Venlafaxine ER Dosing
Start venlafaxine ER at 37.5 mg once or twice daily, increase by 75 mg weekly to a target of 150-225 mg/day, with a maximum of 375 mg/day if needed for severe depression. 1
Starting Dose
- Begin at 37.5 mg once or twice daily 1
- The FDA-approved immediate-release formulation starts at 75 mg/day in divided doses, but extended-release allows for lower initial dosing 2
- Lower starting doses (37.5 mg) reduce initial nausea, the most common side effect 3
Titration Schedule
- Increase by 75 mg each week as tolerated 1
- Allow minimum 4-day intervals between dose increases 2
- Titration to therapeutic effect typically requires 2-4 weeks 1
Target Therapeutic Dose
- 150-225 mg/day is the efficacious range for most indications including neuropathic pain and depression 1
- For major depression, 75-225 mg/day demonstrates significant efficacy over placebo 3
- The majority of patients respond adequately to doses ≤225 mg/day 4
Maximum Dose
- Maximum 225 mg/day for routine outpatient depression 1
- Up to 375 mg/day may be used in severely depressed inpatients or treatment-resistant cases 2, 4
- Higher doses (>300 mg/day) show additional benefit in severely ill patients but carry increased risk of dose-dependent blood pressure elevation 4, 5
Duration of Adequate Trial
- Allow 4-6 weeks at target dose to assess response 1
- Some patients show early response by week 1-2, particularly at higher doses 5
Special Population Adjustments
Hepatic Impairment
- Reduce total daily dose by 50% in mild to moderate hepatic impairment 2
- Individual variability may require greater reduction; monitor closely 2
Renal Impairment
Elderly Patients
- No specific dose adjustment required based on age alone 2
- Use caution with dose escalation; consider lower starting doses and slower titration 1
Critical Safety Considerations
Cardiovascular Monitoring
- Monitor blood pressure at doses >150 mg/day 1
- Dose-dependent hypertension occurs in 3-5% at ≤200 mg/day, 7% at 201-300 mg/day, and 13% at >300 mg/day 5
- Use with caution in cardiac disease due to reports of cardiac conduction abnormalities 1
Discontinuation
- Always taper gradually when stopping; never discontinue abruptly 1, 2
- Withdrawal syndrome is well-documented with venlafaxine 1
- If intolerable symptoms occur during taper, resume previous dose and decrease more gradually 2
MAOI Interactions
- Wait 14 days after stopping MAOI before starting venlafaxine 2
- Wait 7 days after stopping venlafaxine before starting MAOI 2
Common Pitfalls to Avoid
- Do not start at 75 mg in ER formulation—this increases nausea and early discontinuation; 37.5 mg is better tolerated 1, 3
- Do not increase doses faster than weekly intervals—this increases adverse effects without improving efficacy 1, 2
- Do not exceed 225 mg/day in outpatients without clear rationale—higher doses increase blood pressure risk without consistent additional benefit 1, 4, 5
- Do not forget to taper—abrupt discontinuation causes withdrawal syndrome 1