend to become pregnant during therapy.
NursingAdvise patients to notify their physician if they are breast-feeding an infant.
Residual SpheroidsEffexor XR contains spheroids, which release the drug slowly into the digestive tract. The insoluble portion of these spheroids is eliminated, and patients may notice spheroids passing in the stool or via colostomy. Patients should be informed that the active medication has already been absorbed by the time the patient sees the spheroids.
Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment Of FertilityCarcinogenesis Tumors were not increased by venlafaxine treatment in mice or rats. Venlafaxine was given by oral gavage to mice for 18 months at doses up to 120 mg/kg per day, which was 1.7 times the maximum recommended human dose on a mg/m2 basis. Venlafaxine was also given to rats by oral gavage for 24 months at doses up to 120 mg/kg per day. In rats receiving the 120 mg/kg dose, plasma concentrations of venlafaxine at necropsy were 1 times (male rats) and 6 times (female rats) the plasma concentrations of patients receiving the maximum recommended human dose. Plasma levels of the O-desmethyl metabolite (ODV) were lower in rats than in patients receiving the maximum recommended dose. O-desmethylvenlafaxine (ODV), the major human metabolite of venlafaxine, administered by oral gavage to mice and rats for 2 years did not increase the incidence of tumors in either study. Mice received ODV at dosages up to 500/300 mg/kg/day (dosage lowered after 45 weeks of dosing). The exposure at the 300 mg/kg/day dose is 9 times that of a human dose of 225 mg/day. Rats received ODV at dosages up to 300 mg/kg/day (males) or 500 mg/kg/day (females). The exposure at the highest dose is approximately 8 (males) or 11 (females) times that of a human dose of 225 mg/day.
MutagenesisVenlafaxine and the major human metabolite, ODV, were not mutagenic in the Ames reverse mutation assay in Salmonella bacteria or the Chinese hamster ovary/HGPRT mammalian cell forward gene mutation assay. Venlafaxine was also not mutagenic or clastogenic in the in vitro BALB/c-3T3 mouse cell transformation assay, the sister chromatid exchange assay in cultured Chinese hamster ovary cells, or in the in vivo chromosomal aberration assay in rat bone marrow. ODV was not clastogenic in the in vitro Chinese hamster ovary cell chromosomal aberration assay or in the in vivo chromosomal aberration assay in rats.
Impairment Of FertilityReproduction and fertility studies of venlafaxine in rats showed no adverse effects of venlafaxine on male or female fertility at oral doses of up to 2 times the maximum recommended human dose of 225 mg/day on a mg/m2 basis. However, reduced fertility was observed in a study in which male and female rats were treated with O-desmethylvenlafaxine (ODV), the major human metabolite of venlafaxine, prior to and during mating and gestation. This occurred at an ODV exposure (AUC) approximately 2 to 3 times that associated with a human venlafaxine dose of 225 mg/day.
Use In Specific Populations Pregnancy Teratogenic Effects Pregnancy Category CVenlafaxine did not cause malformations in offspring of rats or rabbits given doses up to 2.5 times (rat) or 4 times (rabbit) the maximum recommended human daily dose on a mg/m2 basis. However, in rats, there was a decrease in pup weight, an increase in stillborn pups, and an increase in pup deaths during the first 5 days of lactation, when dosing began during pregnancy and continued until weaning. The cause of these deaths is not known. These effects occurred at 2.5 times (mg/m2) the maximum human daily dose. The no effect dose for rat pup mortality was 0.25 times the human dose on a mg/m2 basis. In reproductive developmental studies in rats and rabbits with O-desmethylvenlafaxine (ODV), the major human metabolite of venlafaxine, evidence of teratogenicity was not observed at exposure margins of 13 in rats and 0.3 in rabbits. There are no adequate and well-controlled studies in pregnant women. Effexor XR should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.
Non-Teratogenic EffectsNeonates exposed to Effexor XR, other SNRIs, or SSRIs, late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. Such complications can arise immediately upon delivery. Reported clinical findings have included respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying. These features are consistent with either a direct toxic effect of SSRIs and SNRIs, or possibly a drug discontinuation syndrome. It should be noted, that in some cases the clinical picture is consistent with serotonin syndrome. When treating a pregnant woman with Effexor XR during the third trimester, the physician should carefully consider the potential risks and benefits of treatment.
