EFEXOR

Main information

  • Trade name:
  • EFEXOR Prolonged Release Capsules 150 Milligram
  • Dosage:
  • 150 Milligram
  • Pharmaceutical form:
  • Prolonged Release Capsules
  • Medicine domain:
  • Humans
  • Medicine type:
  • Allopathic drug

Documents

Localization

  • Available in:
  • EFEXOR Prolonged Release Capsules 150 Milligram
    Ireland
  • Language:
  • English

Status

  • Source:
  • HPRA - Health Products Regulatory Authority - Ireland
  • Authorization number:
  • PPA1328/118/003
  • Authorization date:
  • 23-10-2009
  • Last update:
  • 14-10-2016

Summary of Product characteristics: dosage, interactions, side effects

SummaryofProductCharacteristics

1NAMEOFTHEMEDICINALPRODUCT

EfexorXL150mgProlonged-ReleaseCapsules,hard

2QUALITATIVEANDQUANTITATIVECOMPOSITION

Eachcapsulecontains169.7mgvenlafaxinehydrochlorideequivalentto150mgvenlafaxine.

Excipient:lactose

Forafulllistofexcipients,seesection6.1.

3PHARMACEUTICALFORM

Prolonged-releasecapsule,hard

ProductimportedfromItaly:

Opaquedarkorangecapsulesprintedinwhitewith'W'onthecapand‘150'onthebody.

4CLINICALPARTICULARS

4.1TherapeuticIndications

Treatmentofmajordepressiveepisodes.

Forpreventionofrecurrenceofmajordepressiveepisodes.

Treatmentofgeneralisedanxietydisorder.

Treatmentofsocialanxietydisorder.

Treatmentofpanicdisorder,withorwithoutagoraphobia.

4.2Posologyandmethodofadministration

Majordepressiveepisodes

Therecommendedstartingdoseforprolonged-releasevenlafaxineis75mggivenoncedaily.Patientsnotresponding

totheinitial75mg/daydosemaybenefitfromdoseincreasesuptoamaximumdoseof375mg/day.Dosageincreases

canbemadeatintervalsof2weeksormore.Ifclinicallywarrantedduetosymptomseverity,doseincreasescanbe

madeatmorefrequentintervals,butnotlessthan4days.

Becauseoftheriskofdose-relatedadverseeffects,doseincrementsshouldbemadeonlyafteraclinicalevaluation(see

section4.4).Thelowesteffectivedoseshouldbemaintained.

Patientsshouldbetreatedforasufficientperiodoftime,usuallyseveralmonthsorlonger.Treatmentshouldbe

reassessedregularlyonacase-by-casebasis.Longer-termtreatmentmayalsobeappropriateforpreventionof

recurrenceofmajordepressiveepisodes(MDE).Inmostofthecases,therecommendeddoseinpreventionof

recurrenceofMDEisthesameastheoneusedduringthecurrentepisode.

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Generalisedanxietydisorder

Therecommendedstartingdoseforprolonged-releasevenlafaxineis75mggivenoncedaily.Patientsnotresponding

totheinitial75mg/daydosemaybenefitfromdoseincreasesuptoamaximumdoseof225mg/day.Dosageincreases

canbemadeatintervalsof2weeksormore.

Becauseoftheriskofdose-relatedadverseeffects,doseincrementsshouldbemadeonlyafteraclinicalevaluation(see

section4.4).Thelowesteffectivedoseshouldbemaintained.

Patientsshouldbetreatedforasufficientperiodoftime,usuallyseveralmonthsorlonger.Treatmentshouldbe

reassessedregularly,onacase-by-casebasis.

Socialanxietydisorder

Therecommendeddoseforprolonged-releasevenlafaxineis75mggivenoncedaily.Thereisnoevidencethathigher

dosesconferanyadditionalbenefit.

However,inindividualpatientsnotrespondingtotheinitial75mg/day,increasesuptoamaximumdoseof

225mg/daymaybeconsidered.Dosageincreasescanbemadeatintervalsof2weeksormore.

Becauseoftheriskofdose-relatedadverseeffects,doseincrementsshouldbemadeonlyafteraclinicalevaluation(see

section4.4).Thelowesteffectivedoseshouldbemaintained.

Patientsshouldbetreatedforasufficientperiodoftime,usuallyseveralmonthsorlonger.Treatmentshouldbe

reassessedregularly,onacase-by-casebasis.

Panicdisorder

Itisrecommendedthatadoseof37.5mg/dayofprolonged-releasevenlafaxinebeusedfor7days.Dosageshouldthen

beincreasedto75mg/day.Patientsnotrespondingtothe75mg/daydosemaybenefitfromdoseincreasesuptoa

maximumdoseof225mg/day.Dosageincreasescanbemadeatintervalsof2weeksormore.

Becauseoftheriskofdose-relatedadverseeffects,doseincrementsshouldbemadeonlyafteraclinicalevaluation(see

section4.4).Thelowesteffectivedoseshouldbemaintained.

Patientsshouldbetreatedforasufficientperiodoftime,usuallyseveralmonthsorlonger.Treatmentshouldbe

reassessedregularly,onacase-by-casebasis.

Useinelderlypatients

Nospecificdoseadjustmentsofvenlafaxineareconsiderednecessarybasedonpatientagealone.However,caution

shouldbeexercisedintreatingtheelderly(e.g.,duetothepossibilityofrenalimpairment,thepotentialforchangesin

neurotransmittersensitivityandaffinityoccurringwithaging).Thelowesteffectivedoseshouldalwaysbeused,and

patientsshouldbecarefullymonitoredwhenanincreaseinthedoseisrequired.

Useinchildrenandadolescentsundertheageof18years

Venlafaxineisnotrecommendedforuseinchildrenandadolescents.

