FLUVOXAMINE

brands

Class

• Neuroscience-based Nomenclature: serotonin reuptake inhibitor (S-RI)
• SSRI (selective serotonin reuptake inhibitor); often classified as an antidepressant, but it is not just an antidepressant

FLUVOXAMINE commonly prescribed for

(Bold for FDA approved)

How FLUVOXAMINE works

• Boosts neurotransmitter serotonin

• Blocks serotonin reuptake pump (serotonin transporter)

• Desensitizes serotonin receptors, especially serotonin 1A receptors

• Presumably increases serotonergic neurotransmission

• Fluvoxamine also binds at sigma 1 receptors

How long until FLUVOXAMINE works

• Some patients may experience relief of insomnia or anxiety early after initiation of treatment

• Onset of therapeutic actions usually not immediate, but often delayed 2–4 weeks

• If it is not working within 6–8 weeks, it may require a dosage increase or it may not work at all

• May continue to work for many years to prevent relapse of symptoms

Notable Side Effects

• Sexual dysfunction (men: delayed ejaculation, erectile dysfunction; men and women: decreased sexual desire, anorgasmia)

• Gastrointestinal (decreased appetite, nausea, diarrhea, constipation, dry mouth)

• Mostly CNS (insomnia but also sedation, agitation, tremors, headache, dizziness)

• Note: patients with diagnosed or undiagnosed bipolar or psychotic disorders may be more vulnerable to CNS-activating actions of SSRIs

• Autonomic (sweating)

• Bruising and rare bleeding

• Rare hyponatremia

Life Threatening Side Effects

• Rare seizures

• Rare induction of mania

• Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo beyond age 24)

weight gain

unusual

sedation

common

What to do about FLUVOXAMINE side effects

• Wait

• Wait

• Wait

• If fluvoxamine is sedating, take at night to reduce drowsiness

• Reduce dose

• In a few weeks, switch or add other drugs

usual dosage range

• 100–300 mg/day for OCD

• 100–200 mg/day for depression

• 100–300 mg/day for social anxiety disorder

Dosage Forms

• Tablet 25 mg, 50 mg scored, 100 mg scored

• Controlled-release capsule 100 mg, 150 mg

long term use

• Safe

habit forming

• No

Renal Impairment

• Consider lower initial dose

Hepatic Impairment

• Lower dose or give less frequently, perhaps by half; use slower titration

Cardiac Impairment

• Preliminary research suggests that fluvoxamine is safe in these patients

• Treating depression with SSRIs in patients with acute angina or following myocardial infarction may reduce cardiac events and improve survival as well as mood

Elderly

• May require lower initial dose and slower titration

• Reduction in the risk of suicidality with antidepressants compared to placebo in adults age 65 and older

Children and Adolescents

• Immediate-release approved for ages 8–17 for OCD

• 8–17: initial 25 mg/day at bedtime; increase by 25 mg/day every 4–7 days; maximum 200 mg/day; doses above 50 mg/day should be divided into 2 doses with the larger dose administered at bedtime

• Preliminary evidence suggests efficacy for other anxiety disorders and depression in children and adolescents

• Carefully weigh the risks and benefits of pharmacological treatment against the risks and benefits of nontreatment with antidepressants and make sure to document this in the patient’s chart

• Monitor patients face-to-face regularly, particularly during the first several weeks of treatment

• Use with caution, observing for activation of known or unknown bipolar disorder and/ or suicidal ideation, and inform parents or guardians of this risk so they can help observe child or adolescent patients

Pregnancy

• Controlled studies have not been conducted in pregnant women

• Not generally recommended for use during pregnancy, especially during first trimester

• Nonetheless, continuous treatment during pregnancy may be necessary and has not been proven to be harmful to the fetus

• At delivery there may be more bleeding in the mother and transient irritability or sedation in the newborn

• Must weigh the risk of treatment (first trimester fetal development, third trimester newborn delivery) to the child against the risk of no treatment (recurrence of depression, maternal health, infant bonding) to the mother and child

• For many patients this may mean continuing treatment during pregnancy

• Exposure to SSRIs early in pregnancy may be associated with increased risk of septal heart defects (absolute risk is small)

• SSRI use beyond the 20th week of pregnancy may be associated with increased risk of pulmonary hypertension in newborns, although this is not proven

• Exposure to SSRIs late in pregnancy may be associated with increased risk of gestational hypertension and preeclampsia

• Neonates exposed to SSRIs or SNRIs late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding; reported symptoms are consistent with either a direct toxic effect of SSRIs and SNRIs or, possibly, a drug discontinuation syndrome, and include respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying

Breast Feeding

• Some drug is found in mother’s breast milk

• Trace amounts may be present in nursing children whose mothers are on fluvoxamine

• If child becomes irritable or sedated, breast feeding or drug may need to be discontinued

• Immediate postpartum period is a high-risk time for depression, especially in women who have had prior depressive episodes, so drug may need to be reinstituted late in the third trimester or shortly after childbirth to prevent a recurrence during the postpartum period

• Must weigh benefits of breast feeding with risks and benefits of antidepressant treatment versus nontreatment to both the infant and the mother

• For many patients this may mean continuing treatment during breast feeding