l TREATMENT CESSATION Associated with a higher risk of
withdrawal reactions. The dose should preferably be
reduced gradually over about 4 weeks, or longer if
withdrawal symptoms emerge (6 months in patients who
have been on long-term maintenance treatment).
Driving and skilled tasks Patients should be counselled
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 5, 21
▶ Seroxat (GlaxoSmithKline UK Ltd)
Paroxetine (as Paroxetine hydrochloride) 2 mg per 1 ml Seroxat
20mg/10ml liquid sugar-free | 150 ml P £9.12 DT = £9.12
CAUTIONARY AND ADVISORY LABELS 21
▶ Paroxetine (Non-proprietary)
Paroxetine (as Paroxetine hydrochloride) 10 mg Paroxetine 10mg
tablets | 28 tablet P £17.03 DT = £5.69
Paroxetine (as Paroxetine hydrochloride) 20 mg Paroxetine 20mg
tablets | 30 tablet P £12.18 DT = £1.12
Paroxetine (as Paroxetine hydrochloride) 30 mg Paroxetine 30mg
tablets | 30 tablet P £2.65 DT = £1.79
Paroxetine (as Paroxetine hydrochloride) 40 mg Paroxetine 40mg
tablets | 28 tablet P £16.99–£17.03 DT = £17.03 | 30 tablet P £18.25–£25.07
▶ Seroxat (GlaxoSmithKline UK Ltd)
Paroxetine (as Paroxetine hydrochloride) 10 mg Seroxat 10mg
tablets | 28 tablet P £14.21 DT = £5.69
Paroxetine (as Paroxetine hydrochloride) 20 mg Seroxat 20mg
tablets | 30 tablet P £15.23 DT = £1.12
Paroxetine (as Paroxetine hydrochloride) 30 mg Seroxat 30mg
tablets | 30 tablet P £26.74 DT = £1.79
▶ Adult: Initially 50 mg daily, then increased in steps of
50 mg at intervals of at least 1 week if required;
maintenance 50 mg daily; maximum 200 mg per day
▶ Adult: Initially 50 mg daily, then increased in steps of
50 mg at intervals of at least 1 week if required;
Panic disorder | Post-traumatic stress disorder | Social
▶ Adult: Initially 25 mg daily for 1 week, then increased
to 50 mg daily, then increased in steps of 50 mg at
intervals of at least 1 week if required, increase only if
response is partial and if drug is tolerated; maximum
l INTERACTIONS → Appendix 1: SSRIs
▶ Rare or very rare Balanoposthitis . bone disorder. cardiac
abnormal . genital discharge . glaucoma . hair texture
malignant syndrome . pancreatitis
l BREAST FEEDING Not known to be harmful but consider
l HEPATIC IMPAIRMENT Manufacturer advises avoid in
severe impairment (no information available).
Dose adjustments Manufacturer advises dose reduction or
increasing dose interval in mild to moderate impairment.
l RENAL IMPAIRMENT Use with caution.
l TREATMENT CESSATION The dose should preferably be
reduced gradually over about 4 weeks, or longer if
withdrawal symptoms emerge (6 months in patients who
have been on long-term maintenance treatment).