Controlledclinicalstudiesinchildrenandadolescentswithmajordepressivedisorderfailedtodemonstrateefficacy

anddonotsupporttheuseofvenlafaxineinthesepatients(seesections4.4and4.8).

Theefficacyandsafetyofvenlafaxineforotherindicationsinchildrenandadolescentsundertheageof18havenot

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Useinpatientswithhepaticimpairment

Inpatientswithmildandmoderatehepaticimpairment,ingenerala50%dosereductionshouldbeconsidered.

However,duetointer-individualvariabilityinclearance,individualisationofdosagemaybedesirable.

Therearelimiteddatainpatientswithseverehepaticimpairment.Cautionisadvised,andadosereductionbymore

than50%shouldbeconsidered.Thepotentialbenefitshouldbeweighedagainsttheriskinthetreatmentofpatients

withseverehepaticimpairment.

Useinpatientswithrenalimpairment

Althoughnochangeindosageisnecessaryforpatientswithglomerularfiltrationrate(GFR)between30-70ml/minute,

cautionisadvised.Forpatientsthatrequirehaemodialysisandinpatientswithsevererenalimpairment(GFR<

30ml/min),thedoseshouldbereducedby50%.Becauseofinter-individualvariabilityinclearanceinthesepatients,

individualisationofdosagemaybedesirable.

Withdrawalsymptomsseenondiscontinuationofvenlafaxine

Abruptdiscontinuationshouldbeavoided.Whenstoppingtreatmentwithvenlafaxine,thedoseshouldbegradually

reducedoveraperiodofatleastonetotwoweeksinordertoreducetheriskofwithdrawalreactions(seesections4.4

and4.8).Ifintolerablesymptomsoccurfollowingadecreaseinthedoseorupondiscontinuationoftreatment,then

resumingthepreviouslyprescribeddosemaybeconsidered.Subsequently,thephysicianmaycontinuedecreasingthe

dose,butatamoregradualrate.

Fororaluse.

Itisrecommendedthatvenlafaxineprolonged-releasecapsulesbetakenwithfood,atapproximatelythesametime

eachday.Capsulesmustbeswallowedwholewithfluidandnotdivided,crushed,chewed,ordissolved.

Patientstreatedwithvenlafaxineimmediate-releasetabletsmaybeswitchedtovenlafaxineprolonged-releasecapsules

atthenearestequivalentdailydosage.Forexample,venlafaxineimmediate-releasetablets37.5mgtwicedailymaybe

switchedtovenlafaxineprolonged-releasecapsules75mgoncedaily.Individualdosageadjustmentsmaybenecessary.

Venlafaxineprolonged-releasecapsulescontainspheroids,whichreleasetheactivesubstanceslowlyintothedigestive

tract.Theinsolubleportionofthesespheroidsiseliminatedandmaybeseeninfaeces.

4.3Contraindications

Hypersensitivitytotheactivesubstanceortoanyoftheexcipients.

Concomitanttreatmentwithirreversiblemonoamineoxidaseinhibitors(MAOIs)iscontraindicatedduetotheriskof

serotoninsyndromewithsymptomssuchasagitation,tremorandhyperthermia.Venlafaxinemustnotbeinitiatedforat

least14daysafterdiscontinuationoftreatmentwithanirreversibleMAOI.

Venlafaxinemustbediscontinuedforatleast7daysbeforestartingtreatmentwithanirreversibleMAOI(seesections

4.4and4.5).

4.4Specialwarningsandprecautionsforuse

Suicide/suicidalthoughtsorclinicalworsening

Depressionisassociatedwithanincreasedriskofsuicidalthoughts,selfharmandsuicide(suicide-relatedevents).This

riskpersistsuntilsignificantremissionoccurs.Asimprovementsmaynotoccurduringthefirstfewweeksormoreof

treatment,patientsshouldbecloselymonitoreduntilsuchimprovementoccurs.Itisgeneralclinicalexperiencethatthe

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Otherpsychiatricconditionsforwhichvenlafaxineisprescribedcanalsobeassociatedwithanincreasedriskof

suicide-relatedevents.Inaddition,theseconditionsmaybeco-morbidwithmajordepressivedisorder.Thesame

precautionsobservedwhentreatingpatientswithmajordepressivedisordershouldthereforebeobservedwhentreating

patientswithotherpsychiatricdisorders.

Patientswithahistoryofsuicide-relatedevents,orthoseexhibitingasignificantdegreeofsuicidalideationpriorto

commencementoftreatmentareknowntobeatgreaterriskofsuicidalthoughtsorsuicideattempts,andshouldreceive

carefulmonitoringduringtreatment.Ameta-analysisofplacebo-controlledclinicaltrialsofantidepressantdrugsin

adultpatientswithpsychiatricdisordersshowedanincreasedriskofsuicidalbehaviourwithantidepressantscompared

toplaceboinpatientslessthan25yearsold.

Closesupervisionofpatientsandinparticularthoseathighriskshouldaccompanydrugtherapyespeciallyinearly

treatmentandfollowingdosechanges.Patients(andcaregiversofpatients)shouldbealertedabouttheneedtomonitor

foranyclinicalworsening,suicidalbehaviourorthoughtsandunusualchangesinbehaviourandtoseekmedicaladvice

immediatelyifthesesymptomspresent.

Useinchildrenandadolescentsunder18yearsofage

Efexordepotshouldnotbeusedinthetreatmentofchildrenandadolescentsundertheageof18years.Suicide-related

behaviours(suicideattemptandsuicidalthoughts)andhostility(predominantlyaggression,oppositionalbehaviourand

anger)weremorefrequentlyobservedinclinicaltrialsamongchildrenandadolescentstreatedwithantidepressants

comparedtothosetreatedwithplacebo.If,basedonclinicalneed,adecisiontotreatisneverthelesstaken,thepatient

shouldbecarefullymonitoredfortheappearanceofsuicidalsymptoms.Inaddition,long-termsafetydatainchildren

andadolescentsconcerninggrowth,maturationandcognitiveandbehaviouraldevelopmentarelacking.

