What is the recommended starting dose, titration schedule, and maximum dose of Luvox (fluvoxamine) for adults, children/adolescents, and elderly patients, including any special considerations such as hepatic impairment and MAOI interactions?

Luvox (Fluvoxamine) Dosing Guidelines

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

Adult Dosing

• Starting dose: 50 mg once daily at bedtime 1
• Titration schedule: Increase by 50 mg increments every 4-7 days based on tolerability 1
• Therapeutic range: 100-300 mg/day (established in controlled OCD trials) 1
• Maximum dose: 300 mg/day 1
• Divided dosing: Total daily doses exceeding 100 mg should be split into two doses, with the larger dose given at bedtime 1

Pharmacokinetic Considerations in Adults

• Steady-state plasma concentrations are achieved within 5-10 days and are 30-50% higher than predicted from single-dose data 2
• Fluvoxamine displays nonlinear pharmacokinetics, with disproportionately higher plasma levels at higher doses 2
• Terminal elimination half-life is 12-15 hours after single dose, prolonged by 30-50% at steady-state 2

Pediatric Dosing (Ages 8-17 Years)

• Starting dose: 25 mg once daily at bedtime 1
• Titration schedule: Increase by 25 mg increments every 4-7 days as tolerated 1
• Therapeutic range: 50-200 mg/day (established in controlled pediatric OCD trials) 1
• Maximum dose in children ≤11 years: 200 mg/day 1
• Maximum dose in adolescents: 300 mg/day (adult maximum) 1
• Divided dosing: Total daily doses exceeding 50 mg should be split into two doses, with the larger dose given at bedtime 1

Gender and Age Considerations in Pediatrics

• Female children may achieve therapeutic effect at lower doses 1
• Adolescents may require dose adjustment up to the adult maximum of 300 mg to achieve therapeutic benefit 1

Elderly and Hepatically Impaired Patients

Elderly patients and those with hepatic impairment require lower initial doses and slower titration due to decreased fluvoxamine clearance. 1

Hepatic Impairment Specifics

• Elimination half-life is prolonged in patients with liver cirrhosis (mean 25 ± 11 hours vs 12-15 hours in healthy adults) 3
• AUC is approximately 50% higher in cirrhotic patients compared to healthy volunteers 3
• Half-life increases with higher plasma bilirubin levels 3
• In patients with active liver disease (elevated bilirubin), lower the initial daily dose and carefully monitor during upward dose adjustments 3
• Liver dysfunction markedly decreases fluvoxamine's inhibition of CYP1A2, reducing drug interaction severity as liver function worsens 4

Critical MAOI Interaction Warning

Fluvoxamine must not be used concurrently with MAOIs or within 14 days of MAOI discontinuation due to high risk of serotonin syndrome. 5

• The fluoxetine-MAOI combination (same class as fluvoxamine) causes serotonin syndrome in most patients, characterized by mental status changes (hypomania, confusion), myoclonus, hypertension, tremor, and diarrhea 6
• Due to fluvoxamine's long half-life and extensive metabolism, adequate washout periods are essential when switching to or from MAOIs 6

Maintenance and Continuation Treatment

• Although efficacy beyond 10 weeks has not been documented in controlled trials, OCD is chronic and continuation is reasonable for responding patients 1
• Maintain patients on the lowest effective dosage 1
• Periodically reassess to determine need for continued treatment 1

Discontinuation Strategy

Taper fluvoxamine gradually rather than stopping abruptly to minimize discontinuation symptoms. 1

• If intolerable symptoms occur after dose reduction or discontinuation, resume the previous dose and then decrease more gradually 1
• This approach is particularly important in pregnant women during the third trimester, where the physician must carefully weigh risks and benefits and may consider tapering 1

Common Pitfalls to Avoid

• Do not increase doses more frequently than every 4-7 days, as steady-state takes 5-10 days to achieve and premature escalation increases side effect burden without additional benefit 1, 2
• Do not ignore hepatic function when dosing elderly patients, as decreased clearance occurs even without overt cirrhosis and requires conservative initial dosing 1, 3
• Do not overlook the need for divided dosing at higher doses, as single daily dosing above 100 mg (adults) or 50 mg (pediatrics) increases tolerability issues 1
• Do not combine with other serotonergic agents without extreme caution, particularly MAOIs, SNRIs, or SSRIs, due to serotonin syndrome risk 5, 6