Venlafaxine insomnia

Venlafaxine extended release, in doses of 75 to 225 mg/day, improves social anxiety, performance, and avoidance behavior with a reduction in disability.61 Treatment with venlafaxine results in response rates similar to those seen with paroxetine.60 Venlafaxine may be effective in SSRI non-responders.62 As with SSRIs, doses should be tapered slowly when discontinuing therapy. Tolerability is similar to that observed in depression trials with venlafaxine extended release. Common side effects are anorexia, dry mouth, nausea, insomnia, and sexual dysfunction. 

Lorazepam is a short-acting benzodiazepine indicated for use in relieving anxiety and insomnia. Lorazepam may also be administered perioperatively to alleviate pain and in status epilepticus. Imipramine is a tricyclic antidepressant, paroxetine is a selective serotonin re-uptake inhibitor, venlafaxine is a serotonin and adrenaline re-uptake inhibitor and moclobemide is a reversible monoamine oxidase inhibitor. Imipramine, paroxetine, venlafaxine and moclobemide are all classified as antidepressants. 

Anxiety and Insomnia Anx ety, nervousness, and insomnia were reported for venlafaxine-treated patients, and led to drug discontinuation. 

Adverse reactions include nausea, nervousness, headache, insomnia, anxiety. Sexual dysfunction with loss of libido is a common complaint. Insomnia can be a problem. Urticaria and rashes have been described. Venlafaxine may significantly increase the risk of suicide and is therefore not recommended as a first line treatment of depression. The view that also fluoxetine and other SSRIs can lead to suicide is under debate for quite some time now. In most countries SSRIs are not approved for use in pediatric populations. In the UK and in the USA only fluoxetine can be prescribed for children. 

Venlafaxine is generally well tolerated. The most common adverse effects include nausea, drowsiness, insomnia, dizziness, headache, and dry mouth. At higher doses, elevations in blood pressure have been observed. 

Nierenberg AA, Amsterdam JD Resistant depression definition and treatment approaches. J Chn Psychiatry 51 (suppl) 39-47, 1990 Nierenberg AA, Adler LA, Peselow E, et al Trazodone for antidepressant-associated insomnia. Am J Psychiatry 151 1069-1072, 1994a Nierenberg AA, Feighner JP, Rudolph R, et al Venlafaxine for treatment-resistant unipolar depression. J Chn Psychopharmacol 14 419-423, 1994b... 

Although more stimulating antidepressants (e.g., bupropion, SSRIs, venlafaxine, or certain MAOIs) do not potentiate alcohol, they can produce insomnia. To minimize this problem, the dose may be given earlier in the day. TCAs may cause episodes of excitement (rare), confusion, or mania, usually in patients with an underlying psychotic illness, suggesting that a preexisting disorder must be present for these drugs to exert any psychotomimetic effects. 

SNRIs have many of the serotonergic adverse effects associated with SSRIs. In addition, SNRIs may also have noradrenergic effects, including increased blood pressure and heart rate, and CNS activation, such as insomnia, anxiety, and agitation. The hemodynamic effects of SNRIs tend not to be problematic in most patients. A dose-related increase in blood pressure has been seen more commonly with the immediate-release form of venlafaxine than with other SNRIs. Likewise, there are more reports of cardiac toxicity with venlafaxine overdose than with either the other SNRIs or SSRIs. Duloxetine is rarely associated with hepatic toxicity in patients with a history of liver damage. All the SNRIs have been associated with a discontinuation syndrome resembling that seen with SSRI discontinuation. 

Venlafaxine (Effexor), approved by the FDA in December 1993, was described in more detail early in this chapter. It is one of the newer antidepressants implicated in causing suicidality. It is a NSRI that also strongly inhibits the reuptake of epinephrine. Its profile is very similar to the SSRIs in producing stimulation, including anxiety, nervousness, insomnia, anorexia, and weight loss. It causes the various emotional and behavioral abnormalities that go along with stimulation, such as agitation and mania, and has been associated with hostility, paranoid reaction, psychotic depression, and psychosis. It can cause hypertension. 