Serotoninsyndrome

Aswithotherserotonergicagents,serotoninsyndrome,apotentiallylife-threateningcondition,mayoccurwith

venlafaxinetreatment,particularlywithconcomitantuseofotheragents,suchasMAO-inhibitors,thatmayaffectthe

serotonergicneurotransmittersystems(seesections4.3and4.5).

Serotoninsyndromesymptomsmayincludementalstatuschanges(e.g.,agitation,hallucinations,coma),autonomic

instability(e.g.,tachycardia,labilebloodpressure,hyperthermia),neuromuscularaberrations(e.g.,hyperreflexia,

incoordination)and/orgastrointestinalsymptoms(e.g.,nausea,vomiting,diarrhoea).

Narrow-angleglaucoma

Mydriasismayoccurinassociationwithvenlafaxine.Itisrecommendedthatpatientswithraisedintraocularpressure

orpatientsatriskforacutenarrow-angleglaucoma(angle-closureglaucoma)becloselymonitored.

Bloodpressure

Dose-relatedincreasesinbloodpressurehavebeencommonlyreportedwithvenlafaxine.Insomecases,severely

elevatedbloodpressurerequiringimmediatetreatmenthasbeenreportedinpostmarketingexperience.Allpatients

shouldbecarefullyscreenedforhighbloodpressureandpre-existinghypertensionshouldbecontrolledbeforeinitation

oftreatment.Bloodpressureshouldbereviewedperiodically,afterinitiationoftreatmentandafterdoseincreases.

Cautionshouldbeexercisedinpatientswhoseunderlyingconditionsmightbecompromisedbyincreasesinblood

pressure,e.g.,thosewithimpairedcardiacfunction.

Heartrate

Increasesinheartratecanoccur,particularlywithhigherdoses.Cautionshouldbeexercisedinpatientswhose

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Cardiacdiseaseandriskofarrhythmia

Venlafaxinehasnotbeenevaluatedinpatientswitharecenthistoryofmyocardialinfarctionorunstableheartdisease.

Therefore,itshouldbeusedwithcautioninthesepatients.

Inpostmarketingexperience,fatalcardiacarrhythmiashavebeenreportedwiththeuseofvenlafaxine,especiallyin

overdose.Thebalanceofrisksandbenefitsshouldbeconsideredbeforeprescribingvenlafaxinetopatientsathighrisk

ofseriouscardiacarrhythmia.

Convulsions

Convulsionsmayoccurwithvenlafaxinetherapy.Aswithallantidepressants,venlafaxineshouldbeintroducedwith

cautioninpatientswithahistoryofconvulsions,andconcerned

patientsshouldbecloselymonitored.Treatmentshouldbediscontinuedinanypatientwhodevelopsseizures.

Hyponatraemia

Casesofhyponatraemiaand/ortheSyndromeofInappropriateAntidiureticHormone(SIADH)secretionmayoccur

withvenlafaxine.Thishasmostfrequentlybeenreportedinvolume-depletedordehydratedpatients.Elderlypatients,

patientstakingdiuretics,andpatientswhoareotherwisevolume-depletedmaybeatgreaterriskforthisevent.

Abnormalbleeding

Medicinalproductsthatinhibitserotoninuptakemayleadtoreducedplateletfunction.Theriskofskinandmucous

membranebleeding,includinggastrointestinalhaemorrhage,maybeincreasedinpatientstakingvenlafaxine.Aswith

otherserotonin-reuptakeinhibitors,venlafaxineshouldbeusedcautiouslyinpatientspredisposedtobleeding,

includingpatientsonanticoagulantsandplateletinhibitors.

Serumcholesterol

Clinicallyrelevantincreasesinserumcholesterolwererecordedin5.3%ofvenlafaxine-treatedpatientsand0.0%of

placebo-treatedpatientstreatedforatleast3monthsinplacebo-controlledclinicaltrials.Measurementofserum

cholesterollevelsshouldbeconsideredduringlong-termtreatment.

Co-administrationwithweightlossagents

Thesafetyandefficacyofvenlafaxinetherapyincombinationwithweightlossagents,includingphentermine,havenot

beenestablished.Co-administrationofvenlafaxineandweightlossagentsisnotrecommended.Venlafaxineisnot

indicatedforweightlossaloneorincombinationwithotherproducts.

Mania/hypomania

Mania/hypomaniamayoccurinasmallproportionofpatientswithmooddisorderswhohavereceivedantidepressants,

includingvenlafaxine.Aswithotherantidepressants,venlafaxineshouldbeusedcautiouslyinpatientswithahistoryor

familyhistoryofbipolardisorder.

Aggression

Aggressionmayoccurinasmallnumberofpatientswhohavereceivedantidepressants,includingvenlafaxine.This

hasbeenreportedunderinitiation,dosechangesanddiscontinuationoftreatment.

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Discontinuationoftreatment

Withdrawalsymptoms,whentreatmentisdiscontinued,arecommon,particularlyifdiscontinuationisabrupt(see

section4.8).Inclinicaltrials,adverseeventsseenontreatmentdiscontinuation(taperingandpost-tapering)occurredin

approximately31%ofpatientstreatedwithvenlafaxineand17%ofpatientstakingplacebo.

