levomilnacipran(lee-voe-mil-na-si-pran ) ,
Pregnancy Category: C
Pharmacologic: selective serotonin norepinephrine reuptake inhibitors
Pharmacologic: selective serotonin norepinephrine reuptake inhibitors
Treatment of Major Depressive Disorder (MDD)
Inhibits neuronal reuptake of norepinephrine and serotonin in the CNS (SNRI).
Decrease in depressive symptomatology, with fewer relapses/recurrences
Absorption: Well absorbed (92%) following oral administration
Distribution: Widely distributed
Metabolism and Excretion: 58% eliminated unchanged in urine; 42% metabolized, primarily by the CYP3A4 enzyme system; metabolites are renally eliminated
Half-life: 12 hr
|PO||Unk||6–8 hr (blood level)||Unk|
Contraindicated in: Hypersensitivity to levomilnacipran or milnacipranUncontrolled narrow-angle glaucomaConcurrent use of or in close temporal proximity to MAO inhibitors, linezolid or methylene blue (risk of serotonin syndrome)Concurrent use of alcohol
Use Cautiously in: History of hypertension, cardiovascular or cerebrovascular disease (blood pressure should be controlled prior to treatment)History of bipolar disorder (may activate mania/hypomania)Renal impairment (dosage reduction required for CCr< 60 mL/min) Geriatric: Consider age-related ↓ in renal function, chronic disease state and concurrent drug therapy; may have ↑ risk of hyponatremia; Obstetric: Use only if clearly required during pregnancy weighing benefit to mother versus potential harm to fetus; Lactation: Potential for serious adverse reactions in infant; discontinue drug or discontinue breast feeding; Pediatric: ↑ risk of suicidal thinking and behavior (suicidality) in adolescents and young adults up to 24 yrs with MDD
Exercise Extreme Caution in: Concurrent use with other serotonergic drugs (↑ risk of serotonin syndrome especially during initiation and dose adjustment).
Adverse Reactions/Side Effects
Central nervous system
- activation of mania/hypomania
Ear, Eye, Nose, Throat
- nausea (most frequent)
- ↓ appetite
- ejaculation disorder
- erectile dysfunction
- testicular pain
- urinary hesitation/retention
- hot flush
Fluid and Electrolyte
- hyponatremia (in association with syndrome of inappropriate antidiuretic hormone [SIADH])
- serotonin syndrome (life-threatening)
Drug-Drug interactionConcurrent use with MAO inhibitors used for psychiatric disorders may result in serious, potentially fatal reactions; wait at least 14 days following discontinuation of MAO inhibitor before initiation of levomilnacipran. Wait at least 7 days after discontinuing levomilnacipran before initiation of MAO inhibitorConcurrent use of serotonergic drugs (including triptans, lithium, buspirone, fentanyl, tricyclics and tramadol ) may ↑ the risk of serotinin syndrome, especially during initiation and dose adjustment; also ↑ risk of coronary vasoconstriction and hypertension.Concurrent use with methylene blue or linezolid is contraindicated due to risk of serotonin syndromeConcurrent use of NSAIDs, aspirin, warfarin or otherdrugs that affect coagulation may ↑ the risk of bleeding.Blood levels and risk of toxicity ↑ by concurrent use of CYP3A4 inhitors including ketoconazole, clarithromycin, ritonavir ; daily dose should not exceed 80 mgConcurrent use of other medications that may ↑ blood pressure may ↑ risk of hypertensionConcurrent use with alcohol may cause a rapid release of drug and should be avoidedConcurrent use with other CNS-active medications, especially other NSRIs Concurrent use with St. John's wort or tryptophan may ↑ the risk of serotinin syndrome; also ↑ risk of coronary vasoconstriction and hypertension.
Oral (Adults) 20 mg once daily for two days, then increase to 40 mg once daily, may then be increased by 40 mg every two or more days; may be increased up to 120 mg/day; concurrent use of CYP3A4 inhibitors (including ketoconazole, clarithromycin, ritonavir)—not to exceed 80 mg/day.
Renal ImpairmentOral (Adults) CCr 30–59 mL/minnot to exceed 80 mg/day; CCr 15–29 mL/minnot to exceed 40 mg/day
Extended-release capsules: 20 mg, 40 mg, 80 mg, 120 mg
- Monitor blood pressure and heart rate before and periodically during therapy. Treat per-existing hypertension and cardiac disease prior to therapy. Sustained hypertension may require discontinuation of therapy.
- Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression.
- Lab Test Considerations: May cause hyponatremia.
Potential Nursing DiagnosesIneffective coping (Indications)
Risk for suicide (Adverse Reactions)
- Oral: Administer daily without regard to food. Swallow capsule whole; do not open, crush, or chew.
- Instruct patient to take levomilnacipran as directed at the same time each day. Take missed doses as soon as possible unless time for next dose; do not double dose. Do not stop abruptly; must be decreased gradually. Abrupt discontinuation may cause dysphoric mood, irritability, agitation, dizziness, paresthesia, electric shock sensation, anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania, tinnitus and seizures. Advise patient to read Medication Guide prior to therapy and with each Rx refill in case of changes.
- May cause drowsiness and may affect ability to make decisions or react quickly. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
- Advise patient, family, and caregivers to look for activation of mania/hypomania and suicidality, especially during early therapy or dose changes. Notify health care professional immediately if thoughts about suicide or dying, attempts to commit suicide; new or worse depression or anxiety; agitation or restlessness; panic attacks; insomnia; new or worse irritability; aggressiveness; acting on dangerous impulses, mania, or other changes in mood or behavior or if symptoms of serotonin syndrome occur.
- Caution patient of the risk or serotonin syndrome (agitation, hallucinations, changes in mental status, muscle twitching, fast heartbeat, high or low blood pressure, sweating or fever, nausea or vomiting, diarrhea, muscle stiffness or tightness), especially when taking triptans, tramadol, tryptophan supplements and other serotonergic or antipsychotic agents.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to avoid concurrent use of Rx, OTC, and herbal products, especially NSAIDs, aspirin, and warfarin, without consulting health care professional; may increase bleeding.
- Instruct patient to notify health care professional if signs of hyponatremia (headache, difficulty concentrating, memory impairment, confusion, weakness, unsteadiness) occur.
- Advise patient to avoid taking alcohol during levomilnacipran therapy.
- Instruct patient to notify health care professional if pregnancy is planned or suspected or if breast feeding.
- Encourage patient to maintain routine follow-up visits with health care provider to determine effectiveness.
- Increased sense of well-being
- Renewed interest in surroundings. Need for therapy should be periodically reassessed.