February 1, 2023

This medication is a Serotonin and norepinephrine reuptake inhibitor or SNRI. In the case of depression most patients will be started on a serotonin reuptake inhibitor SRI first, if they fail a trial on an SRI the next step may be to try a medication like venlafaxine for its dual action boosting both serotonin and norepinephrine.

What’s up everybody dr rossi shrinks and sneakers.com so i’ve received a lot of requests to cover some of these other medications that are commonly prescribed and i want to start today off with talking about venal vaccine specifically and not in the context nexus necessarily of combining it with murtazapine so let’s talk mental faxing and some of the interesting

Points about this medication and specifically one thing we’re going to cover here is how to stop this medication which is a difficult situation for a lot of patients so this medication is as you might expect a serotonin norepinephrine reuptake inhibitor okay now when we treat depression and we’ll use depression sort of as as our model here we think about

Treatment in a stepwise progression so a lot of times if you present to your primary care doctor or you present to a psychiatrist with depression they’re going to start you on a medication most likely a selective serotonin or serotonin reuptake inhibitor the so the starting point is going to be just a regular old serotonin reuptake inhibitor this would be things

Like escitalopram or lexapro citalopram this could be something like fluoxetine right those kind of medications are usually the starting point now if you titrate up on this medication and you don’t get enough of a response and you don’t get remission of symptoms with this medication you may for adult population you may consider switching to another serotonin

Reuptake inhibitor medication so say switching from lexico lexapro to uh prozac that is one option but in some cases we might just forego that step and say okay for an adult we’re going to go to a serotonin norepinephrine reuptake inhibitor like venol vaccine so this is sort of a step up from your in in your depression treatment algorithm now mental vaccine is

Approved for a lot of different things actually so it’s fda approved for depression of course like we would have expected it’s also fda approved for generalized anxiety disorder it’s fda approved for social anxiety disorder panic disorder separation anxiety disorder and if you’ve ever worked in the veterans administration or the va then you would know that they

Also use this commonly for ptsd or post-traumatic stress disorder so a lot of different things that this medication could potentially treat now the mechanism of action like i said is similar to what we’ve seen in the discussion on cymbalta or duloxetine it’s very similar we’re going to be blocking the serotonin reuptake pump as well as blocking the norepinephrine

Reuptake pump and this has that same effect of increasing dopamine in the prefrontal cortex or in the frontal cortex because again that dopamine is deactivated or removed by the norepinephrine uh reuptake pump so when you block that you get increased dopamine in the frontal cortex as well if you want more details on that i covered it in the cybalta video so the

Mechanism of action is quite similar now the dosing and the dosing is is a little complicated kind of weird numbers so we usually start with 37.5 milligrams of extended release or we’ll start with 50 milligrams of immediate release in two divided doses so we’ll divide that into two doses or twice daily dosing for the first week now you can increase by 75 milligrams

Every four days until the desired response is achieved and there’s an fda approved maximum dose of 375 milligrams per day so that’s the top end of this medication now this medication is marketed as a serotonin norepinephrine reuptake inhibitor however what we find with this medication is that often the norepinephrine effect does not start to kick in until you

Get to doses of 225 milligrams or better so if a patient’s not having a good response on say you know 150 milligrams or 100 milligrams whatever the case is that you’re working with then you want to consider continuing the titration until you’ve reached the dose of 225 or better to see whether or not gaining that extra efficacy at the higher dose helps with the

Depression so you may need to target norepinephrine at higher doses for some patients with this medication that’s one of the challenges so again it’s marketed as an snri it really doesn’t have that effect until you get to higher doses now there is an active metabolite and this active metabolite is called o des methyl venal vaccine so the liver metabolizes the drug

And then you get this oh des methylmental vaccine metabolite which is also active and you can actually follow the plasma levels so if you do blood draw and you follow the plasma levels you can see whether or not number one the person’s taking the medication regularly but you can also see whether or not the person is metabolizing the medication rapidly so in some

Cases patients metabolize medication more rapidly than others and what you will find is a low level of this metabolite in their c in their plasma now if the level is low you can consider going to doses above 375 milligrams some people have even used what we call in psychiatry heroic doses of 600 milligrams per day of of this medication so it can get pretty high

Depending on the circumstances now i promised i would talk a little bit about stopping this medication because this is a big question and a lot of people have difficulty stopping this medication so what do you do what you need to do is you need to do what’s called a prolonged taper it’s best if you have a psychiatrist to do this taper with you because it’s kind

Of difficult to achieve on your own or with a primary care doctor you really need someone with a little bit more of an expert knowledge in how to stop this medication to do it effectively and to do it safely but with that said i’ll tell you what what is one of the methods or actually two of the methods you could potentially use to stop this medication that will

Make the withdrawal symptoms less of a problem so the starting point i would say is you want to switch if you’re on the extended release to the immediate release tablets and the reason i’m saying this is because you can crush the immediate release tablets and suspend them in something like juice say some type of fruit juice let’s say apple juice and what you’re