Labor And DeliveryThe effect of venlafaxine on labor and delivery in humans is unknown.
Nursing MothersVenlafaxine and ODV have been reported to be excreted in human milk. Because of the potential for serious adverse reactions in nursing infants from Effexor XR, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.
Pediatric UseTwo placebo-controlled trials in 766 pediatric patients with MDD and two placebo-controlled trials in 793 pediatric patients with GAD have been conducted with Effexor XR, and the data were not sufficient to support a claim for us
Effexor XR should be administered in a single dose with food, either in the morning or in the evening at approximately the same time each day. Each capsule should be swallowed whole with fluid and not divided, crushed, chewed, or placed in water or it may be administered by carefully opening the capsule and sprinkling the entire contents on a spoonful of applesauce. This drug/food mixture should be swallowed immediately without chewing and followed with a glass of water to ensure complete swallowing of the pellets (spheroids).
Major Depressive DisorderFor most patients, the recommended starting dose for Effexor XR is 75 mg per day, administered in a single dose. For some patients, it may be desirable to start at 37.5 mg per day for 4 to 7 days to allow new patients to adjust to the medication before increasing to 75 mg per day. Patients not responding to the initial 75 mg per day dose may benefit from dose increases to a maximum of 225 mg per day. Dose increases should be in increments of up to 75 mg per day, as needed, and should be made at intervals of not less than 4 days, since steady-state plasma levels of venlafaxine and its major metabolites are achieved in most patients by day 4. In the clinical studies establishing efficacy, upward titration was permitted at intervals of 2 weeks or more.
It should be noted that, while the maximum recommended dose for moderately depressed outpatients is also 225 mg per day for Effexor (immediate-release), more severely depressed inpatients in one study of the development program for that product responded to a mean dose of 350 mg per day (range of 150 to 375 mg per day). Whether or not higher doses of Effexor XR are needed for more severely depressed patients is unknown; however, the experience with Effexor XR doses higher than 225 mg per day is very limited.
Generalized Anxiety DisorderFor most patients, the recommended starting dose for Effexor XR is 75 mg per day, administered in a single dose. For some patients, it may be desirable to start at 37.5 mg per day for 4 to 7 days to allow new patients to adjust to the medication before increasing to 75 mg per day. Patients not responding to the initial 75 mg per day dose may benefit from dose increases to a maximum of 225 mg per day. Dose increases should be in increments of up to 75 mg per day, as needed, and should be made at intervals of not less than 4 days, since steady-state plasma levels of venlafaxine and its major metabolites are achieved in most patients by day 4.
Social Anxiety Disorder (Social Phobia)The recommended dose is 75 mg per day, administered in a single dose. There was no evidence that higher doses confer any additional benefit.
Panic DisorderThe recommended starting dose is 37.5 mg per day of Effexor XR for 7 days. Patients not responding to 75 mg per day may benefit from dose increases to a maximum of approximately 225 mg per day. Dose increases should be in increments of up to 75 mg per day, as needed, and should be made at intervals of not less than 7 days.
Switching Patients From Effexor TabletsDepressed patients who are currently being treated at a therapeutic dose with Effexor (immediate release) may be switched to Effexor XR at the nearest equivalent dose (mg per day), e.g., 37.5 mg venlafaxine twice a day to 75 mg Effexor XR once daily. However, individual dosage adjustments may be necessary.
Specific Populations Patients With Hepatic ImpairmentThe total daily dose should be reduced by 50% in patients with mild (Child-Pugh=5-6) to moderate (Child-Pugh=7-9) hepatic impairment. In patients with severe hepatic impairment (Child-Pugh=10-15) or hepatic cirrhosis, it may be necessary to reduce the dose by 50% or more.
Patients With Renal ImpairmentThe total daily dose should be reduced by 25% to 50% in patients with mild (CLcr= 60-89 mL/min) or moderate (CLcr= 30-59 mL/min) renal impairment. In patients undergoing hemodialysis or with severe renal impairment (CLcr < 30 mL/min), the total daily dose should be reduced by 50% or more. Because there was much individual variability in clearance between patients with renal impairment, individualization of dosage may be desirable in some patients.
Maintenance TreatmentThere is no body of evidence available from controlled studies to indicate how long patients with MDD, GAD, SAD, or PD should be treated with Effexor XR.