Theriskofwithdrawalsymptomsmaybedependentonseveralfactors,includingthedurationanddoseoftherapyand

therateofdosereduction.Dizziness,sensorydisturbances(includingparaesthesia),sleepdisturbances(including

insomniaandintensedreams),agitationoranxiety,nauseaand/orvomiting,tremorandheadachearethemost

commonlyreportedreactions.Generally,thesesymptomsaremildtomoderate;however,insomepatientstheymaybe

severeinintensity.Theyusuallyoccurwithinthefirstfewdaysofdiscontinuingtreatment,buttherehavebeenvery

rarereportsofsuchsymptomsinpatientswhohaveinadvertentlymissedadose.Generally,thesesymptomsareself-

limitingandusuallyresolvewithin2weeks,thoughinsomeindividualstheymaybeprolonged(2-3monthsormore).

Itisthereforeadvisedthatvenlafaxineshouldbegraduallytaperedwhendiscontinuingtreatmentoveraperiodof

severalweeksormonths,accordingtothepatient’sneeds(seesection4.2).

Akathisia/psychomotorrestlessness

Theuseofvenlafaxinehasbeenassociatedwiththedevelopmentofakathisia,characterisedbyasubjectively

unpleasantordistressingrestlessnessandneedtomoveoftenaccompaniedbyaninabilitytositorstandstill.Thisis

mostlikelytooccurwithinthefirstfewweeksoftreatment.Inpatientswhodevelopthesesymptoms,increasingthe

dosemaybedetrimental.

Drymouth

Drymouthisreportedin10%ofpatientstreatedwithvenlafaxine.Thismayincreasetheriskofcaries,andpatients

shouldbeadvisedupontheimportanceofdentalhygiene.

4.5Interactionwithothermedicinalproductsandotherformsofinteraction

MonoamineOxidaseInhibitors(MAOI)

Irreversiblenon-selectiveMAOIs

Venlafaxinemustnotbeusedincombinationwithirreversiblenon-selectiveMAOIs.Venlafaxinemustnotbeinitiated

foratleast14daysafterdiscontinuationoftreatmentwithanirreversiblenon-selectiveMAOI.Venlafaxinemustbe

discontinuedforatleast7daysbeforestartingtreatmentwithanirreversiblenon-selectiveMAOI(seesections4.3and

4.4).

Reversible,selectiveMAO-Ainhibitor(moclobemide)

Duetotheriskofserotoninsyndrome,thecombinationofvenlafaxinewithareversibleandselectiveMAOI,suchas

moclobemide,isnotrecommended.FollowingtreatmentwithareversibleMAO-inhibitor,ashorterwithdrawalperiod

than14daysmaybeusedbeforeinitiationofvenlafaxinetreatment.Itisrecommendedthatvenlafaxineshouldbe

discontinuedforatleast7daysbeforestartingtreatmentwithareversibleMAOI(seesection4.4).

Reversible,non-selectiveMAOI(linezolid)

Theantibioticlinezolidisaweakreversibleandnon-selectiveMAOIandshouldnotbegiventopatientstreatedwith

venlafaxine(seesection4.4).

SevereadversereactionshavebeenreportedinpatientswhohaverecentlybeendiscontinuedfromanMAOIand

startedonvenlafaxine,orhaverecentlyhadvenlafaxinetherapydiscontinuedpriortoinitiationofanMAOI.These

reactionshaveincludedtremor,myoclonus,diaphoresis,nausea,vomiting,flushing,dizziness,andhyperthermiawith

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Serotoninsyndrome

Aswithotherserotonergicagents,serotoninsyndromemayoccurwithvenlafaxinetreatment,particularlywith

concomitantuseofotheragentsthatmayaffecttheserotonergicneurotransmittersystem(includingtriptans,SSRIs,

SNRIs,lithium,sibutramine,tramadol,orSt.John'swort[Hypericumperforatum]),withmedicinalagentswhich

impairmetabolismofserotonin(includingMAOIs),orwithserotoninprecursors(suchastryptophansupplements).

IfconcomitanttreatmentofvenlafaxinewithanSSRI,anSNRIoraserotoninreceptoragonist(triptan)isclinically

warranted,carefulobservationofthepatientisadvised,particularlyduringtreatmentinitiationanddoseincreases.The

concomitantuseofvenlafaxinewithserotoninprecursors(suchastryptophansupplements)isnotrecommended(see

section4.4).

CNS-activesubstances

TheriskofusingvenlafaxineincombinationwithotherCNS-activesubstanceshasnotbeensystematicallyevaluated.

Consequently,cautionisadvisedwhenvenlafaxineistakenincombinationwithotherCNS-activesubstances.

Ethanol

Venlafaxinehasbeenshownnottoincreasetheimpairmentofmentalandmotorskillscausedbyethanol.However,as

withallCNS-activesubstances,patientsshouldbeadvisedtoavoidalcoholconsumption.

Effectofothermedicinalproductsonvenlafaxine

Ketoconazole(CYP3A4inhibitor)

ApharmacokineticstudywithketoconazoleinCYP2D6extensive(EM)andpoormetabolisers(PM)resultedinhigher

AUCofvenlafaxine(70%and21%inCYP2D6PMandEMsubjects,respectively)andO-desmethylvenlafaxine(33%

and23%inCYP2D6PMandEMsubjects,respectively)followingadministrationofketoconazole.Concomitantuseof

CYP3A4inhibitors(e.g.,atazanavir,clarithromycin,indinavir,itraconazole,voriconazole,posaconazole,ketoconazole,

nelfinavir,ritonavir,saquinavir,telithromycin)andvenlafaxinemayincreaselevelsofvenlafaxineand

O-desmethylvenlafaxine.Therefore,cautionisadvisedifapatient’stherapyincludesaCYP3A4inhibitorand

venlafaxineconcomitantly.

Effectofvenlafaxineonothermedicinalproducts

Lithium

Serotoninsyndromemayoccurwiththeconcomitantuseofvenlafaxineandlithium(seeSerotoninsyndrome).