Driving and skilled tasks Patients should be counselled on
the effects on driving and skilled tasks.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: tablet, oral
▶ Sertraline (Non-proprietary)
Sertraline (as Sertraline hydrochloride) 50 mg Sertraline 50mg
tablets | 28 tablet P £17.00 DT = £0.82
Sertraline (as Sertraline hydrochloride) 100 mg Sertraline 100mg
tablets | 28 tablet P £28.00 DT = £1.08
Sertraline (as Sertraline hydrochloride) 50 mg Lustral 50mg
tablets | 28 tablet P £17.82 DT = £0.82
Sertraline (as Sertraline hydrochloride) 100 mg Lustral 100mg
tablets | 28 tablet P £29.16 DT = £1.08
ANTIDEPRESSANTS › SEROTONIN AND
NORADRENALINE RE-UPTAKE INHIBITORS
l DRUG ACTION Inhibits the re-uptake of serotonin and
▶ Adult: 60 mg once daily continued→
▶ Adult: Initially 30 mg once daily, increased if necessary
to 60 mg once daily; maximum 120 mg per day
▶ Adult: 60 mg once daily, discontinue if inadequate
response after 2 months; review treatment at least
every 3 months, maximum dose to be given in divided
Moderate to severe stress urinary incontinence
▶ Adult (female): 40 mg twice daily, patient should be
assessed for benefit and tolerability after 2–4 weeks,
alternatively initially 20 mg twice daily for 2 weeks, this
can minimise side effects, then increased to 40 mg
twice daily, the patient should be assessed for benefit
and tolerability after 2–4 weeks.
if uncontrolled).raised intra-ocular pressure . susceptibility to angle-closure glaucoma
l INTERACTIONS → Appendix 1: duloxetine
dysfunction . skin reactions . sleep disorders . sweat
changes .tinnitus .tremor. urinary disorders . vision
disorders . vomiting . weight changes . yawning
tendencies . syncope .taste altered .temperature sensation
altered .testicular pain .thirst.throat tightness . vertigo
disorders . seizure . serotonin syndrome . SIADH . StevensJohnson syndrome . urine odour abnormal
l PREGNANCY Toxicity in animal studies—avoid in patients
with stress urinary incontinence; in other conditions use
only if potential benefit outweighs risk. Risk of neonatal
withdrawal symptoms if used near term.
l BREAST FEEDING Present in milk—manufacturer advises
l HEPATIC IMPAIRMENT Manufacturer advises avoid.
l RENAL IMPAIRMENT Avoid if eGFR less than
l TREATMENT CESSATION Nausea, vomiting, headache,
anxiety, dizziness, paraesthesia, sleep disturbances, and
tremor are the most common features of abrupt
withdrawal or marked reduction of the dose; dose should
be reduced over at least 1–2 weeks.
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
▶ With oral use for Diabetic neuropathy The Scottish Medicines
Consortium has advised (September 2006) that duloxetine
(Cymbalta ®) should be restricted for use by specialists
when other treatments for diabetic peripheral neuropathic
pain are unsuitable or inadequate.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 2
▶ Duloxetine (Non-proprietary)
Duloxetine (as Duloxetine hydrochloride) 20 mg Duloxetine 20mg
gastro-resistant capsules | 28 capsule P £18.48 DT = £3.53
Duloxetine (as Duloxetine hydrochloride) 30 mg Duloxetine 30mg
gastro-resistant capsules | 28 capsule P £22.40 DT = £1.68
Duloxetine (as Duloxetine hydrochloride) 40 mg Duloxetine 40mg
gastro-resistant capsules | 56 capsule P £36.96 DT = £5.40
Duloxetine (as Duloxetine hydrochloride) 60 mg Duloxetine 60mg
gastro-resistant capsules | 28 capsule P £27.72 DT = £2.37
▶ Cymbalta (Eli Lilly and Company Ltd)
Duloxetine (as Duloxetine hydrochloride) 30 mg Cymbalta 30mg
gastro-resistant capsules | 28 capsule P £22.40 DT = £1.68
Duloxetine (as Duloxetine hydrochloride) 60 mg Cymbalta 60mg
gastro-resistant capsules | 28 capsule P £27.72 DT = £2.37
▶ Depalta (Disposable Medical Equipment Ltd)
Duloxetine (as Duloxetine hydrochloride) 30 mg Depalta 30mg
