Usual Dose of Venlafaxine
Start venlafaxine ER at 37.5 mg once or twice daily, increase by 75 mg weekly to reach the target therapeutic dose of 150-225 mg/day, with a maximum of 375 mg/day for severe or treatment-resistant depression. 1, 2, 3
Starting Dose and Initial Titration
- Begin with 37.5 mg once or twice daily for better tolerability, especially in patients sensitive to side effects 1, 2
- The FDA-approved immediate-release formulation starts at 75 mg/day divided into 2-3 doses with food, but the extended-release formulation allows for lower initial dosing 3
- Increase the dose by 75 mg increments every 4-7 days as tolerated 1, 3
Target Therapeutic Range
- The efficacious dose range is 150-225 mg/day for most indications including depression and neuropathic pain 1, 2
- This therapeutic range typically takes 2-4 weeks to reach with gradual titration 2
- At 75 mg/day, venlafaxine acts as a selective serotonin reuptake inhibitor only; dual serotonin-norepinephrine reuptake inhibition occurs at doses ≥150 mg/day 4
Maximum Dosing for Severe Depression
- The maximum dose is 225 mg/day for routine outpatient depression 1
- For more severely depressed patients or treatment-resistant cases, doses can be increased up to 375 mg/day (generally in three divided doses for immediate-release) 3, 5
- Inpatients with severe depression may respond to mean doses of 350 mg/day, with some requiring up to 375 mg/day 3
- Doses up to 600 mg/day have been studied and tolerated, though this exceeds standard recommendations 6
Critical Monitoring Requirements
- Monitor blood pressure at doses exceeding 150 mg/day due to dose-dependent hypertension risk 1, 2
- Blood pressure elevations occur in 3-5% of patients at ≤200 mg/day, 7% at 201-300 mg/day, and 13% at >300 mg/day 7
- Prescribe with caution in patients with pre-existing cardiac disease 1, 2
Common Pitfalls to Avoid
- Never discontinue venlafaxine abruptly—always taper gradually to prevent withdrawal syndrome 1, 2
- Nausea is the most common side effect and occurs in a dose-dependent manner, but typically resolves within 1-3 weeks 1, 7
- Higher doses (≥375 mg/day) are associated with increased frequency and severity of side effects including fatigue, concentration difficulties, sleepiness, and memory problems, though discontinuation rates remain similar 6
Special Population Adjustments
- Reduce total daily dose by 50% in patients with mild to moderate hepatic impairment 3
- Reduce total daily dose by 25% in patients with mild to moderate renal impairment (GFR 10-70 mL/min) 3
- Reduce total daily dose by 50% in patients undergoing hemodialysis 3
- No dose adjustment needed for elderly patients based on age alone, though extra caution is warranted when increasing doses 3