It is generally agreed that acute episodes of MDD require several months or longer of sustained pharmacological therapy beyond response to the acute episode. Effexor XR/Effexor have demonstrated continuation of response in clinical studies up to 52 weeks, at the same dose at which patients responded during the initial treatment. It is not known whether or not the dose of Effexor XR needed for maintenance treatment is identical to the dose needed to achieve an initial response. Patients should be periodically reassessed to determine the need for maintenance treatment and the appropriate dose for such treatment.
In patients with GAD and SAD, Effexor XR has been shown to be effective in 6-month clinical studies. The need for continuing medication in patients with GAD and SAD who improve with Effexor XR treatment should be periodically reassessed.
In a clinical study for PD, patients continuing Effexor XR at the same dose at which they responded during the initial 12 weeks of treatment experienced a statistically significantly longer time to relapse than patients randomized to placebo. The need for continuing medication in patients with PD who improve with Effexor XR treatment should be periodically reassessed.
Discontinuing Effexor XRA gradual reduction in the dose, rather than abrupt cessation, is recommended whenever possible. In clinical studies with Effexor XR, tapering was achieved by reducing the daily dose by 75 mg at one-week intervals. Individualization of tapering may be necessary.
Switching Patients To Or From A Monoamine Oxidase Inhibitor (MAOI) Intended To Treat Psychiatric DisordersAt least 14 days should elapse between discontinuation of an MAOI (intended to treat psychiatric disorders) and initiation of therapy with Effexor XR. In addition, at least 7 days should be allowed after stopping Effexor XR before starting an MAOI intended to treat psychiatric disorders.
Use Of Effexor XR With Other MAOIs Such As Linezolid Or Intravenous Methylene BlueDo not start Effexor XR in a patient who is being treated with linezolid or intravenous methylene blue, because there is an increased risk of serotonin syndrome. In a patient who requires more urgent treatment of a psychiatric condition, other interventions, including hospitalization should be considered.
In some cases, a patient already receiving Effexor XR therapy may require urgent treatment with linezolid or intravenous methylene blue. If acceptable alternatives to linezolid or intravenous methylene blue are not available and the potential benefits of linezolid or intravenous methylene blue treatment are judged to outweigh the risks of serotonin syndrome in a particular patient, Effexor XR should be stopped promptly, and linezolid or intravenous methylene blue can be administered. Monitor the patient for symptoms of serotonin syndrome for 7 days or until 24 hours after the last dose of linezolid or intravenous methylene blue, whichever comes first. Therapy with Effexor XR can be resumed 24 hours after the last dose of linezolid or intravenous methylene blue.
The risk of administering methylene blue by non-intravenous routes (such as oral tablets or by local injection) or in intravenous doses much lower than 1 mg/kg concomitantly with Effexor XR is unclear.
The clinician should, nevertheless, be aware of the possibility of emergent symptoms of serotonin syndrome with such use.
The following adverse reactions are discussed in greater detail in other sections of the label:
Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.
Most Common Adverse ReactionsThe most commonly observed adverse reactions in the clinical study database in Effexor XR treated patients in MDD, GAD, SAD, and PD (incidence ≥ 5% and at least twice the rate of placebo) were: nausea (30.0%), somnolence (15.3%), dry mouth (14.8%), sweating (11.4%), abnormal ejaculation (9.9%), anorexia (9.8%), constipation (9.3%), impotence (5.3%) and decreased libido (5.1%).
Adverse Reactions Reported As Reasons For Discontinuation Of TreatmentCombined across short-term, placebo-controlled premarketing studies for all indications, 12% of the 3,558 patients who received Effexor XR (37.5-225 mg) discontinued treatment due to an adverse experience, compared with 4% of the 2,197 placebo-treated patients in those studies.
The most common adverse reactions leading to discontinuation in ≥ 1% of the Effexor XR treated patients in the short-term studies (up to 12 weeks) across indications are shown in Table 7.