Diazepam

Venlafaxinehasnoeffectsonthepharmacokineticsandpharmacodynamicsofdiazepamanditsactivemetabolite,

desmethyldiazepam.Diazepamdoesnotappeartoaffectthepharmacokineticsofeithervenlafaxineor

O-desmethylvenlafaxine.Itisunknownwhetherapharmacokineticand/orpharmacodynamicinteractionwithother

benzodiazepinesexists.

Imipramine

Venlafaxinedidnotaffectthepharmacokineticsofimipramineand2-OH-imipramine.Therewasadose-dependent

increaseof2-OH-desipramineAUCby2.5to4.5-foldwhenvenlafaxine75mgto150mgdailywasadministered.

ImipraminedidnotaffectthepharmacokineticsofvenlafaxineandO-desmethylvenlafaxine.Theclinicalsignificance

ofthisinteractionisunknown.Cautionshouldbeexercisedwithco-administrationofvenlafaxineandimipramine.

Haloperidol

Apharmacokineticstudywithhaloperidolhasshowna42%decreaseintotaloralclearance,a70%increaseinAUC,

an88%increaseinC

,butnochangeinhalf-lifeforhaloperidol.Thisshouldbetakenintoaccountinpatients

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Risperidone

VenlafaxineincreasedtherisperidoneAUCby50%,butdidnotsignificantlyalterthepharmacokineticprofileofthe

totalactivemoiety(risperidoneplus9-hydroxyrisperidone).Theclinicalsignificanceofthisinteractionisunknown.

Metoprolol

Concomitantadministrationofvenlafaxineandmetoprololtohealthyvolunteersinapharmacokineticinteractionstudy

forbothmedicinalproductsresultedinanincreaseofplasmaconcentrationsofmetoprololbyapproximately30-40%

withoutalteringtheplasmaconcentrationsofitsactivemetabolite,-hydroxymetoprolol.Theclinicalrelevanceofthis

findinginhypertensivepatientsisunknown.Metoprololdidnotalterthepharmacokineticprofileofvenlafaxineorits

activemetabolite,O-desmethylvenlafaxine.Cautionshouldbeexercisedwithco-administrationofvenlafaxineand

metoprolol.

Indinavir

Apharmacokineticstudywithindinavirhasshowna28%decreaseinAUCanda36%decreaseinC

forindinavir.

IndinavirdidnotaffectthepharmacokineticsofvenlafaxineandO-desmethylvenlafaxine.Theclinicalsignificanceof

thisinteractionisunknown.

4.6Pregnancyandlactation

Pregnancy

Therearenoadequatedatafromtheuseofvenlafaxineinpregnantwomen.

Studiesinanimalshaveshownreproductivetoxicity(seesection5.3).Thepotentialriskforhumansisunknown.

Venlafaxinemustonlybeadministeredtopregnantwomeniftheexpectedbenefitsoutweighanypossiblerisk.

Aswithotherserotoninreuptakeinhibitors(SSRIs/SNRIs),discontinuationsymptomsmayoccurinthenewbornsif

venlafaxineisuseduntilorshortlybeforebirth.Somenewbornsexposedtovenlafaxinelateinthethirdtrimesterhave

developedcomplicationsrequiringtube-feeding,respiratorysupportorprolongedhospitalisation.Suchcomplications

canariseimmediatelyupondelivery.

ThefollowingsymptomsmaybeobservedinneonatesifthemotherhasusedanSSRI/SNRIlateinpregnancy:

irritability,tremor,hypotonia,persistentcrying,anddifficultyinsuckingorinsleeping.Thesesymptomsmaybedue

toeitherserotonergiceffectsorexposuresymptoms.Inthemajorityofcases,thesecomplicationsareobserved

immediatelyorwithin24hoursafterpartus.

Lactation

Venlafaxineanditsactivemetabolite,O-desmethylvenlafaxine,areexcretedinbreastmilk.Arisktothesucklingchild

cannotbeexcluded.Therefore,adecisiontocontinue/discontinuebreast-feedingortocontinue/discontinuetherapy

withEfexordepotshouldbemade,takingintoaccountthebenefitofbreast-feedingtothechildandthebenefitof

Efexordepottherapytothewoman.

EpidemiologicaldatahavesuggestedthattheuseofSSRIsinpregnancy,particularlyinlatepregnancies,mayincrease

theriskofpotentialpulmonaryhypertensioninthenewborn(PPHN).Althoughthereisnoevidencefortheassociation

ofPPHNtoSNRItreatment,thispotentialriskcannotberuledoutwithEfexorXLtakingintoaccounttherelated

mechanismsofaction(inhibitionofthere-uptakeofserotonin).

4.7Effectsonabilitytodriveandusemachines

Anypsychoactivemedicinalproductmayimpairjudgment,thinking,andmotorskills.Therefore,anypatientreceiving

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4.8Undesirableeffects

Themostcommonly(>1/10)reportedadversereactionsinclinicalstudieswerenausea,drymouth,headacheand

sweating(includingnightsweats).

Adversereactionsarelistedbelowbysystemorganclassandfrequency.

Frequenciesaredefinedas:verycommon(1/10),common(1/100to<1/10),uncommon(1/1,000to<1/100),rare

(1/10,000to<1/1,000),notknown(cannotbeestimatedfromtheavailabledata).

