Venlafaxine Starting Dose for Pain Management

For neuropathic pain management, start venlafaxine at 50-75 mg daily, then titrate upward to a target therapeutic range of 75-225 mg daily. 1

Initial Dosing Strategy

Begin with 50-75 mg daily as the starting dose for pain management, which is lower than the FDA-approved starting dose of 75 mg/day for depression 1, 2
The lower starting dose (50 mg) may improve tolerability, particularly for nausea, which is the most common adverse effect 2
Administer in divided doses (two or three times daily) with food to minimize gastrointestinal side effects 2

Increase to 75-225 mg daily as the therapeutic target range for neuropathic pain 1
When increasing the dose, make increments of up to 75 mg/day at intervals of no less than 4 days 2
The effective dose range for painful diabetic peripheral neuropathy is specifically 150-225 mg/day 1
Allow 2-4 weeks to titrate to an efficacious dosage of 150-225 mg/day 1

Venlafaxine has demonstrated efficacy in relieving painful symptomatology in diabetic peripheral neuropathy at dosages of 150-225 mg/day 1
It has also shown efficacy in painful polyneuropathies of different origins, though notably not in postherpetic neuralgia 1
The analgesic effect is independent of antidepressant activity, and the effective analgesic dose is often lower than that required to treat depression 1

Cardiovascular adverse events limit venlafaxine's use in diabetes and should be considered when selecting this agent for pain management 1
Dose-dependent blood pressure elevation occurs in 3-5% of patients at doses ≤200 mg/day, 7% at 201-300 mg/day, and 13% at >300 mg/day 3
Monitor blood pressure, particularly when titrating above 150 mg/day 1
Cardiac conduction abnormalities have been reported; prescribe with caution in patients with cardiac disease 1
Nausea is the most common adverse effect but typically resolves within 1-3 weeks 3

Reduce total daily dose by 50% in patients with mild to moderate hepatic impairment 2
Reduce total daily dose by 25% in patients with mild to moderate renal impairment (GFR 10-70 mL/min) 2
Reduce total daily dose by 50% in patients undergoing hemodialysis 2
Exercise caution in elderly patients, taking extra care when increasing the dose 2

Do not abruptly discontinue venlafaxine—taper gradually as a withdrawal syndrome has been described 1
Be aware that paresthesias (tingling, numbness, itching) can occur at doses ≥150 mg/day, which is particularly problematic when treating pain disorders 4
Patients receiving venlafaxine for pain should be closely monitored for paradoxical worsening of pain symptoms and may require dose adjustment 4
The onset of analgesic action is usually earlier than antidepressant effects, but patient education should emphasize the trial-and-error nature of treatment 1