Desvenlafaxine

Desvenlafaxine is a prescription medication used for the treatment of the major depressive disorder.

• Desvenlafaxine is available under the following different brand names: Pristiq, Khedezla (DSC)

Adult dosage

Tablet, extended-release

Pristiq

• 25mg (contains 38 mg of desvenlafaxine succinate)
• 50mg (contains 76 mg of desvenlafaxine succinate)
• 100mg (contains 152 mg of desvenlafaxine succinate) 

Major Depressive Disorder

Adult dosage

• 50 mg orally every day
• Higher dosages, up to 400 mg/day, have been used but no additional benefit was demonstrated at doses greater than 50mg/day; increased side effects have been reported

Dosage Considerations – Should be Given as Follows: 

• See “Dosages”

Common side effects of Desvenlafaxine include:

• dizziness,
• drowsiness,
• anxiety,
• increased sweating,
• nausea,
• decreased appetite,
• constipation,
• sleep problems (insomnia),
• decreased sex drive,
• impotence, and
• difficulty having an orgasm

Serious side effects of Desvenlafaxine include:

• convulsion (seizure),
• easy bruising or bleeding (nosebleeds, bleeding gums),
• blood in the urine or stools,
• coughing up blood,
• blurred vision,
• eye pain or swelling,
• seeing halos around lights,
• cough,
• chest discomfort,
• trouble breathing,
• headache,
• confusion,
• severe weakness,
• memory problems,
• feeling unsteady, and
• hallucinations

Rare side effects of Desvenlafaxine include:

• none 

If your medical doctor is using this medicine to treat your pain, your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor, health care provider, or pharmacist first

• Desvenlafaxine has severe interactions with at least 11 other drugs.
• Desvenlafaxine has serious interactions with at least 73 other drugs:
• Desvenlafaxine has moderate interactions with at least 93 other drugs
• Desvenlafaxine has minor interaction with the following drugs:
  • ruxolitinib
  • ruxolitinib topical

This information does not contain all possible interactions or adverse effects. Visit the RxList Drug Interaction Checker for any drug interactions. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you and share this information with your doctor and pharmacist. Check with your health care professional or doctor for additional medical advice, or if you have health questions, concerns.

Contraindications

• Hypersensitivity to desvenlafaxine succinate, venlafaxine hydrochloride, or to any excipients in the desvenlafaxine formulation

Coadministration with serotonergic drugs

• Coadministration with MAOIs increases the risk of serotonin syndrome
• Use of MAOIs concomitantly within 14 days before initiating desvenlafaxine or within 7 days after discontinuing desvenlafaxine
• Symptoms include tremor, myoclonus, diaphoresis, nausea, vomiting, flushing, dizziness, hyperthermia with features resembling neuroleptic malignant syndrome (NMS), seizures, rigidity, autonomic instability with possible rapid fluctuations of vital signs, and mental status changes that include extreme agitation progressing to delirium and coma
• Starting desvenlafaxine inpatient being treated with linezolid or IV methylene blue is contraindicated because of the increased risk of serotonin syndrome
• If linezolid or IV methylene blue must be administered, discontinue desvenlafaxine immediately and monitor for central nervous system (CNS) toxicity; therapy may be resumed 24 hours after the last linezolid or methylene blue dose or after 2 weeks of monitoring, whichever comes first

Effects of drug abuse

• None

Short-Term Effects

• See “What Are Side Effects Associated with Using Desvenlafaxine?”

Long-Term Effects

• See “What Are Side Effects Associated with Using Desvenlafaxine?”

Cautions

• Suicidality: monitor for clinical worsening and suicide risk (especially in children, adolescents, and young adults aged 18-24 years), during early phases of treatment and alterations in dosages
• Neonates exposed to SNRIs or SSRIs late in 3rd trimester of pregnancy have developed complications necessitating prolonged hospitalization, respiratory support, and tube feeding
• Control hypertension before initiating treatment; monitor blood pressure regularly during treatment; if sustained hypertension is observed, consider dosage reduction or discontinuance
• Risk of mydriasis; may trigger angle closure attack in patients with angle-closure glaucoma with anatomically narrow angles without a patent iridectomy; avoid the use of antidepressants, including desvenlafaxine, in patients with untreated anatomically narrow angles
• Use caution in patients with a history of seizure disorders
• Screen for bipolar disorder; risk of mixed or manic episodes is increased in patients treated with antidepressants
• May precipitate shift to mania or hypomania in patients with bipolar disorder; avoid monotherapy in patients with bipolar disorder; screen for bipolar disorder patients presenting with depressive symptoms
• Cardiovascular, cerebrovascular, or lipid metabolism disorders; monitor patients who have a history of or are at risk for these disorders
• Monitor serum lipids periodically; risk of elevations in fasting serum total cholesterol, low-density lipoprotein, and triglycerides is increased
• Hyponatremia due to syndrome of inappropriate antidiuretic hormone; cases of serum sodium less than 110 mmol/L have been reported; monitor patients who are taking diuretics or at risk for volume depletion
• Rare reports of interstitial lung disease and eosinophilic pneumonia; monitor patients for progressive dyspnea, cough, or chest discomfort
• Risk of mydriasis; may trigger angle closure attack in patients with angle-closure glaucoma with anatomically narrow angles without a patent iridectomy
• May impair cognitive abilities; use caution operating heavy machinery

