Venlafaxine Titration Schedule
Start venlafaxine at 75 mg/day divided into two or three doses with food, then increase by up to 75 mg/day at intervals of no less than 4 days, targeting 150-225 mg/day for most patients with major depression. 1
Initial Dosing
- Begin at 75 mg/day in divided doses (2-3 times daily) taken with food 1
- This starting dose balances efficacy with tolerability, as lower initial doses reduce early discontinuation from side effects 2
Titration Schedule
- Increase in increments of up to 75 mg/day at intervals of no less than 4 days 1
- The typical progression is: 75 mg/day → 150 mg/day → 225 mg/day 1
- For neuropathic pain specifically, allow 2-4 weeks to reach efficacious dosing (150-225 mg/day range) 3
Target Dosing by Indication
Major Depression (Outpatients)
- Target dose: 150-225 mg/day 1
- No evidence of additional benefit beyond 225 mg/day in moderately depressed outpatients 1
- Early response may be evident by week 1-2, particularly at higher doses within this range 2, 4
Severe Depression (Inpatients)
- May require 225-375 mg/day 1
- More severely depressed inpatients responded to a mean dose of 350 mg/day 1
- Maximum dose is 375 mg/day, generally divided into three doses 1
Treatment-Resistant Depression
- Consider doses up to 375-600 mg/day 5, 6
- Mean effective dose in treatment-resistant patients was 260 mg/day, with 58% achieving response 5
- High doses (375-600 mg/day) are tolerated, though side effects increase in frequency and severity 6
Critical Monitoring During Titration
Blood Pressure Surveillance
- Monitor blood pressure at each dose increase, especially above 200 mg/day 3, 2
- Dose-dependent hypertension occurs in 3-5% at ≤200 mg/day, 7% at 201-300 mg/day, and 13% at >300 mg/day 2
- Modest blood pressure increases are more common at higher doses 3
Cardiac Monitoring
- Exercise caution in patients with cardiac disease due to rare cardiac conduction abnormalities 3
Special Population Adjustments
Hepatic Impairment
- Reduce total daily dose by 50% in mild to moderate hepatic impairment 1
- Individual variability is high; some patients may require >50% reduction 1
Renal Impairment
- Reduce total daily dose by 25% for GFR 10-70 mL/min 1
- Reduce total daily dose by 50% for patients on hemodialysis 1
CYP2D6 Poor Metabolizers
- Consider switching to an alternative antidepressant rather than dose reduction 3
- These patients have significantly reduced clearance and higher adverse effect risk 3
Elderly Patients
- No specific dose adjustment required based on age alone 1
- Exercise extra caution when increasing doses in elderly patients 1
Common Pitfalls to Avoid
- Do not increase doses faster than every 4 days to allow assessment of tolerability 1
- Do not abruptly discontinue—taper over 10-14 days to prevent withdrawal syndrome 3, 7
- Do not ignore nausea in the first 1-3 weeks—this is the most common early side effect but typically resolves rapidly 2, 4
- Do not exceed 225 mg/day in outpatients without clear rationale for treatment resistance or severe depression 1