Table 7: Incidence (%) of Patients Reporting Adverse Reactions Leading to Discontinuation in
Placebo-controlled Clinical Studies (up to 12 Weeks Duration)
| Body System Adverse Reaction |
Effexor XR n = 3,558 |
Placebo n = 2,197 |
| Body as a whole | ||
| Asthenia | 1.7 | 0.5 |
| Headache | 1.5 | 0.8 |
| Digestive system | ||
| Nausea | 4.3 | 0.4 |
| Nervous system | ||
| Dizziness | 2.2 | 0.8 |
| Insomnia | 2.1 | 0.6 |
| Somnolence | 1.7 | 0.3 |
| Skin and appendages | 1.5 | 0.6 |
| Sweating | 1.0 | 0.2 |
The number of patients receiving multiple doses of Effexor XR during the premarketing assessment for each approved indication is shown in Table 8. The conditions and duration of exposure to venlafaxine in all development programs varied greatly, and included (in overlapping categories) open and double-blind studies, uncontrolled and controlled studies, inpatient (Effexor only) and outpatient studies, fixed-dose, and titration studies.
Table 8: Patients Receiving Effexor XR in Premarketing Clinical Studies
| Indication | Effexor XR |
| MDD | 705a |
| GAD | 1,381 |
| SAD | 819 |
| PD | 1,314 |
| a In addition, in the premarketing assessment of Effexor, multiple doses were administered to 2,897 patients in studies for MDD. |
The incidences of common adverse reactions (those that occurred in ≥ 2% of Effexor XR treated patients [357 MDD patients, 1,381 GAD patients, 819 SAD patients, and 1,001 PD patients] and more frequently than placebo) in Effexor XR treated patients in short-term, placebo-controlled, fixed-and flexible-dose clinical studies (doses 37.5 to 225 mg per day) are shown in Table 9.
The adverse reaction profile did not differ substantially between the different patient populations.
Table 9: Common Adverse Reactions: Percentage of Patients Reporting Adverse Reactions (≥ 2% and > placebo) in Placebo-controlled Studies (up to 12 Weeks Duration) across All Indications
| Body System Adverse Reaction |
Effexor XR n = 3,558 |
Placebo n = 2,197 |
| Body as a whole | ||
| Asthenia | 12.6 | 7.8 |
| Cardiovascular system | ||
| Hypertension | 3.4 | 2.6 |
| Palpitation | 2.2 | 2.0 |
| Vasodilatation | 3.7 | 1.9 |
| Digestive system | ||
| Anorexia | 9.8 | 2.6 |
| Constipation | 9.3 | 3.4 |
| Diarrhea | 7.7 | 7.2 |
| Dry mouth | 14.8 | 5.3 |
| Nausea | 30.0 | 11.8 |
| Vomiting | 4.3 | 2.7 |
| Nervous system | ||
| Abnormal dreams | 2.9 | 1.4 |
| Dizziness | 15.8 | 9.5 |
| Insomnia | 17.8 | 9.5 |
| Libido decreased | 5.1 | 1.6 |
| Nervousness | 7.1 | 5.0 |
| Paresthesia | 2.4 | 1.4 |
| Somnolence | 15.3 | 7.5 |
| Tremor | 4.7 | 1.6 |
| Respiratory system | ||
| Yawn | 3.7 | 0.2 |
| Skin and appendages | ||
| Sweating (including night sweats) | 11.4 | 2.9 |
| Special senses | ||
| Abnormal vision | 4.2 | 1.6 |
| Urogenital system | ||
| Abnormal ejaculation/orgasm (men)a | 9.9 | 0.5 |
| Anorgasmia (men)a | 3.6 | 0.1 |
| Anorgasmia (women)b | 2.0 | 0.2 |
| Impotence (men)a | 5.3 | 1.0 |
| a Percentages based on the number of men (Effexor XR, n = 1,440; placebo, n = 923) b Percentages based on the number of women (Effexor XR, n = 2,118; placebo, n = 1,274) |
Body as a whole - Photosensitivity reaction, chills
Cardiovascular system - Postural hypotension, syncope, hypotension, tachycardia
Digestive system - Gastrointestinal hemorrhage , bruxism
Hemic/Lymphatic system - Ecchymosis
Metabolic/Nutritional - Hypercholesterolemia, weight gain , weight loss
Nervous system - Seizures , manic reaction , agitation, confusion, akathisia, hallucinations, hypertonia, myoclonus, depersonalization, apathy
Skin and appendages - Urticaria, pruritus, rash, alopecia
Special senses - Mydriasis, abnormality of accommodation, tinnitus, taste perversion
Urogenital system - Urinary retention, urination impaired, urinary incontinence, urinary frequency increased, menstrual disorders associated with increased bleeding or increased irregular bleeding (e.g., menorrhagia, metrorrhagia)
Vital Sign ChangesIn placebo-controlled premarketing studies, there were increases in mean blood pressure (see Table 10). Across most indications, a dose-related increase in mean supine systolic and diastolic blood pressure was evident in patients treated with Effexor XRs. Across all clinical studies in MDD, GAD, SAD and PD, 1.4% of patients in the Effexor XR groups experienced an increase in SDBP of ≥15 mm Hg along with a blood pressure ≥ 105 mm Hg, compared to 0.9% of patients in the placebo groups. Similarly, 1% of patients in the Effexor XR groups experienced an increase in SSBP of ≥ 20 mm Hg with a blood pressure ≥ 180 mm Hg, compared to 0.3% of patients in the placebo groups.