Discontinuation syndrome

• There have been postmarketing reports of serious discontinuation symptoms which can be protracted and severe; completed suicide, suicidal thoughts, aggression, and violent behavior reported in patients during a reduction in dosage, including during discontinuation
• Other postmarketing reports describe visual changes (such as blurred vision or trouble focusing) and increased blood pressure after stopping or reducing the dose
• If intolerable symptoms occur following a decrease in dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered
• Subsequently, the healthcare provider may continue decreasing the dose, but at a more gradual rate; in some patients, discontinuation may need to occur over several months

Sexual dysfunction

• Use may cause symptoms of sexual dysfunction in both male and female patients; inform patients that they should discuss any changes in sexual function and potential management strategies with their healthcare provider
• Use of SSRIs may cause symptoms of sexual dysfunction; in male patients, SSRI use may result in ejaculatory delay or failure, decreased libido, and erectile dysfunction
• In female patients, SSRI/SNRI use may result in decreased libido and delayed or absent orgasm
• Important for prescribers to inquire about sexual function before initiating and to inquire specifically about changes in sexual function during treatment because the sexual function may not be spontaneously reported
• When evaluating changes in sexual function, obtaining a detailed history (including the timing of symptom onset) is important because sexual symptoms may have other causes, including underlying psychiatric disorder
• Discuss potential management strategies to support patients in making informed decisions about treatment

Serotonin syndrome

• Consider the risk of serotonin syndrome if administered concomitantly with other serotonergic drugs including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. John’s Wort
• Serotonin syndrome or NMS-like reactions may occur; discontinue and initiate supportive therapy; closely monitor patients concomitantly receiving triptans, antipsychotics, or serotonin precursors
• Serotonin syndrome signs and symptoms may include mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea)
• Neonates exposed to SNRIs or SSRIs late in 3rd trimester of pregnancy have developed complications necessitating prolonged hospitalization, respiratory support, and tube feeding
• Monitor for the emergence of serotonin syndrome
• Discontinue desvenlafaxine and any concomitant serotonergic agents immediately if the above symptoms occur, and initiate supportive symptomatic treatment
• If concomitant use of desvenlafaxine with other serotonergic drugs is clinically warranted, inform patients of the increased risk for serotonin syndrome and monitor for symptoms

Risk of bleeding

• SSRIs and SNRIs may impair platelet aggregation and increase the risk of bleeding events, ranging from ecchymoses, hematomas, epistaxis, petechiae, and GI hemorrhage to life-threatening hemorrhage
• Concomitant use of aspirin, NSAIDs, warfarin, other anticoagulants, or other drugs are known to affect platelet function may add to this risk
• For patients taking warfarin, carefully monitor coagulation indices when initiating, titrating, or discontinuing therapy

Pregnancy and Lactation

• No published studies on desvenlafaxine in pregnant women; however, published epidemiologic studies of pregnant women exposed to venlafaxine, the parent compound, have not reported a clear association with adverse developmental outcomes
• Exposure to SNRIs in mid-to-late pregnancy may increase the risk for preeclampsia, and exposure to SNRIs near delivery may increase the risk for postpartum hemorrhage
• Exposure to SNRIs or SSRIs in late pregnancy may lead to an increased risk for neonatal complications requiring prolonged hospitalization, respiratory support, and tube feeding; monitor neonates who were exposed to desvenlafaxine in the third trimester of pregnancy for drug discontinuation syndrome

Pregnancy exposure registry

Monitors pregnancy outcomes in women exposed to antidepressants during pregnancy

Encourage patients to register by calling the National Pregnancy Registry for Antidepressants at 1-844-405-6185

Lactation

• Available limited data from published literature show low levels of desvenlafaxine in human milk and have not shown adverse reactions in breastfed infants
• There are no data on the effects of desvenlafaxine on milk production
• Consider the developmental and health benefits of breastfeeding along with the mother’s clinical need for desvenlafaxine and any potential adverse effects on the breastfed child from desvenlafaxine or the underlying maternal condition