BodySystem Very

Common Common Uncommon Rare NotKnown

Haemato-

logical/

Lymphatic Ecchymosis,

Gastrointestinal

haemorrhage Mucousmembrane

bleeding,Prolonged

bleedingtime,

Thrombocytopaenia,

Blooddyscrasias,

(including

agranulocytosis,

aplasticanaemia,

neutropaeniaand

pancytopaenia)

Metabolic/

Nutritional Serumcholesterol

increased,Weight

loss Weightgain Abnormalliver

functiontests,

Hyponatraemia,

Hepatitis,Syndromeof

Inappropriate

AntidiureticHormone

Secretion(SIADH),

Prolactinincreased

Nervous Dry

mouth

(10.0%),

Headache

(30.3%)* Abnormaldreams,

Decreasedlibido,

Dizziness,Increased

muscletonus

(hypertonia),

Insomnia,

Nervousness,

Paresthesia,

Sedation,Tremor,

Confusion,

Apathy,

Hallucinations,

Myoclonus,

Agitation,

Impaired

coordinationand

balance Akathisia/

Psychomotor

restlessness,

Convulsion,

Manicreaction NeurolepticMalignant

Syndrome(NMS),

Serotonergicsyndrome,

Delirium,

Extrapyramidal

reactions(including

dystoniaand

dyskinaesia),tardive

dyskinaesia,Suicidal

ideationand

behaviours**

Special

Senses Abnormalityof

accommodation,

Mydriasis,Visual

disturbance, Alteredtaste

sensation,

Tinnitus Angle-closure

glaucoma

Cardio-

vascular Hypertension,

Vasodilatation

(mostlyhot

flashes/flushes),

Palpitations Postural

hypotension,

Syncope,

Tachycardia Hypotension,QT

prolongation,

Ventricularfibrillation,

Ventriculartachycardia

(includingtorsadede

pointes)

Respiratory Yawning Pulmonaryeosinophilia

Digestive Nausea

(20.0%) Appetitedecreased

(anorexia),

Constipation, Bruxism,

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*Inpooledclinicaltrials,theincidenceofheadachewas30.3%withvenlafaxineversus31.3%withplacebo.

**Casesofsuicidalideationandsuicidalbehaviourshavebeenreportedduringvenlafaxinetherapyorearlyafter

treatmentdiscontinuation(seesection4.4).

Discontinuationofvenlafaxine(particularlywhenabrupt)commonlyleadstowithdrawalsymptoms.Dizziness,

sensorydisturbances(includingparaethesia),sleepdisturbances(includinginsomniaandintensedreams),agitationor

anxiety,nauseaand/orvomiting,tremor,headacheandflusyndromearethemostcommonlyreportedreactions.

Generally,theseeventsaremildtomoderateandareself-limiting;however,insomepatients,theymaybesevere

and/orprolonged.Itisthereforeadvisedthatwhenvenlafaxinetreatmentisnolongerrequired,gradualdiscontinuation

bydosetaperingshouldbecarriedout(seesections4.2and4.4).

Paediatricpatients

Ingeneral,theadversereactionprofileofvenlafaxine(inplacebo-controlledclinicaltrials)inchildrenandadolescents

(ages6to17)wassimilartothatseenforadults.Aswithadults,decreasedappetite,weightloss,increasedblood

pressure,andincreasedserumcholesterolwereobserved(seesection4.4).

Inpaediatricclinicaltrialstheadversereactionsuicidalideationwasobserved.Therewerealsoincreasedreportsof

hostilityand,especiallyinmajordepressivedisorder,self-harm.

Particularly,thefollowingadversereactionswereobservedinpaediatricpatients:abdominalpain,agitation,dyspepsia,

ecchymosis,epistaxis,andmyalgia.

4.9Overdose

Inpostmarketingexperience,overdosewithvenlafaxinewasreportedpredominantlyincombinationwithalcohol

and/orothermedicinalproducts.

Themostcommonlyreportedeventsinoverdoseincludetachycardia,changesinlevelofconsciousness(rangingfrom

Vomiting

Skin Sweating

(including

night

sweats)

[12.2%] Rash,Alopecia Erythemamultiforme,

Toxicepidermal

necrolysis,Stevens-

Johnsonsyndrome,

Pruritus,Urticaria

Musculo-

skeletal Rhabdomyolysis

Urogenital Abnormal

ejaculation/orgasm

(males),Anorgasmia,

Erectiledysfunction

(impotence),

Urinationimpaired

(mostlyhesitancy),

Menstrualdisorders

associatedwith

increasedbleedingor

increasedirregular

bleeding(e.g.,

menorrhagia,

metrorrhagia),

Abnormal

orgasm

(females),

Urinary

retention

Bodyasa

Whole Asthenia(fatigue),

Chills Photo-

sensitivity

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changes(e.g.,prolongationofQTinterval,bundlebranchblock,QRSprolongation),ventriculartachycardia,

bradycardia,hypotension,vertigo,anddeath.

Publishedretrospectivestudiesreportthatvenlafaxine,overdosagemaybeassociatedwithanincreasedriskoffatal

outcomescomparedtothatobservedwithSSRIantidepressantproducts,butlowerthanthatfortricyclic

antidepressants.

Epidemiologicalstudieshaveshownthatvenlafaxine-treatedpatientshaveahigherburdenofsuicideriskfactorsthan

SSRIpatients.Theextenttowhichthefindingofanincreasedriskoffataloutcomescanbeattributedtothetoxicityof

venlafaxineinoverdosageasopposedtosomecharacteristicsofvenlafaxine-treatedpatientsisnotclear.Prescriptions

ofvenlafaxineshouldbewrittenforthesmallestquantityofdrugconsistentwithgoodpatientmanagement,inorderto

reducetheriskofoverdose.

RecommendedTreatment

Generalsupportiveandsymptomaticmeasuresarerecommended;cardiacrhythmandvitalsignsmustbemonitored.

Whenthereisariskofaspiration,inductionofemesisisnotrecommended.

GastricLavagemaybeindicatedifperformedsoonafteringestionorinsymptomaticpatients.

Administrationofactivatedcharcoalmayalsolimitabsorptionoftheactivesubstance.