gastro-resistant capsules | 28 capsule P £2.95 DT = £1.68
Duloxetine (as Duloxetine hydrochloride) 60 mg Depalta 60mg
gastro-resistant capsules | 28 capsule P £4.25 DT = £2.37
▶ Duciltia (Aristo Pharma Ltd)
Duloxetine (as Duloxetine hydrochloride) 30 mg Duciltia 30mg
gastro-resistant capsules | 28 capsule P £22.40 DT = £1.68
Duloxetine (as Duloxetine hydrochloride) 60 mg Duciltia 60mg
gastro-resistant capsules | 28 capsule P £27.72 DT = £2.37
▶ Dutor (Torrent Pharma (UK) Ltd)
Duloxetine (as Duloxetine hydrochloride) 20 mg Dutor 20mg
gastro-resistant capsules | 28 capsule P s DT = £3.53
Duloxetine (as Duloxetine hydrochloride) 30 mg Dutor 30mg
gastro-resistant capsules | 28 capsule P s DT = £1.68
Duloxetine (as Duloxetine hydrochloride) 40 mg Dutor 40mg
gastro-resistant capsules | 56 capsule P s DT = £5.40
Duloxetine (as Duloxetine hydrochloride) 60 mg Dutor 60mg
gastro-resistant capsules | 28 capsule P s DT = £2.37
▶ Yentreve (Eli Lilly and Company Ltd)
Duloxetine (as Duloxetine hydrochloride) 20 mg Yentreve 20mg
gastro-resistant capsules | 28 capsule P £18.48 DT = £3.53
Duloxetine (as Duloxetine hydrochloride) 40 mg Yentreve 40mg
gastro-resistant capsules | 56 capsule P £36.96 DT = £5.40
l DRUG ACTION A serotonin and noradrenaline re-uptake
▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES
▶ Adult: Initially 75 mg daily in 2 divided doses, then
increased if necessary up to 375 mg daily, dose to be
increased if necessary at intervals of at least 2 weeks,
faster dose titration may be necessary in some
patients; maximum 375 mg per day
▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES
▶ Adult: Initially 75 mg once daily, increased if necessary
up to 375 mg once daily, dose to be increased if
necessary at intervals of at least 2 weeks, faster dose
titration may be necessary in some patients; maximum
▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES
▶ Adult: 75 mg once daily, increased if necessary up to
225 mg once daily, dose to be increased at intervals of
at least 2 weeks; maximum 225 mg per day
▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES
▶ Adult: 75 mg once daily, there is no evidence of greater
efficacy at higher doses, increased if necessary up to
225 mg once daily, dose to be increased if necessary at
intervals of at least 2 weeks; maximum 225 mg per day
368 Mental health disorders BNF 78
Menopausal symptoms, particularly hot flushes, in women
▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES
▶ Adult: 37.5 mg once daily for one week, then increased
if necessary to 75 mg once daily
l UNLICENSED USE g Venlafaxine is used for menopausal
symptoms, hbut it is not licensed for this indication.
l CONTRA-INDICATIONS Conditions associated with high risk
of cardiac arrhythmia . uncontrolled hypertension
l CAUTIONS Diabetes . heart disease (monitor blood
pressure). history of bleeding disorders . history of
epilepsy . history or family history of mania . susceptibility
l INTERACTIONS → Appendix 1: venlafaxine
cycle irregularities . movement disorders . muscle tone
▶ Uncommon Alopecia . angioedema . apathy . behaviour
syndrome . severe cutaneous adverse reactions (SCARs). SIADH .thrombocytopenia
▶ Frequency not known Suicidal tendencies . vertigo . withdrawal syndrome
l PREGNANCY Avoid unless potential benefit outweighs
risk—toxicity in animal studies. Risk of withdrawal effects
l BREAST FEEDING Present in milk—avoid.
l HEPATIC IMPAIRMENT Manufacturer advises caution
(inter-individual variability in clearance; limited
information available in severe impairment).
Dose adjustments Manufacturer advises consider dose
reduction of 50% in mild to moderate impairment and of
more than 50% in severe impairment.
l RENAL IMPAIRMENT Use with caution.
