Recommended Starting Dose of Venlafaxine ER for PTSD
The recommended starting dose of venlafaxine ER for PTSD is 37.5 mg once daily, with flexible titration up to 300 mg/day based on clinical response and tolerability. 1, 2
Dosing Strategy
Initial Dosing
- Start at 37.5 mg/day as the entry dose for venlafaxine ER in PTSD patients 1, 2
- The extended-release formulation allows for convenient once-daily administration 3
- Take in the morning to minimize potential sleep disturbances, as venlafaxine can be activating 4
Dose Titration
- Flexible dose range: 37.5-300 mg/day based on individual response 1, 2
- In clinical trials, the mean maximum daily dose achieved was approximately 221.5-225 mg/day 1, 2
- Titrate gradually based on symptom response and side effect tolerability 1
Expected Clinical Response
Efficacy Timeline
- Significant improvement in PTSD symptoms can be observed as early as 1 week of treatment at adequate doses 5
- Mean improvement in CAPS-SX17 scores: -41.8 points with venlafaxine ER versus -33.9 with placebo at 12 weeks 2
- Remission rates (CAPS-SX17 ≤20) reached 50.9% with venlafaxine ER versus 37.5% with placebo at 6 months 1
Symptom Cluster Response
- Venlafaxine ER shows significant improvement in reexperiencing/intrusion symptoms (p=0.008) 6, 2
- Avoidance/numbing symptoms improve significantly (p=0.006) 6, 2
- Hyperarousal symptoms show improvement, though effect may be less robust 1, 2
Critical Safety Monitoring
Blood Pressure Surveillance
- Monitor blood pressure regularly, especially when exceeding 150 mg/day, as venlafaxine causes dose-dependent hypertension 3
- This is a common pitfall—many clinicians fail to monitor BP adequately during dose escalation 3
Discontinuation Protocol
- Never stop abruptly—taper over 10-14 days minimum to prevent withdrawal syndrome 3
- Withdrawal symptoms can be severe and include dizziness, nausea, and sensory disturbances 3
Important Clinical Caveat
Nightmare-Specific Limitation
- Venlafaxine ER is NOT recommended specifically for PTSD-associated nightmares 6, 3
- Pooled analysis of 687 PTSD patients showed no significant difference between venlafaxine ER and placebo for distressing dreams (CAPS-SX17 nightmare item) 6
- While venlafaxine improved 13 other PTSD symptoms significantly, the nightmare component remained unresponsive 6
- If nightmares are the predominant symptom, consider alternative agents rather than venlafaxine 6