Can flupentixol and melitracen be stopped and propranolol started while continuing desvenlafaxine (50mg)?

Switching from Flupentixol/Melitracen to Propranolol while Continuing Desvenlafaxine

Yes, flupentixol and melitracen can be safely discontinued and propranolol started while continuing desvenlafaxine 50mg, but this transition should be done with appropriate monitoring for potential cardiovascular effects and withdrawal symptoms.

Understanding the Current Medications

• Flupentixol/melitracen (Deanxit) is a combination medication containing an antipsychotic (flupentixol) and a tricyclic antidepressant (melitracen) that has been associated with use disorders and is not approved in several countries 1
• Desvenlafaxine (50mg) is an SNRI antidepressant that will be continued in the regimen
• Propranolol is a non-selective beta-blocker commonly used for anxiety, hypertension, and other cardiovascular conditions 2

Considerations for Medication Transition

Discontinuing Flupentixol/Melitracen

• Abrupt discontinuation of flupentixol/melitracen may lead to withdrawal symptoms due to the tricyclic antidepressant component 1
• Consider a gradual taper over 1-2 weeks rather than abrupt discontinuation to minimize withdrawal effects 1
• Monitor for potential rebound anxiety or mood symptoms during the transition period 3

Starting Propranolol

• Baseline cardiovascular assessment is recommended before initiating propranolol 4
• Check for contraindications including:
  • Heart block (second or third degree)
  • Asthma or reactive airway disease
  • Decompensated heart failure
  • Hypotension
  • History of hypoglycemic episodes 2, 4
• Initial propranolol dosing typically ranges from 30-60 mg daily in divided doses or as a single dose with long-acting formulations 2
• Maximum maintenance dose is typically 40-160 mg daily in divided doses or as a single dose with long-acting formulations 2

Continuing Desvenlafaxine

• Desvenlafaxine 50mg can be safely continued during this transition 4
• No specific dose adjustments of desvenlafaxine are required when adding propranolol 4

Monitoring During Transition

• Monitor for potential adverse effects of propranolol including:
  • Hypotension
  • Bradycardia
  • Bronchospasm
  • Worsening heart failure 2
• Be alert for drug interactions, though significant interactions between propranolol and desvenlafaxine are not commonly reported 2
• Follow up within 2-4 weeks of starting propranolol to assess efficacy and tolerability 4

Implementation Plan

1. Begin gradual taper of flupentixol/melitracen over 1-2 weeks
2. Start propranolol at a low dose (e.g., 10-20 mg twice daily) after baseline cardiovascular assessment
3. Continue desvenlafaxine 50mg without interruption
4. Gradually increase propranolol dose as needed and tolerated
5. Monitor for withdrawal symptoms from flupentixol/melitracen and adverse effects from propranolol

Potential Pitfalls and Cautions

• Propranolol may mask symptoms of hypoglycemia in susceptible patients 2
• Abrupt discontinuation of propranolol should be avoided to prevent rebound hypertension or tachycardia 2
• Patients with underlying depression should be monitored closely as beta-blockers have been associated with depression in some cases 4
• Flupentixol/melitracen has been associated with use disorders, and patients may experience psychological dependence during discontinuation 1