Going to do is you’re going to suspend those that medication those crushed tablets in a hundred milliliters of juice so you’re going to measure this out it’s a little complicated takes a lot a little bit of work on the patient’s part for sure so this can be difficult so you’re going to suspend those crushed tablets in 100 milliliters of juice and what you’re

Going to do is you’re going to remove one milliliter of juice from that mixture and drink the rest so you’re going to drink up the crushed tablets suspended in the juice and you’re going to and before you do that you’re going to remove one milliliter in three to seven days you’re gonna then remove two milliliters and drink the rest right so this is a very very

Slow taper over time what you’re doing is removing a small amount of this mixture every time you go down so it’ll be three milliliters the next time four milliliters the next time right etc etc all the way down and this is th this is a good method for someone who’s really prone to those withdrawal symptoms or who’s having it difficult who has tried to um come

Off the medication and has dif has had difficulty or withdrawal symptoms that were significant enough to impair their function so you’re going to want to do this very very slowly so that’s one method another potential way you could stop this medication would be to add a medication first and then start the taper so the reason we add this medication is because it

Has the longest half-life of the antidepressant medications and what a long half-life is going to do for you in this case is it’s going to provide you with sustained blood levels over a period of time as you’re tapering down so it’s going to help to again ward off some of those withdrawal symptoms so what you do is you add the medication fluoxetine also known

As prozac to this medication regiment before tapering the venal vaccine so you add the fluoxetine in and then you begin a slow taper of the metal vaccine while keeping the fluoxetine in place and then after the patient’s been tapered off of ventil vaccine you can then taper the fluoxetine off as well so that’s another method converting to a long acting or a

Long half-life medication and then tapering from there things to be mindful of you definitely want to monitor blood pressure before starting the medication and of course during the treatment because this medication has been known to increase blood pressure specifically when we’re talking about doses above 225 milligrams so you can see some of the complications

Here side effects increase as we go with higher doses but higher doses also provide us more of that norepinephrine effect that may in improve a patient’s depression who has not responded to a serotonin-based drug now in the uk they actually have data indicating that this medication in overdoses is more fatal than serotonin reuptake inhibitors now the data is a

Little complicated it’s unclear but in the uk they’ve chosen really not to prescribe this medication very often for that reason and also for the reason that it has significant cardiac effects and you want to be mindful and anyone who has hypertension or pre-existing cardiovascular disease so this medication has kind of fallen out of favor in the uk i’m going to

Talk about the common side effects especially ones that are over 10 so some of those side effects include things like insomnia sleepiness or sedation during the day dizziness nausea decreased appetite in some cases weight loss dry mouth sexual dysfunctions increased sweating which i had a great question from somebody about that i answered in one of the one of the

Comments sections nervousness increased blood pressure and then the rare side effects which are definitely less than 10 percent are going to be things like seizure hyponatremia which is low sodium and activation of suicidal ideation in patients under the age of 24. so we’re talking about some some significant side effects um but that are very common and kind of

Seen in many of the other medications we’ve discussed in the past now of course like other medications the antidepressant effects are going to take two to four weeks to occur if it’s not working by six to eight weeks you want to consider changing this medication for anxiety though this is the one caveat to that point is that for anxiety disorders sometimes the

Symptoms will resolve after eight weeks and even up to six months into the treatment so for anxiety disorders you want to keep the patient on the medication a little bit longer to make sure that you’re getting the full benefit and to make sure that you’re not prematurely switching to another medication or stopping the medication so i want to wrap this video with

A couple of clinical points the first one being that this medication can be effective for people who have failed treatment with a serotonin reuptake inhibitor so if they fail treatment with lexapro this may be a medication that could help that patient again because we’re targeting a different neurotransmitter system it can be combined as i’ve talked about in

Previous videos to form california rocket fuel if you combine it with mertazapine it’s also commonly commonly combined with bupropion which is a dopamine norepinephrine reuptake inhibitor that can enhance all three of those neurotransmitters in this case the xr version or extended release formulation is preferred because it increases tolerability it reduces side

Effects and also can allow for once daily dosing which is more convenient for most of my patients it may be effective for other psychiatric disorders some of those being things like adhd there is some evidence of support in adhd and it also may have some evidence to support its use in pain syndromes things like neuropathy and fibromyalgia wow so that’s a lot of

Information about venom vaccine it’s a solid medication but it is falling out of favor now i i prefer to stay away from it if possible and use alternative medications that achieve a similar effect on the norepinephrine system if that’s what you’re going for however it’s still widely used it’s widely available you will come across patients on it on a regular basis

So please drop any comments in the comment section below any questions you have anything that i didn’t cover in this video that you want to see covered we’ll answer those things below and please like and subscribe to the channel so we can keep making videos about this medication

Transcribed from video
Most Commonly Prescribed Psychiatric Medications: Venlafaxine or Effexor By Shrinks In Sneakers