What is the recommended titration schedule for Luvox (fluvoxamine)?

Luvox (Fluvoxamine) Titration

For adults with OCD or depression, start fluvoxamine at 50 mg once daily at bedtime, then increase by 50 mg every 4-7 days as tolerated up to a target dose of 100-150 mg/day, with a maximum of 300 mg/day divided into two doses if exceeding 100 mg/day. 1

Adult Dosing Schedule

Initial dose: 50 mg once daily at bedtime 1

Titration strategy:

• Increase by 50 mg increments every 4-7 days as tolerated 1
• Target therapeutic dose: 100-150 mg/day for optimal response 2
• Maximum dose: 300 mg/day 1

Dose division:

• Doses ≤100 mg/day: Give as single bedtime dose 1
• Doses >100 mg/day: Split into two divided doses, with the larger dose at bedtime 1

The evidence strongly supports higher dosing for better outcomes. A retrospective analysis found 73.7% improvement with 100-150 mg/day versus only 47.1% improvement with 50-75 mg/day, showing statistically significant superiority of higher doses 2. This supports aggressive titration to at least 100 mg/day rather than remaining at lower doses.

Pediatric Dosing (Ages 8-17)

Initial dose: 25 mg once daily at bedtime 1

Titration strategy:

• Increase by 25 mg increments every 4-7 days as tolerated 1, 3
• Children (ages 8-11): Maximum 200 mg/day 1, 4
• Adolescents (ages 12-17): Maximum 300 mg/day 1, 4

Dose division:

• Doses ≤50 mg/day: Give as single bedtime dose 1
• Doses >50 mg/day: Split into two divided doses, with larger dose at bedtime 1

Important consideration: Female children may achieve therapeutic effect at lower doses than males 1. Steady-state plasma concentrations are 2-3 times higher in children aged 6-11 compared to adolescents, justifying the lower maximum dose 3, 4.

Special Populations

Elderly or hepatically impaired patients: Use lower initial doses and slower titration due to decreased clearance 1, 5. The terminal elimination half-life is prolonged by 30-50% at steady-state and further extended in hepatic cirrhosis 5.

Renal impairment: No dosage adjustment necessary, as pharmacokinetics are substantially unaltered 5

Timeline to Response

Expected response timeline:

• Steady-state concentrations: Achieved within 5-10 days 5
• Initial therapeutic response: May begin within 2-4 weeks
• Optimal response assessment: 6 weeks at therapeutic dose 2

More than 80% of responders show improvement by 6 weeks of treatment 2. If no improvement occurs after 6 weeks at adequate doses (≥100 mg/day), the treatment regimen should be altered 2.

Discontinuation

When discontinuing: Gradual dose reduction is recommended rather than abrupt cessation to minimize withdrawal symptoms 1. For pregnant women in the third trimester, consider tapering to reduce neonatal complications 1.

Common Pitfalls to Avoid

• Underdosing: Remaining at 50 mg/day is inadequate for most patients; titrate to at least 100 mg/day 2
• Premature discontinuation: Allow full 6-week trial at therapeutic dose before declaring treatment failure 2
• Ignoring drug interactions: Fluvoxamine potently inhibits CYP1A2 and moderately inhibits CYP2C19 and CYP3A4, requiring dose adjustments of concomitant medications like theophylline, warfarin, tricyclic antidepressants, and benzodiazepines 5, 6
• Single daily dosing at high doses: Doses >100 mg/day should be divided to improve tolerability 1