What is the recommended treatment and dosage for obsessive-compulsive disorder (OCD) using Fluvoxamine (Luvox)?

Fluvoxamine for Obsessive-Compulsive Disorder

Fluvoxamine is a first-line SSRI for OCD treatment, with an effective dose range of 100-300 mg/day in adults, requiring 8-12 weeks at maximum tolerated dose to assess efficacy. 1, 2

Initial Dosing and Titration

Adults:

• Start at 50 mg once daily at bedtime 2
• Increase in 50 mg increments every 4-7 days as tolerated 2
• Maximum dose: 300 mg/day 2
• Doses above 100 mg/day should be split into two divided doses, with the larger dose given at bedtime 2

Pediatric Patients (ages 8-17):

• Start at 25 mg once daily at bedtime 2
• Increase in 25 mg increments every 4-7 days as tolerated 2
• Maximum dose for children up to age 11: 200 mg/day 2
• Maximum dose for adolescents: 300 mg/day 2
• Doses above 50 mg/day should be split into two divided doses, with the larger dose at bedtime 2
• Female children may achieve therapeutic effect at lower doses 2

Special Populations:

• Elderly and hepatically impaired patients require lower initial doses and slower titration due to decreased clearance 2

Treatment Duration and Response

• Allow 8-12 weeks at maximum tolerated dose to determine efficacy 1
• Significant improvement may be observed within the first 2 weeks, with greatest incremental gains occurring early in treatment 1
• Maintenance treatment should continue for a minimum of 12-24 months after achieving remission 1
• Many patients require longer treatment due to high relapse risk after discontinuation 1

Critical Drug Interactions

Fluvoxamine is a potent CYP1A2 inhibitor and moderate inhibitor of CYP2C19, CYP2C9, and CYP3A4, requiring careful attention to drug interactions. 3

• Contraindicated: Concomitant use with MAOIs due to serotonin syndrome risk 1
• Avoid: Alprazolam and triazolam due to significant interaction risk 3
• Caution with: Drugs metabolized by CYP1A2 (theophylline, caffeine, clozapine), CYP2C19, CYP2C9, and CYP3A4 1, 3

Adverse Effects and Monitoring

Common adverse effects (>10%):

• Nausea is the most common, occurring in >10% of patients 4

Less common adverse effects:

• Somnolence, asthenia, headache, dry mouth, insomnia, dizziness, sexual dysfunction 4
• Abdominal discomfort occurs more frequently with fluvoxamine than placebo 5

Serious adverse effects requiring monitoring:

• Serotonin syndrome (especially when combined with other serotonergic agents) 1
• Suicidal thinking or behavior 1
• Behavioral activation/agitation 1
• Seizures, hypomania, abnormal bleeding 1

Discontinuation Considerations

Fluvoxamine has been associated with discontinuation syndrome due to its shorter half-life compared to other SSRIs. 1, 3

• Symptoms include: dizziness, fatigue, myalgias, nausea, insomnia, sensory disturbances, anxiety, irritability 1
• Taper gradually rather than abrupt cessation 2
• If intolerable symptoms occur during taper, resume previous dose and decrease more gradually 2

Treatment-Resistant OCD

If inadequate response after 8-12 weeks at maximum tolerated dose:

• Combine with CBT (most effective augmentation strategy) 1
• Switch to another SSRI or clomipramine 1
• Consider augmentation with antipsychotics or glutamatergic agents 1
• Higher doses up to 600 mg/day have been reported in case reports for treatment-resistant OCD, though this exceeds FDA-approved maximum 6

Clinical Positioning

Fluvoxamine is equivalent in efficacy to other SSRIs for OCD, with effect sizes similar across all SSRIs. 1

• Comparable efficacy to clomipramine but better tolerability profile 1, 4
• Higher doses are required for OCD compared to depression or other anxiety disorders 1
• Higher doses are associated with greater efficacy but also increased adverse effects and dropout rates 1