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milnacipran (Savella)
Indications:
- fibromyalgia (FDA-approved use)
- used for treatment of depression in Europe
Contraindications:
- do not use with 14 days of MAO inhibitor
- narrow-angle glaucoma
- use with caution in patient with a history of dysuria
- use with caution in patient with a history of seizures
- end-stage renal disease
- avoid concurrent use of other antidepressants
Pregnancy category: C
Dosage:
- start 12.5 mg PO QD
- maintenance dose: 50 mg BID
Tabs: 12.5, 25, 50, 100 mg film-coated, immediate release tablets
Pharmacokinetics:
- majority is excreted unchanged in the urine (55%)
- minimal CYP450-related metabolism
- low binding to plasma protein (13%)
Dosage adjustment in renal failure:
- decrease dose by 50% for creatinine clearance of 5-30 mL/min
Monitor:
- blood pressure & heart rate
a) prior to initiation of therapy
b) periodically thereafter
Adverse effects:
- nausea, headache, palpitations
- hypertension: mean increase of 3 mm Hg in systolic BP
- tachycardia: mean increase of 7-8 beats/min
- hyponatremia due to SIADH
- hepatitis (rare)
- seizures (rare)
- increased risk of mydriasis
Drug interactions:
- may increase risk of bleeding when used in combination with aspirin or other NSAIDs
Laboratory:
- milnacipran in blood
- milnacipran in serum/plasma
- milnacipran in urine
Mechanism of action:
- serotonin-norepinephrine reuptake inhibitor (SNRI)
- allegedly more potent inhibitor of norepinephrine reuptake than the other SNRIs
- about 1 in 12 patients taking Savella for 3 months will have a 50% or greater improvement in symptoms compared to placebo [1]
Notes:
- contains FD&C Yellow No. 5 (tartrazine)
Interactions
drug adverse effects of antidepressants
Specific
levomilnacipran (Savella)
General
serotonin & norepinephrine reuptake inhibitor (SNRI, dual-acting reuptake inhibitor)
References
- Prescriber's Letter 16(3): 2009
New Drug: Savella (Milnacipran)
Detail-Document#: 250310
(subscription needed) http://www.prescribersletter.com
- Arnold LM et al.
Efficacy and safety of milnacipran 100 mg/day in patients with
fibromyalgia: Results of a randomized, double-blind, placebo-
controlled trial. Arthritis Rheum 2010 Sep; 62:2745.
PMID: 20496365
http://dx.doi.org/10.1002/art.27559