Duloxetine has recently been marketed as an antidepressant in Europe. It inhibits the re-uptake of serotonin and noradrenaline, with minimal effects on other neurotransmitter mechanisms. It is therefore classified as a serotonin and noradrenaline re-uptake inhibitor (SNRI) and is grouped with venlafaxine. The adverse effect profile of duloxetine appears to be similar to that of the SSRIs and venlafaxine. In placebo-controlled trials the most common adverse effects were nausea (37%), dry mouth (32%), dizziness (22%), somnolence (20%), insomnia (20%), and diarrhea (14%). Sexual dysfunction has also been reported. Current data suggest that, unlike venlafaxine, duloxetine does not increase the blood pressure, but further post-marketing surveillance studies will be needed to confirm this (1). 

Like venlafaxine and the SSRIs, acute withdrawal of duloxetine causes a characteristic abstinence syndrome, with tachycardia, dizziness, insomnia, headache, and anxiety. 

A 72-year-old woman taking venlafaxine 150 mg/day for depression was abruptly switched to the noradrenaline re-uptake inhibitor maprotiline 75 mg/day 1 day later she developed agitation, sweating, nausea, vomiting, tinnitus, and insomnia (27). These symptoms continued for another week, but disappeared on the second day of sertraline treatment 50 mg/day. 

Adding mirtazapine to venlafaxine or SSRIs may reverse drug-induced anxiety and insomnia... 

Serotonin and norepinephrine reuptake inhibitors. The only member of this class which has received regulatory approval is venlafaxine (Effexor). Venlafaxine is a phenethylamine bicyclic derivative, chemically unrelated to tricyclic, tetracyclic or other available antidepressant agents. In a retrospective review of 35 consecutively treated overweight or obese outpatients with BED, venlafaxine 75-300 mg daily given for 1 to 43 weeks appeared to reduce the frequency of binge eating and to lower body weight (Malhotra et al. 2002). Reported side effects included dry mouth, sexual dysfunction, insomnia and nausea As there have thus far been no published randomised controlled trials, its place in the treatment of BED must remain uncertain. 

Patients should receive a 2-3 month initial course of treatment, with close monitoring for improvement in PTSD symptoms such as reexperiencing (flashbacks, nightmares), hyperarousal (insomnia and startle responses) and avoidance (30). Patients showing no improvement after 8 weeks of maximal doses are candidates for treatment with a different SSRI or with either venlafaxine or mirtazapine (30). Those with partial responses may need more time to respond to the first line SSRI (30). 

The most common adverse events of venlafaxine in patients with GAD were nausea, somnolence, and dry mouth." Paroxetine was associated with a high rate of somnolence, nausea, abnormal ejaculation, dry mouth, decreased libido, and asthenia compared with placebo." Escitalopram caused nausea, insomnia, fatigue, decreased libido, ejaculation disorders, and decreased libido at a higher rate than placebo in patients with GAD. The use of TCAs may be limited by troublesome adverse events (e.g., sedation, orthostatic hypotension,... 

Among the TCAs, desipramine and nortriptyline are the most recommended, since they have few anticholinergic side-effects. Sertraline has been studied in a placebo-controlled randomized trial and is considered one of the safest drugs for elderly patients post myocardial infarction, since it has no negative impact on cardiac measures. A number of placebo-controlled studies of post-stroke depression have shown efficacy for citalopram at doses of 10 mg and for nortriptyline (but not for fluoxetine). Venlafaxine may also be considered however, it should be used with caution since in 3-5% of patients it increases blood pressure. Mirtazapine may be used in patients with insomnia and decreased appetite due to its sedative side-effects and its promotion of increased appetite. ... 

Comparative trials Non-stimulant medications are being evaluated for the treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents as alternatives to stimulants. In these studies reduced appetite and restlessness were more common with methylphenidate than with amantadine [54 ], and headache and insomnia were more common with methylphenidate than with venlafaxine [55 ]. Nevertheless, these studies do not constitute proof of efficacy. 

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