What is the recommended dosing for Venlafaxine (Effexor) Extended Release (ER)?

Venlafaxine ER Dosing Recommendations

The recommended starting dose for Venlafaxine ER is 75 mg once daily, with a target therapeutic dose range of 150-225 mg daily for most conditions. 1

Initial Dosing and Titration

• Starting dose: 75 mg once daily (extended release formulation) 1
• Titration: Increase by 75 mg increments at intervals of no less than 4 days 1
• Target therapeutic dose:
  • 150-225 mg daily for most patients 1, 2
  • Higher doses (up to 375 mg daily) may be needed for more severely depressed patients 1

Condition-Specific Dosing

Depression

• Start with 75 mg daily
• Increase to 150-225 mg daily based on response 1
• Maximum dose: 375 mg daily 1

Neuropathic Pain

• Starting dose: 37.5-50 mg once or twice daily 2
• Target dose: 150-225 mg daily 2, 3
• Efficacy for pain management is typically seen at 150-225 mg daily 3

Special Populations

Hepatic Impairment

• Reduce total daily dose by 50% in patients with mild to moderate hepatic impairment 1
• Further dose reduction may be necessary in patients with cirrhosis 1
• Individualize dosing due to variable clearance in these patients 1

Renal Impairment

• Reduce total daily dose by 25% in patients with mild to moderate renal impairment (GFR 30-70 mL/min) 1
• Reduce total daily dose by 50% in patients undergoing hemodialysis 1

Elderly Patients

• No specific dose adjustment based on age alone, but use caution when increasing the dose 1
• Consider starting at lower doses and titrating more slowly 1

Administration Guidelines

• Take with food to improve tolerability 1
• Extended-release formulation should be taken once daily 4
• Do not crush, chew, or split extended-release capsules

Efficacy Considerations

• Therapeutic response may be seen as early as 1-2 weeks 5, 4
• Once-daily venlafaxine XR has shown superior efficacy compared to twice-daily immediate-release formulation at week 12 in clinical trials 4
• Higher doses (>150 mg/day) may be more effective in severely depressed patients 6

Discontinuation

• Gradual tapering is recommended rather than abrupt cessation to minimize discontinuation symptoms 1
• If intolerable symptoms occur during discontinuation, consider resuming the previously prescribed dose and decrease more gradually 1

Monitoring and Safety

• Monitor blood pressure regularly, especially at doses above 150 mg daily, as venlafaxine can increase blood pressure 3
• Be cautious in patients with cardiac disease due to potential for cardiac conduction abnormalities 2
• Avoid in combination with MAOIs (allow 14 days between stopping an MAOI and starting venlafaxine, and 7 days between stopping venlafaxine and starting an MAOI) 1

Common Side Effects

• Nausea (highest during first 2 weeks of treatment) 4
• Dizziness, somnolence, insomnia 5
• Dry mouth 5
• Sexual dysfunction 5
• Sweating 5

Venlafaxine ER's unique dual mechanism of action (inhibiting both serotonin and norepinephrine reuptake) becomes more pronounced at higher doses, with norepinephrine effects becoming more clinically relevant at doses above 150 mg daily 7. This dose-dependent mechanism allows for tailored treatment based on individual patient needs and symptom profiles.