Forceddiuresis,dialysis,hemoperfusionandexchangetransfusionareunlikelytobeofbenefit.

Nospecificantidotesforvenlafaxineareknown

5PHARMACOLOGICALPROPERTIES

5.1Pharmacodynamicproperties

Pharmacotherapeuticgroup:Otherantidepressants-ATCcode:NO6AX16.

Themechanismofvenlafaxine'santidepressantactioninhumansisbelievedtobeassociatedwithitspotentiationof

neurotransmitteractivityinthecentralnervoussystem.Preclinicalstudieshaveshownthatvenlafaxineanditsmajor

metabolite,O-desmethylvenlafaxine(ODV),areinhibitorsofserotoninandnoradrenalinereuptake.Venlafaxinealso

weaklyinhibitsdopamineuptake.Venlafaxineanditsactivemetabolitereduce-adrenergicresponsivenessafterboth

acute(singledose)andchronicadministration.VenlafaxineandODVareverysimilarwithrespecttotheiroverall

actiononneurotransmitterreuptakeandreceptorbinding.

Venlafaxinehasvirtuallynoaffinityforratbrainmuscarinic,cholinergic,H

-histaminergicor

-adrenergicreceptors

invitro.Pharmacologicalactivityatthesereceptorsmayberelatedtovarioussideeffectsseenwithother

antidepressantmedicinalproducts,suchasanticholinergic,sedativeandcardiovascularsideeffects.

Venlafaxinedoesnotpossessmonoamineoxidase(MAO)inhibitoryactivity.

Invitrostudiesrevealedthatvenlafaxinehasvirtuallynoaffinityforopiateorbenzodiazepinesensitivereceptors.

Majordepressiveepisodes

Theefficacyofvenlafaxineimmediate-releaseasatreatmentformajordepressiveepisodeswasdemonstratedinfive

randomised,double-blind,placebo-controlled,short-termtrialsrangingfrom4to6weeksduration,fordosesupto

375mg/day.Theefficacyofvenlafaxineprolonged-releaseasatreatmentformajordepressiveepisodeswas

establishedintwoplacebo-controlled,short-termstudiesfor8and12weeksduration,whichincludedadoserangeof

75to225mg/day.

Inonelonger-termstudy,adultoutpatientswhohadrespondedduringan8-weekopentrialonvenlafaxine

prolonged-release(75,150,or225mg)wererandomisedtocontinuationoftheirsamevenlafaxineprolonged-release

doseortoplacebo,forupto26weeksofobservationforrelapse.

Inasecondlonger-termstudy,theefficacyofvenlafaxineinpreventionofrecurrentdepressiveepisodesfora

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majordepressiveepisodeswhohadrespondedtovenlafaxinetreatment(100to200mg/day,onab.i.d.schedule)onthe

lastepisodeofdepression.

Generalisedanxietydisorder

Theefficacyofvenlafaxineprolonged-releasecapsulesasatreatmentforgeneralisedanxietydisorder(GAD)was

establishedintwo8-week,placebo-controlled,fixed-dosestudies(75to225mg/day),one6-month,placebo-controlled,

fixed-dosestudy(75to225mg/day),andone6-month,placebo-controlled,flexible-dosestudy(37.5,75,and

150mg/day)inadultoutpatients.

Whiletherewasalsoevidenceforsuperiorityoverplaceboforthe37.5mg/daydose,thisdosewasnotasconsistently

effectiveasthehigherdoses.

Socialanxietydisorder

Theefficacyofvenlafaxineprolonged-releasecapsulesasatreatmentforsocialanxietydisorderwasestablishedin

fourdouble-blind,parallel-group,12-week,multi-center,placebo-controlled,flexible-dosestudiesandonedouble-

blind,parallel-group,6-month,placebo-controlled,fixed/flexible-dosestudyinadultoutpatients.Patientsreceived

dosesinarangeof75to225mg/day.Therewasnoevidenceforanygreatereffectivenessofthe150to225mg/day

groupcomparedtothe75mg/daygroupinthe6-monthstudy.

Panicdisorder

Theefficacyofvenlafaxineprolonged-releasecapsulesasatreatmentforpanicdisorderwasestablishedintwodouble-

blind,12-week,multi-center,placebo-controlledstudiesinadultoutpatientswithpanicdisorder,withorwithout

agoraphobia.Theinitialdoseinpanicdisorderstudieswas37.5mg/dayfor7days.Patientsthenreceivedfixeddoses

of75or150mg/dayinonestudyand75or225mg/dayintheotherstudy.

Efficacywasalsoestablishedinonelong-termdouble-blind,placebo-controlled,parallel-groupstudyofthelong-term

safety,efficacy,andpreventionofrelapseinadultoutpatientswhorespondedtoopen-labeltreatment.Patients

continuedtoreceivethesamedoseofvenlafaxineprolonged-releasethattheyhadtakenattheendoftheopen-label

phase(75,150,or225mg).

5.2Pharmacokineticproperties

Venlafaxineisextensivelymetabolised,primarilytotheactivemetabolite,O-desmethylvenlafaxine(ODV).Mean±

SDplasmahalf-livesofvenlafaxineandODVare5±2hoursand11±2hours,respectively.Steady-stateconcentrations

ofvenlafaxineandODVareattainedwithin3daysoforalmultiple-dosetherapy.VenlafaxineandODVexhibitlinear

kineticsoverthedoserangeof75mgto450mg/day.

