From the Guidelines
Pristiq (desvenlafaxine) can be augmented with bupropion (Wellbutrin) at doses of 150-300 mg daily to enhance norepinephrine and dopamine activity, potentially reducing Pristiq-related sexual side effects, as supported by low-quality evidence from studies such as 1 and 1. When considering add-on medications to Pristiq for treating depression, several options are available, including:
- Bupropion (Wellbutrin) at 150-300 mg daily, which can enhance norepinephrine and dopamine activity while potentially reducing Pristiq-related sexual side effects, as shown in studies like 1 and 1.
- Aripiprazole (Abilify) at 2-15 mg daily or quetiapine (Seroquel) at 50-300 mg daily, which are atypical antipsychotics that can augment antidepressant effects, particularly for treatment-resistant depression.
- Mirtazapine (Remeron) at 15-45 mg nightly, which can improve sleep and appetite while providing additional antidepressant action through different mechanisms.
- Lithium (300-900 mg daily, maintaining blood levels of 0.4-0.8 mEq/L), which can enhance serotonergic function and has anti-suicidal properties.
- Thyroid supplementation with liothyronine (Cytomel) at 25-50 mcg daily, which may help even with normal thyroid function. These combinations should be initiated at low doses and titrated gradually while monitoring for side effects and drug interactions, as recommended by guidelines such as 1 and 1. The choice of augmentation strategy depends on specific symptoms (energy, sleep, anxiety), side effect profile, and previous treatment response, with regular follow-up essential to assess effectiveness and manage any emerging side effects, as emphasized in studies like 1 and 1.
From the Research
Potential Add-ons to Pristiq (Desvenlafaxine) for Treating Depression
- Atypical antipsychotics: Studies have shown that adding atypical antipsychotics to ongoing treatments with antidepressants, including desvenlafaxine, can be beneficial in ameliorating drug-resistant depression 2.
- Second-generation antidepressants: Current guidelines recommend augmentation with a second-generation antidepressant as a pharmacologic option for treatment-resistant depression 3.
- Lithium or triiodothyronine medication: These medications can also be used as augmentation for treatment-resistant depression 3.
- Ketamine and esketamine: These medications can be used as augmentation for treatment-resistant depression and may help reduce suicidal ideation 3.
- Psychotherapy: Adding psychotherapy to pharmacologic treatment can be an effective management strategy for treatment-resistant depression 3.
Considerations for Add-ons
- The choice of add-on therapy should be based on the individual patient's needs and medical history.
- The potential for drug-drug interactions should be considered when adding a new medication to desvenlafaxine 4.
- Hepatic impairment does not significantly alter dose requirements for desvenlafaxine, whereas severe renal disease requires some adjustments of dose 4.