Table 10: Final On-therapy Mean Changes From Baseline in Supine Systolic (SSBP) and Diastolic (SDBP) Blood Pressure (mm Hg) in Placebo-controlled Studies
| Indication (Duration) |
Effexor XR | Placebo | ||||
| ≤ 75 mg per day | > 75 mg per day | |||||
| SSBP | SDBP | SSBP | SDBP | SSBP | SDBP | |
| MDD | ||||||
| (8-12 weeks) | -0.28 | 0.37 | 2.93 | 3.56 | -1.08 | -0.10 |
| GAD | ||||||
| (8 weeks) | -0.28 | 0.02 | 2.40 | 1.68 | -1.26 | -0.92 |
| (6 months) | 1.27 | -0.69 | 2.06 | 1.28 | -1.29 | -0.74 |
| SAD | ||||||
| (12 weeks) | -0.29 | -1.26 | 1.18 | 1.34 | -1.96 | -1.22 |
| (6 months) | -0.98 | -0.49 | 2.51 | 1.96 | -1.84 | -0.65 |
| PD | ||||||
| (10-12 weeks) | -1.15 | 0.97 | -0.36 | 0.16 | -1.29 | -0.99 |
Effexor XR treatment was associated with sustained hypertension (defined as treatment-emergent Supine Diastolic Blood Pressure [SDBP] ≥ 90 mm Hg and ≥ 10 mm Hg above baseline for three consecutive on-therapy visits (see Table 11). An insufficient number of patients received mean doses of Effexor XR over 300 mg per day in clinical studies to fully evaluate the incidence of sustained increases in blood pressure at these higher doses.
Table 11: Sustained Elevations in SDBP in Effexor XR
Premarketing Studies
| Indication | Dose Range (mg per day) | Incidence (%) |
| MDD | 75-375 | 19/705 (3) |
| GAD | 37.5-225 | 5/1011 (0.5) |
| SAD | 75-225 | 5/771 (0.6) |
| PD | 75-225 | 9/973 (0.9) |
Effexor XR was associated with mean increases in pulse rate compared with placebo in premarketing placebo-controlled studies (see Table 12).
Table 12: Approximate Mean Final On-therapy Increase in Pulse Rate (beats/min) in Effexor XR Premarketing Placebo-controlled Studies (up to 12 Weeks Duration)
| Indication (Duration) | Effexor XR | Placebo |
| MDD | ||
| (12 weeks) | 2 | 1 |
| GAD | ||
| (8 weeks) | 2 | < 1 |
| SAD | ||
| (12 weeks) | 3 | 1 |
| PD | ||
| (12 weeks) | 1 | < 1 |
Effexor XR was associated with mean final increases in serum cholesterol concentrations compared with mean final decreases for placebo in premarketing MDD, GAD, SAD and PD clinical studies (Table 13).