Absorption

Atleast92%ofvenlafaxineisabsorbedfollowingsingleoraldosesofimmediate-releasevenlafaxine.Absolute

bioavailabilityis40%to45%duetopresystemicmetabolism.Afterimmediate-releasevenlafaxineadministration,the

peakplasmaconcentrationsofvenlafaxineandODVoccurin2and3hours,respectively.Followingtheadministration

ofvenlafaxineprolonged-releasecapsules,peakplasmaconcentrationsofvenlafaxineandODVareattainedwithin5.5

hoursand9hours,respectively.Whenequaldailydosesofvenlafaxineareadministeredaseitheranimmediate-release

tabletorprolonged-releasecapsule,theprolonged-releasecapsuleprovidesaslowerrateofabsorption,butthesame

extentofabsorptioncomparedwiththeimmediate-releasetablet.Fooddoesnotaffectthebioavailabilityofvenlafaxine

andODV.

Distribution

VenlafaxineandODVareminimallyboundattherapeuticconcentrationstohumanplasmaproteins(27%and30%,

respectively).Thevolumeofdistributionforvenlafaxineatsteady-stateis4.4±1.6L/kgfollowingintravenous

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Metabolism

Venlafaxineundergoesextensivehepaticmetabolism.Invitroandinvivostudiesindicatethatvenlafaxineis

biotransformedtoitsmajoractivemetabolite,ODV,byCYP2D6.Invitroandinvivostudiesindicatethatvenlafaxine

ismetabolisedtoaminor,lessactivemetabolite,N-desmethylvenlafaxine,byCYP3A4.Invitroandinvivostudies

indicatethatvenlafaxineisaweakinhibitorofCYP2D6.VenlafaxinedidnotinhibitCYP1A2,CYP2C9,orCYP3A4.

Elimination

Venlafaxineanditsmetabolitesareexcretedprimarilythroughthekidneys.Approximately87%ofavenlafaxinedose

isrecoveredintheurinewithin48hoursaseitherunchangedvenlafaxine(5%),unconjugatedODV(29%),conjugated

ODV(26%),orotherminorinactivemetabolites(27%).Mean±SDplasmasteady-stateclearancesofvenlafaxineand

ODVare1.3±0.6L/h/kgand0.4±0.2L/h/kg,respectively.

Specialpopulations

Ageandgender

SubjectageandgenderdonotsignificantlyaffectthepharmacokineticsofvenlafaxineandODV.

CYP2D6extensive/poormetabolisers

PlasmaconcentrationsofvenlafaxinearehigherinCYP2D6poormetabolisersthanextensivemetabolisers.Because

thetotalexposure(AUC)ofvenlafaxineandODVissimilarinpoorandextensivemetabolisers,thereisnoneedfor

differentvenlafaxinedosingregimensforthesetwogroups.

Patientswithhepaticimpairment

InChild-PughA(mildlyhepaticallyimpaired)andChild-PughB(moderatelyhepaticallyimpaired)subjects,

venlafaxineandODVhalf-liveswereprolongedcomparedtonormalsubjects.Theoralclearanceofbothvenlafaxine

andODVwasreduced.Alargedegreeofintersubjectvariabilitywasnoted.Therearelimiteddatainpatientswith

severehepaticimpairment(seesection4.2).

Patientswithrenalimpairment

Indialysispatients,venlafaxineeliminationhalf-lifewasprolongedbyabout180%andclearancereducedbyabout

57%comparedtonormalsubjects,whileODVeliminationhalf-lifewasprolongedbyabout142%andclearance

reducedbyabout56%.Dosageadjustmentisnecessaryinpatientswithsevererenalimpairmentandinpatientsthat

requirehaemodialysis(seesection4.2).

5.3Preclinicalsafetydata

Studieswithvenlafaxineinratsandmicerevealednoevidenceofcarcinogenesis.Venlafaxinewasnotmutagenicina

widerangeofinvitroandinvivotests.

Animalstudiesregardingreproductivetoxicityhavefoundinratsadecreaseinpupweight,anincreaseinstillborn

pups,andanincreaseinpupdeathsduringthefirst5daysoflactation.Thecauseofthesedeathsisunknown.These

effectsoccurredat30mg/kg/day,4timesthehumandailydoseof375mgofvenlafaxine(onanmg/kgbasis).The

no-effectdoseforthesefindingswas1.3timesthehumandose.Thepotentialriskforhumansisunknown.

ReducedfertilitywasobservedinastudyinwhichbothmaleandfemaleratswereexposedtoODV.Thisexposurewas

approximately1to2timesthatofahumanvenlafaxinedoseof375mg/day.Thehumanrelevanceofthisfindingis

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6PHARMACEUTICALPARTICULARS

6.1Listofexcipients

Microcrystallinecellulose

Ethylcellulose

Hypromellose

Gelatin

Redironoxide(E172)

Yellowironoxide(E172)

TitaniumDioxide(E171)

Printingink(Shellacinethanol,butylalcohol,isopropylalcohol,propyleneglycol,sodiumhydroxide,polyvinyl

pyrrolidone,titaniumdioxide(E171))

6.2Incompatibilities

Notapplicable.

6.3ShelfLife

Theshelflifeexpirydateforthisproductshallbethedateshownonthecontainerandouterpackageoftheproducton

themarketinthecountryoforigin.

6.4Specialprecautionsforstorage

Storeintheoriginalpackage.Donotstoreabove25°C.

6.5Natureandcontentsofcontainer

Blisterpackswithpush-throughfoillidding,packsize10.

6.6Specialprecautionsfordisposal

Nospecialrequirements.

7PARALLELPRODUCTAUTHORISATIONHOLDER

B&SHealthcare

Unit4BradfieldRoad

Ruislip

MiddlesexHA40NU

UnitedKingdom

8PARALLELPRODUCTAUTHORISATIONNUMBER

PPA1328/118/3

9DATEOFFIRSTAUTHORISATION/RENEWALOFTHEAUTHORISATION

Dateoffirstauthorisation:23 rd

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10DATEOFREVISIONOFTHETEXT

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