What are the guidelines for restarting Viibryd (vilazodone) in an adult patient with a history of depression or anxiety who has previously taken the medication?

Restarting Viibryd (Vilazodone)

When restarting Viibryd after discontinuation, follow the standard FDA-approved titration schedule: begin with 10 mg once daily with food for 7 days, then increase to 20 mg once daily, with optional further titration to 40 mg after a minimum of 7 additional days. 1

Standard Restart Protocol

The FDA label provides clear guidance for initiating or restarting vilazodone, regardless of prior exposure 1:

• Start at 10 mg once daily with food for 7 days 1
• Increase to 20 mg once daily with food after the initial week 1
• May increase to target dose of 40 mg once daily after a minimum of 7 days at 20 mg 1
• Always take with food to optimize absorption and reduce gastrointestinal side effects 1

Critical Pre-Restart Assessment

Before restarting vilazodone, you must address several key clinical considerations:

Rule Out Medical Causes of Symptoms

First evaluate and treat any medical causes of depression or anxiety symptoms before restarting antidepressant therapy, including uncontrolled pain, fatigue, thyroid hormone imbalance, electrolyte disturbances, or delirium 2. This is particularly important as these conditions can mimic or exacerbate psychiatric symptoms.

Screen for Bipolar Disorder

Prior to initiating vilazodone, screen patients for personal or family history of bipolar disorder, mania, or hypomania 1. This is essential as antidepressants can precipitate manic episodes in susceptible individuals.

MAOI Washout Period

At least 14 days must elapse between discontinuation of an MAOI antidepressant and initiation of vilazodone, and vice versa 1. This prevents potentially fatal serotonin syndrome.

Duration of Treatment Considerations

Antidepressant treatment should not be stopped before 9-12 months after recovery 3. If the patient discontinued prematurely and symptoms have returned, this supports the decision to restart therapy. The WHO guidelines emphasize this minimum treatment duration to prevent relapse 3.

Drug Interaction Adjustments

If the patient is taking interacting medications, dose modifications are required 1:

With CYP3A4 Inhibitors

• Do not exceed 20 mg once daily during concomitant use of strong CYP3A4 inhibitors (itraconazole, clarithromycin, voriconazole) 1
• Resume original dose when inhibitor is discontinued 1

With CYP3A4 Inducers

• Consider increasing vilazodone dose by 2-fold (up to maximum 80 mg once daily) over 1-2 weeks if patient has been on strong CYP3A4 inducers (carbamazepine, phenytoin, rifampin) for >14 days 1
• Gradually reduce back to original level over 1-2 weeks when inducer is discontinued 1

Monitoring and Follow-Up

Assess treatment response at 4 weeks, 8 weeks, and throughout treatment using standardized instruments 4. The ASCO guidelines recommend monthly monitoring until symptoms subside, including 3:

• Compliance with medication and concerns about adverse effects 3
• Satisfaction with symptom relief provided by treatment 3
• Suicidal ideation monitoring, though vilazodone shows little risk of treatment-emergent suicidal thoughts in adults 5

After 8 weeks of treatment, if symptom reduction is poor despite good compliance, alter the treatment course by adding psychological intervention, changing medication, or referring to individual psychotherapy 3, 2

Common Pitfalls to Avoid

Do not restart at the full 40 mg dose without proper titration, as this increases risk of gastrointestinal side effects 1. The most common adverse events are diarrhea, nausea, and headache, which are typically mild to moderate 6, 7.

Do not assume the patient will automatically comply with the restart - patients with depression and anxiety often fail to follow through on treatment recommendations 3. Proactive follow-up and assessment of barriers to compliance is essential 2.

Exercise caution in patients with seizure history - there is at least one case report of breakthrough seizures after starting vilazodone in a patient with controlled epilepsy 8. While rare, this warrants closer monitoring in this population 8.

Adjunctive Treatment Considerations

Consider combining pharmacotherapy with cognitive behavioral therapy (CBT), behavioral activation, or problem-solving therapy for optimal outcomes 3, 2. Psychological interventions show equivalent or superior efficacy to pharmacotherapy alone and should be offered when resources permit 3.