Table 13: Mean Final On-therapy Changes in Cholesterol Concentrations (mg/dL) in Effexor XR
Premarketing Studies
| Indication (Duration) | Effexor XR | Placebo |
| MDD | ||
| (12 weeks) | +1.5 | -7.4 |
| GAD | ||
| (8 weeks) | +1.0 | -4.9 |
| (6 months) | +2.3 | -7.7 |
| SAD | ||
| (12 weeks) | +7.9 | -2.9 |
| (6 months) | +5.6 | -4.2 |
| PD | ||
| (12 weeks) | 5.8 | -3.7 |
Effexor XR (venlafaxine hydrochloride) extended-release capsules treatment for up to 12 weeks in premarketing placebo-controlled trials for major depressive disorder was associated with a mean final on-therapy increase in serum cholesterol concentration of approximately 1.5 mg/dL compared with a mean final decrease of 7.4 mg/dL for placebo. Effexor XR treatment for up to 8 weeks and up to 6 months in premarketing placebo-controlled GAD trials was associated with mean final on-therapy increases in serum cholesterol concentration of approximately 1.0 mg/dL and 2.3 mg/dL, respectively while placebo subjects experienced mean final decreases of 4.9 mg/dL and 7.7 mg/dL, respectively. Effexor XR treatment for up to 12 weeks and up to 6 months in premarketing placebo-controlled Social Anxiety Disorder trials was associated with mean final on-therapy increases in serum cholesterol concentration of approximately 7.9 mg/dL and 5.6 mg/dL, respectively, compared with mean final decreases of 2.9 and 4.2 mg/dL, respectively, for placebo. Effexor XR treatment for up to 12 weeks in premarketing placebo-controlled panic disorder trials was associated with mean final on-therapy increases in serum cholesterol concentration of approximately 5.8 mg/dL compared with a mean final decrease of 3.7 mg/dL for placebo.
Patients treated with Effexor (immediate release) for at least 3 months in placebo-controlled 12-month extension trials had a mean final on-therapy increase in total cholesterol of 9.1 mg/dL compared with a decrease of 7.1 mg/dL among placebo-treated patients. This increase was duration dependent over the study period and tended to be greater with higher doses. Clinically relevant increases in serum cholesterol, defined as 1) a final on-therapy increase in serum cholesterol ≥50 mg/dL from baseline and to a value ≥261 mg/dL, or 2) an average on-therapy increase in serum cholesterol ≥50 mg/dL from baseline and to a value ≥261 mg/dL, were recorded in 5.3% of venlafaxine-treated patients and 0.0% of placebo-treated patients.
Serum TriglyceridesEffexor XR was associated with mean final on-therapy increases in fasting serum triglycerides compared with placebo in premarketing clinical studies of SAD and PD up to 12 weeks (pooled data) and 6 months duration (Table 14).
Table 14: Mean Final On-therapy Increases in Triglyceride Concentrations (mg/dL) in Effexor
XR Premarketing Studies
| Indication (Duration) | Effexor XR | Placebo |
| SAD | 8.2 | 0.4 |
| (12 weeks) | ||
| SAD | 11.8 | 1.8 |
| (6 months) | ||
| PD | 5.9 | 0.9 |
| (12 weeks) | ||
| PD | 9.3 | 0.3 |
| (6 months) |
In general, the adverse reaction profile of venlafaxine (in placebo-controlled clinical studies) in children and adolescents (ages 6 to 17) was similar to that seen for adults. As with adults, decreased appetite, weight loss, increased blood pressure, and increased serum cholesterol were observed.
In pediatric clinical studies, the adverse reaction, suicidal ideation, was observed.
Particularly, the following adverse reactions were observed in pediatric patients: abdominal pain, agitation, dyspepsia, ecchymosis, epistaxis, and myalgia.
Adverse Reactions Identified During Postapproval UseThe following adverse reactions have been identified during postapproval use of Effexor XR. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure:
Body as a whole - Anaphylaxis, angioedema
Cardiovascular system - QT prolongation, ventricular fibrillation, ventricular tachycardia (including torsade de pointes)
Digestive system - Pancreatitis
Hemic/Lymphatic system - Mucous membrane bleeding , blood dyscrasias (including agranulocytosis, aplastic anemia, neutropenia and pancytopenia), prolonged bleeding time, thrombocytopenia
Metabolic/Nutritional - Hyponatremia , Syndrome of Inappropriate Antidiuretic Hormone (SIADH) secretion , abnormal liver function tests, hepatitis, prolactin increased
Musculoskeletal - Rhabdomyolysis
Nervous system - Neuroleptic Malignant Syndrome (NMS) , serotonergic syndrome , delirium, extrapyramidal reactions (including dystonia and dyskinesia), impaired coordination and balance, tardive dyskinesia
Respiratory system - Dyspnea, interstitial lung disease, pulmonary eosinophilia
Skin and appendages - Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme
Special senses - Angle-closure glaucoma
DRUG INTERACTIONS Central Nervous System (CNS)-Active DrugsThe risk of using venlafaxine in combination with other CNS-active drugs has not been systematically evaluated. Consequently, caution is advised when Effexor XR is taken in combination with other CNS-active drugs.
