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  • 1.SELECTIVE SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS Dr. Soumya Nath Maiti IMO Chairperson Dr. F.A Sattar, Department of Psychiatry, VIMS n RC

2. Overview Introduction Venlafaxine Pharmacological Actions Therapeutic Indications Precautions and Adverse Reactions Dosage and Administration Duloxetine Pharmacological Actions Therapeutic Indications Precautions and Adverse Reactions Dosage and Administration 3. Introduction Venlafaxine and duloxetine are selective serotonin norepinephrine reuptake inhibitors (SNRIs). Venlafaxine and duloxetine are not unique with respect to their dual action.Tricyclic and tetracyclic antidepressants (TCAs) also inhibit reuptake of norepinephrine and serotonin.TCAs, however, also possess numerous other receptor properties, such as muscarinic, adrenergic, and histaminergic effects, and thus are not considered selective. 4. Venlafaxine Pharmacological Actions Venlafaxine is well absorbed from the gastrointestinal (GI) tract.The extended-release formulation reach peak plasma concentrations in 5.5 hours to 9 hours. Venlafaxine has a half-life of about 3.5 hours, It is metabolized by hepatic cytochrome P450. Venlafaxine is a potent inhibitor of serotonin and norepinephrine reuptake and a weak inhibitor of dopamine reuptake. It does not have activity at muscarinic, nicotinic, histaminergic, opioid, or adrenergic receptors. 5. Therapeutic Indications Depression US Food and Drug Administration (FDA) does not recognize any class of antidepressant as being more effective than any other.This does not mean that differences do not exist. There is some evidence to suggest that venlafaxine has a potential to induce higher rates of remission in depressed patients.This difference of the venlafaxine advantage is about 6 percent. 6. Generalized Anxiety Disorder The extended-release formulation of venlafaxine is approved for treatment of generalized anxiety disorder. In clinical trials lasting 6 months, dosages of 75 to 225 mg a day were effective against insomnia, poor concentration, restlessness, irritability, and excessive muscle tension related to generalized anxiety disorder. 7. Social Anxiety Disorder The extended-release formulation of venlafaxine is approved for treatment of social anxiety disorder. Panic Disorder The extended-release formulation of venlafaxine is also approved for treatment of panic disorder. 8. Other Indications Case reports and uncontrolled studies have indicated that venlafaxine may be beneficial in the treatment of obsessive-compulsive disorder, agoraphobia, attention-deficit/hyperactivity disorder (ADHD), and in patients with a dual diagnosis of depression and cocaine dependence 9. Precautions and Adverse Reactions Most common adverse reactions- Nausea, somnolence, dry mouth, dizziness, nervousness, constipation, asthenia, anorexia, blurred vision, abnormal ejaculation or orgasm, erectile disturbances, and impotence. Sweating is also more common with venlafaxine than the SSRIs Abrupt discontinuation of venlafaxine use can produce a discontinuation syndrome consisting of dizziness, anxiety, nausea, somnolence, paresthesias, and insomnia.Therefore, venlafaxine use should be tapered gradually over 2 to 4 weeks. 10. Hyperetnsion -Venlafaxine can cause an increase in blood pressure (BP) in some persons Mydriasis -Venlafaxine can cause mydriasis, so patients with raised intraocular pressure or those at risk for acute narrow-angle glaucoma should be monitored during venlafaxine treatment. Hepatic Cirrhosis - The pharmacokinetic dispositions of venlafaxine are altered in patients with hepatic cirrhosis.Venlafaxine elimination half-life is prolonged by about 30 percent and clearance decreased by about 50 percent Dosage adjustment, thus, is necessary in patients with liver disease. 11. Dosage and Administration Venlafaxine is available in 25-, 37.5-, 50-, 75-, and 100-mg tablets and 37.5-, 75-, and 150- mg extended-release capsules. The tablets and the extended-release capsules are equally potent, and persons stabilized with one can switch to an equivalent dosage of the other. 