Is it safe to prescribe Pristiq (desvenlafaxine) to a patient with a family history of glaucoma?

Pristiq and Family History of Glaucoma

Pristiq (desvenlafaxine) can be prescribed to patients with a family history of glaucoma, but requires careful screening for anatomically narrow angles before initiation and monitoring during treatment. 1

Key Clinical Distinction

The critical issue is not family history itself, but whether the patient has anatomically narrow angles:

• The FDA label explicitly states to avoid desvenlafaxine in patients with untreated anatomically narrow angles, as pupillary dilation from the medication may trigger an angle closure attack in susceptible individuals 1
• Family history of glaucoma increases risk of developing primary open-angle glaucoma (9.2-fold increased odds with first-degree relatives), but this does not contraindicate desvenlafaxine use 2
• The concern with desvenlafaxine is specifically angle closure glaucoma, not open-angle glaucoma 1

Pre-Treatment Assessment Required

Before prescribing desvenlafaxine to any patient:

• Perform or arrange ophthalmologic evaluation to assess anterior chamber angle anatomy if there is any concern for narrow angles 1
• Patients with confirmed narrow angles should have a patent iridectomy before starting desvenlafaxine 1
• The FDA label advises patients to report changes in vision or eye pain immediately during treatment 1

Understanding the Risk Profile

Family history alone does not contraindicate desvenlafaxine:

• Family history primarily increases risk for primary open-angle glaucoma, which develops gradually and is not acutely triggered by pupillary dilation 2
• The acute angle closure risk from desvenlafaxine depends on anatomic predisposition (narrow angles), not genetic predisposition to open-angle disease 1
• While venlafaxine (the parent compound) has been reported to increase intraocular pressure in two patients with pre-existing narrow angle glaucoma, this occurred in patients with the anatomic risk factor 3

Clinical Algorithm

1. Assess for anatomically narrow angles through ophthalmologic examination if any suspicion exists 1
2. If narrow angles are present and untreated: Do not prescribe desvenlafaxine 1
3. If narrow angles with patent iridectomy: May prescribe with monitoring 1
4. If normal angle anatomy with family history only: May prescribe desvenlafaxine safely 1
5. Educate patient to report vision changes or eye pain immediately 1

Important Caveats

• Approximately 75% of glaucoma cases remain undiagnosed in the general population, making family history reporting unreliable 2
• Patients with family history should undergo comprehensive ophthalmologic screening by age 40 regardless of medication decisions 2
• The mechanism of desvenlafaxine-induced angle closure involves pupillary dilation, not direct effects on intraocular pressure in open-angle disease 1