Effexor (Venlafaxine) Dosing
Start venlafaxine at 75 mg/day divided into 2-3 doses with food, and increase by up to 75 mg every 4 days as needed, with most patients responding to 150-225 mg/day and a maximum dose of 375 mg/day for severe or treatment-resistant depression. 1
Initial Dosing
- Begin with 75 mg/day administered in two or three divided doses, taken with food 1
- This starting dose applies to standard immediate-release formulations 1
Dose Titration
- Increase the dose in increments of up to 75 mg/day at intervals of no less than 4 days based on tolerability and clinical response 1
- The dose may be increased to 150 mg/day, and if needed, further increased up to 225 mg/day 1
- For neuropathic pain specifically, allow 2-4 weeks to titrate to an efficacious dosage 2
Target Therapeutic Doses
- For moderately depressed outpatients: 150-225 mg/day is typically effective, with no evidence of additional benefit beyond 225 mg/day in this population 1
- For more severely depressed inpatients: higher doses up to 350-375 mg/day (mean 350 mg/day) may be necessary, generally administered in three divided doses 1
- For neuropathic pain: the efficacious range is 150-225 mg/day, with a minimum effective dose of 75 mg/day 2
Maximum Dose
- The maximum recommended dose is 375 mg/day 1
- High-dose venlafaxine (≥375 mg/day, up to 600 mg/day) has been used in clinical practice for treatment-resistant depression, though this exceeds standard recommendations 2, 3
Special Population Adjustments
Hepatic Impairment
- Reduce the total daily dose by 50% in patients with mild to moderate hepatic impairment 1
- Individual variability may require even greater dose reductions in some patients with cirrhosis 1
Renal Impairment
- Reduce the total daily dose by 25% in patients with mild to moderate renal impairment (GFR 10-70 mL/min) 1
- Reduce the total daily dose by 50% in patients undergoing hemodialysis 1
Elderly Patients
- No specific dose adjustment is required based on age alone 1
- Exercise caution and use extra care when increasing doses in elderly patients 1
CYP2D6 Poor Metabolizers
- Consider switching to an alternative antidepressant rather than dose reduction, as poor metabolizers have significantly reduced clearance and higher risk of adverse effects 2
Important Safety Monitoring
- Monitor blood pressure, particularly at higher doses (>200 mg/day), as venlafaxine can cause modest increases in blood pressure 2
- Blood pressure elevation occurred in 3-5% of patients receiving ≤200 mg/day, 7% receiving 201-300 mg/day, and 13% receiving >300 mg/day 4
- Exercise caution in patients with cardiac disease due to rare reports of cardiac conduction abnormalities 2
Discontinuation Protocol
- Taper venlafaxine gradually over 10-14 days rather than stopping abruptly to minimize withdrawal symptoms 2
- If intolerable symptoms occur during tapering, resume the previous dose and decrease more gradually 1
- A withdrawal syndrome can occur with abrupt discontinuation 2
MAOI Interactions
- Allow at least 14 days between discontinuing an MAOI and starting venlafaxine 1
- Allow at least 7 days after stopping venlafaxine before starting an MAOI 1
Common Pitfalls to Avoid
- Avoid increasing doses too rapidly (respect the minimum 4-day interval between increases) 1
- Don't overlook blood pressure monitoring, especially when using doses above 200 mg/day 2, 4
- Don't abruptly discontinue—always taper to prevent withdrawal syndrome 2
- In patients with hepatic or renal impairment, failure to reduce the dose appropriately increases risk of adverse effects 1