12. In depressed persons,The initial therapeutic dosage is 75 mg a day, given once a day. Most persons, however, are started at a dosage of 37.5 mg for 4 to 7 days to minimize adverse effects, particularly nausea. The dosage can be raised to 150 mg per day after day 4. As a rule, the dosage can be raised in increments of 75 mg a day every 4 or more days. It is approved by the FDA for use at dosages up to 375 mg a day. The dosage of venlafaxine should be halved in persons with significantly diminished hepatic or renal function. If discontinued, venlafaxine use should be gradually tapered over 2 to 4 weeks to avoid withdrawal symptoms.. 13. Duloxetine PharmacologicalActions Duloxetine is formulated as a delayed-release capsule to reduce the risk of severe nausea associated with the drug. It is well absorbed, but a 2-hour delay occurs before absorption begins. Peak plasma concentrations occur 6 hours after ingestion. Food delays the time to achieve maximal concentrations from 6 to 10 hours and reduces the extent of absorption by about 10 percent. Duloxetine has an elimination half-life of about 12 hours. Elimination is mainly through the isozymes CYP 2D6 and CYP 1A2. About 70 percent of the drug appears in the urine as metabolites and about 20 percent is excreted in the faeces. 14. Therapeutic Indications Depression and Generalized Anxiety Disorder (GAD) - In contrast to venlafaxine, a small number of studies have compared duloxetine with SSRIs in depression.These studies are suggestive of some advantage in efficacy with duloxetine. In GAD higher doses are also used with good results. 15. Neuropathic Pain Associated with Diabetes and Stress Urinary Incontinence Duloxetine is the first drug to be approved by the FDA as a treatment for neuropathic pain associated with diabetes.The drug has been studied for its effects on physical symptoms, including pain, in depressed patients. Duloxetine is currently awaiting approval as a treatment for stress urinary incontinence, The action of duloxetine in the treatment of stress urinary incontinence is associated with its effects in the sacral spinal cord, which in turn increase the activity of the striated urethral sphincter. 16. While duloxetine is approved for the treatment of diabetic peripheral neuropathic pain, it may worsen control of blood sugar levels. Pooled data from clinical trials show that short-term treatment with duloxetine causes an increase in fasting glucose and HA1c levels. Body weight decreased with short-term duloxetine treatment, but increased during long-term treatment. Modest increases in cholesterol may occur during duloxetine therapy. 17. Precautions and Adverse Reactions The most common adverse reactions Nausea, dry mouth, dizziness, constipation, fatigue, decreased appetite, anorexia, somnolence, and increased sweating. Nausea was the most common side effect leading to treatment discontinuation in clinical trials. Patients with substantial alcohol use should not be treated with duloxetine because of possible hepatic effects. It also should not be prescribed for patients with hepatic insufficiency, end-stage renal disease or for patients with uncontrolled narrow-angle glaucoma. Abrupt discontinuation of duloxetine should be avoided because it can produce a discontinuation syndrome similar to that of venlafaxine. 18. Dosage and Administration Duloxetine is available in 20-, 30-, and 60-mg tablets.The recommended therapeutic, and maximal, dosage is 60 mg per day.The 20- and 30-mg doses are useful for either initial therapy or for twice-daily use as strategies to reduce side effects. Difficulties in tolerability were seen, however, with single doses above 60 mg. Accordingly, when dosages of 80 and 120 mg per day were used, they were administered as 40 or 60 mg twice daily. 19. Summary Originally marketed as an antidepressant, venlafaxine is now also indicated for the treatment of generalized anxiety and social anxiety disorders. Duloxetine is indicated for the treatment of depression, generalized anxiety disorder, and painful diabetic neuropathy and is awaiting the indication for stress urinary incontinence 20. References Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition by Sadock, Benjamin James; Sadock, Virginia Alcott p 1081- 1083 21. Thank You