What is the maximum recommended dose of venlafaxine (Effexor) for an adult patient with a history of anxiety or depression who is currently taking 75mg and still experiencing anxiety?

Maximum Dose of Venlafaxine for Persistent Anxiety

The maximum recommended dose of venlafaxine for anxiety is 225 mg/day, though the FDA label permits up to 375 mg/day for severely depressed patients in divided doses. 1

Standard Dosing for Anxiety Disorders

For your patient currently on 75 mg who continues to experience anxiety symptoms:

• Target therapeutic range: 150-225 mg/day for generalized anxiety disorder, social anxiety disorder, and panic disorder 2, 3
• Current dose assessment: 75 mg/day is the starting dose and likely subtherapeutic for most patients with persistent anxiety 1, 4
• Titration schedule: Increase by 75 mg increments at intervals of no less than 4 days 1

Evidence-Based Dosing Algorithm

Step 1: Increase to 150 mg/day

• This represents the minimum effective dose for most anxiety disorders 2, 4
• Efficacy typically requires 2-4 weeks to titrate to this level 2
• Assess response at 4 weeks and 8 weeks using standardized measures 5

Step 2: If inadequate response at 150 mg after 4-6 weeks

• Increase to 225 mg/day (the standard maximum for anxiety) 2, 1, 3
• This dose showed dose-related improvements in anxiety symptoms in controlled trials 4, 3

Step 3: Consider higher doses only for severe cases

• Doses up to 375 mg/day are FDA-approved but primarily studied in severely depressed inpatients (mean dose 350 mg/day) 1
• No evidence supports routine use above 225 mg/day for anxiety disorders specifically 2, 3
• Higher doses increase risk of sustained hypertension and other adverse effects 2

Critical Monitoring Requirements

Blood pressure monitoring is mandatory with each dose increase, as venlafaxine causes dose-dependent hypertension 2, 5

Common adverse effects to monitor include:

• Nausea (most common, often transient) 2, 4, 6, 3
• Dizziness, somnolence, insomnia 4, 6, 3
• Dry mouth, sweating 6, 3
• Sexual dysfunction (abnormal ejaculation) 6

Important Clinical Pitfalls

Do not increase doses too rapidly: Allow at least 4 days between increments to assess tolerability and avoid overshooting the therapeutic window 1

Do not abruptly discontinue: Venlafaxine has significant discontinuation syndrome risk—taper gradually over 10-14 days if switching medications 2, 5

Cardiac precautions: While venlafaxine does not cause clinically significant ECG changes at therapeutic doses, cardiac conduction abnormalities have been reported in a small number of patients 2

Combination Therapy Consideration

If symptoms persist at 225 mg/day after 8 weeks, consider adding cognitive behavioral therapy rather than exceeding 225 mg/day, as combination treatment provides superior outcomes compared to medication alone 2, 5, 7

Special Population Adjustments

• Hepatic impairment: Reduce total daily dose by 50% 1
• Renal impairment (GFR 10-70): Reduce total daily dose by 25% 1
• Hemodialysis: Reduce total daily dose by 50% 1
• Elderly patients: Start at lower doses (37.5 mg) and titrate more gradually 5, 1