What is the typical dosing regimen for Luvox (fluvoxamine) in adults and children with obsessive-compulsive disorder?

Luvox (Fluvoxamine) Dosing for Obsessive-Compulsive Disorder

Adult Dosing

For adults with OCD, start fluvoxamine at 50 mg once daily at bedtime, then increase by 50 mg increments every 4-7 days as tolerated up to a maximum of 300 mg/day, with doses above 100 mg/day split into two divided doses (larger dose at bedtime). 1

Initial Dosing

• Begin with 50 mg as a single daily dose at bedtime 1
• This represents the standard FDA-approved starting dose for adults 1

Titration Schedule

• Increase in 50 mg increments every 4 to 7 days based on tolerability 1
• Continue titration until maximum therapeutic benefit is achieved 1
• The therapeutic dose range in controlled trials was 100-300 mg/day 1

Dose Administration

• Total daily doses exceeding 100 mg should be divided into two doses 1
• When splitting doses unequally, give the larger dose at bedtime 1
• Maximum daily dose is 300 mg 1

Treatment Duration

• Continue treatment for at least 8-12 weeks at an effective dose to assess response 2, 3
• Higher doses of SSRIs are required for OCD compared to depression or other anxiety disorders 2
• After achieving remission, maintain treatment for a minimum of 12-24 months 2

Pediatric Dosing (Ages 8-17 Years)

For children and adolescents with OCD, start fluvoxamine at 25 mg once daily at bedtime, then increase by 25 mg increments every 4-7 days as tolerated, with maximum doses of 200 mg/day for children up to age 11 and 300 mg/day for adolescents. 1

Initial Dosing

• Begin with 25 mg as a single daily dose at bedtime 1
• This lower starting dose accounts for higher plasma concentrations in children 4

Titration Schedule

• Increase in 25 mg increments every 4 to 7 days as tolerated 1
• The therapeutic dose range in controlled trials was 50-200 mg/day 1, 4

Maximum Doses by Age

• Children up to age 11: Maximum 200 mg/day 1
• Adolescents (12-17 years): Maximum 300 mg/day (adult dose) 1
• Female children may achieve therapeutic effect at lower doses 1

Dose Administration

• Total daily doses exceeding 50 mg should be divided into two doses 1
• When splitting doses unequally, give the larger dose at bedtime 1

Special Populations

Elderly and Hepatically Impaired Patients

• Use lower initial doses due to decreased clearance 1
• Titrate more slowly than in younger adults 1
• Monitor closely for adverse effects 1

Pregnant Women (Third Trimester)

• Carefully weigh risks versus benefits when treating during the third trimester 1
• Consider tapering fluvoxamine in the third trimester due to risk of neonatal complications requiring prolonged hospitalization 1

Monitoring and Maintenance

Assessment of Response

• Significant improvement may be observed within the first 2 weeks, with greatest gains occurring early in treatment 2
• However, allow 8-12 weeks at therapeutic doses to fully assess efficacy 2, 3
• Early reduction in symptoms by 4 weeks predicts treatment response at 12 weeks 2

Side Effect Monitoring

• Systematically assess for nausea (most common), somnolence, asthenia, headache, dry mouth, and insomnia 5
• Monitor for gastrointestinal symptoms, which are the most common reason for discontinuation 4, 6
• Abdominal discomfort occurs more frequently with fluvoxamine than placebo 4

Long-Term Management

• Maintain patients on the lowest effective dosage 1
• Periodically reassess the need for continued treatment 1
• Longer treatment beyond 12-24 months may be necessary due to high relapse risk after discontinuation 2

Discontinuation

When stopping fluvoxamine, taper gradually rather than discontinuing abruptly to minimize withdrawal symptoms. 1

• Gradual dose reduction is recommended whenever possible 1
• Monitor for discontinuation symptoms during tapering 1

Treatment-Resistant Cases

Dose Optimization

• In treatment-resistant OCD, doses may occasionally exceed the manufacturer's recommended maximum of 300 mg/day 2, 7
• One case report documented remission with 600 mg/day fluvoxamine, though this is exceptional and requires careful monitoring 7
• Ensure adequate trial duration (at least 8-12 weeks) at maximum tolerated dose before considering treatment failure 2, 3

Alternative Strategies if No Response

• Consider switching to another SSRI or clomipramine 2
• Augment with cognitive-behavioral therapy (CBT), which has larger effect sizes than antipsychotic augmentation 2
• Consider clomipramine augmentation or antipsychotic augmentation if CBT unavailable 2

Important Clinical Considerations

Drug Interactions

• Fluvoxamine is a potent inhibitor of CYP1A2 and moderate inhibitor of CYP2C19 and CYP3A4 5
• Exercise caution when co-administering with alprazolam or triazolam; reduce benzodiazepine doses by 50% 2
• Monitor for drug interactions more carefully than with other SSRIs 5

Comparative Efficacy

• Fluvoxamine has similar efficacy to other SSRIs for OCD 2, 5
• Clomipramine may have slightly greater efficacy but poorer tolerability profile 2
• SSRIs including fluvoxamine are recommended as first-line agents over clomipramine due to better safety and tolerability 2, 3