Monoamine Oxidase InhibitorsAdverse reactions, some of which were serious, have been reported in patients who have recently been discontinued from an MAOI and started on antidepressants with pharmacological properties similar to Effexor XR (SNRIs or SSRIs), or who have recently had SNRI or SSRI therapy discontinued prior to initiation of an MAOI.
Serotonergic DrugsBased on the mechanism of action of Effexor XR and the potential for serotonin syndrome, caution is advised when Effexor XR is coadministered with other drugs that may affect the serotonergic neurotransmitter systems, such as triptans, SSRIs, other SNRIs, linezolid (an antibiotic which is a reversible non-selective MAOI), lithium, tramadol, or St. John’s wort. If concomitant treatment with Effexor XR and these drugs is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases. The concomitant use of Effexor XR with tryptophan supplements is not recommended.
Drugs That Interfere With Hemostasis (e.g., NSAIDs, Aspirin, And Warfarin)Serotonin release by platelets plays an important role in hemostasis. The use of psychotropic drugs that interfere with serotonin reuptake is associated with the occurrence of upper gastrointestinal bleeding and concurrent use of an NSAID or aspirin may potentiate this risk of bleeding. Altered anticoagulant effects, including increased bleeding, have been reported when SSRIs and SNRIs are coadministered with warfarin. Patients receiving warfarin therapy should be carefully monitored when Effexor XR is initiated or discontinued.
Weight Loss AgentsThe safety and efficacy of venlafaxine therapy in combination with weight loss agents, including phentermine, have not been established. Coadministration of Effexor XR and weight loss agents is not recommended. Effexor XR is not indicated for weight loss alone or in combination with other products.
Effects Of Other Drugs On Effexor XRFigure 1: Effect of interacting drugs on the pharmacokinetics of venlafaxine and active metabolite O-desmethylvenlafaxine (ODV).
| Abbreviations: ODV, O-desmethylvenlafaxine; AUC, area under the curve; Cmax, peak plasma concentrations; EM's, extensive metabolizers; PM's, poor metabolizers * No dose adjustment on co-administration with CYP2D6 inhibitors (Fig 3 and Metabolism Section 12.3) |
Figure 2: Effect of venlafaxine on the pharmacokinetics interacting drugs and their active metabolites.
| Abbreviations: AUC, area under the curve; Cmax, peak plasma concentrations; OH, hydroxyl * Data for 2-OH desipramine were not plotted to enhance clarity; the fold change and 90% CI for Cmax and AUC of 2-OH desipramine were 6.6 (5.5, 7.9) and 4.4 (3.8, 5.0), respectively. |
Note: *: Administration of venlafaxine in a stable regimen did not exaggerate the psychomotor and psychometric effects induced by ethanol in these same subjects when they were not receiving venlafaxine.
Drug-Laboratory Test InteractionsFalse-positive urine immunoassay screening tests for phencyclidine (PCP) and amphetamine have been reported in patients taking venlafaxine. This is due to lack of specificity of the screening tests. False positive test results may be expected for several days following discontinuation of venlafaxine therapy. Confirmatory tests, such as gas chromatography/mass spectrometry, will distinguish venlafaxine from PCP and amphetamine.
Drug Abuse And Dependence Controlled SubstanceEffexor XR is not a controlled substance.
AbuseWhile venlafaxine has not been systematically studied in clinical studies for its potential for abuse, there was no indication of drug-seeking behavior in the clinical studies. However, it is not possible to predict on the basis of premarketing experience the extent to which a CNS-active drug will be misused, diverted, and/or abused once marketed. Consequently, physicians should carefully evaluate patients for history of drug abuse and follow such patients closely, observing them for signs of misuse or abuse of venlafaxine (e.g., development of tolerance, incrementation of dose, drug-seeking behavior).
DependenceIn vitro studies revealed that venlafaxine has virtually no affinity for opiate, benzodiazepine, phencyclidine (PCP), or N-methyl-D-aspartic acid (NMDA) receptors.
Venlafaxine was not found to have any significant CNS stimulant activity in rodents. In primate drug discrimination studies, venlafaxine showed no significant stimulant or depressant abuse liability. Discontinuation effects have been reported in patients receiving venlafaxine.