Dose adjustments Use half normal dose (immediate-release
tablets may be given once daily) if eGFR less than
l TREATMENT CESSATION Associated with a higher risk of
withdrawal effects compared with other antidepressants.
Gastro-intestinal disturbances, headache, anxiety,
dizziness, paraesthesia, tremor, sleep disturbances, and
sweating are most common features of withdrawal if
treatment stopped abruptly or if dose reduced markedly;
dose should be reduced over several weeks.
Driving and skilled tasks May affect performance of skilled
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 3, 21, 25
▶ Sunveniz XL (Sun Pharmaceutical Industries Europe B.V.)
Venlafaxine (as Venlafaxine hydrochloride) 75 mg Sunveniz XL
75mg tablets | 30 tablet P £11.14 DT = £2.60
Venlafaxine (as Venlafaxine hydrochloride) 150 mg Sunveniz XL
150mg tablets | 30 tablet P £18.64 DT = £3.90
▶ Venladex XL (Dexcel-Pharma Ltd)
Venlafaxine (as Venlafaxine hydrochloride) 75 mg Venladex XL
75mg tablets | 28 tablet P £11.20
Venlafaxine (as Venlafaxine hydrochloride) 150 mg Venladex XL
150mg tablets | 28 tablet P £18.70
Venlafaxine (as Venlafaxine hydrochloride) 225 mg Venladex XL
225mg tablets | 28 tablet P £31.36
▶ Venlalic XL (Ethypharm UK Ltd)
Venlafaxine (as Venlafaxine hydrochloride) 37.5 mg Venlalic XL
37.5mg tablets | 30 tablet P £6.60 DT = £6.60
Venlafaxine (as Venlafaxine hydrochloride) 75 mg Venlalic XL
75mg tablets | 30 tablet P £2.60 DT = £2.60
Venlafaxine (as Venlafaxine hydrochloride) 150 mg Venlalic XL
150mg tablets | 30 tablet P £3.90 DT = £3.90
Venlafaxine (as Venlafaxine hydrochloride) 225 mg Venlalic XL
225mg tablets | 30 tablet P £33.60 DT = £33.60
▶ ViePax XL (Dexcel-Pharma Ltd)
Venlafaxine (as Venlafaxine hydrochloride) 75 mg ViePax XL
75mg tablets | 28 tablet P £2.60
Venlafaxine (as Venlafaxine hydrochloride) 150 mg ViePax XL
150mg tablets | 28 tablet P £3.90
Venlafaxine (as Venlafaxine hydrochloride) 225 mg ViePax XL
225mg tablets | 28 tablet P £31.36
CAUTIONARY AND ADVISORY LABELS 3
▶ Venlafaxine (Non-proprietary)
Venlafaxine (as Venlafaxine hydrochloride) 37.5 mg Venlafaxine
37.5mg tablets | 56 tablet P £6.99 DT = £2.23
Venlafaxine (as Venlafaxine hydrochloride) 75 mg Venlafaxine
75mg tablets | 56 tablet P £6.06 DT = £3.40
Venlafaxine (as Venlafaxine hydrochloride) 37.5 mg ViePax
37.5mg tablets | 56 tablet P £21.07 DT = £2.23
Venlafaxine (as Venlafaxine hydrochloride) 75 mg ViePax 75mg
tablets | 56 tablet P £35.13 DT = £3.40
CAUTIONARY AND ADVISORY LABELS 3, 21, 25
▶ Venlafaxine (Non-proprietary)
Venlafaxine (as Venlafaxine hydrochloride) 225 mg Venlafaxine
225mg modified-release capsules | 30 capsule P £44.75
▶ Alventa XL (Consilient Health Ltd)
Venlafaxine (as Venlafaxine hydrochloride) 75 mg Alventa XL
75mg capsules | 28 capsule P £19.12 DT = £2.60
Venlafaxine (as Venlafaxine hydrochloride) 150 mg Alventa XL
150mg capsules | 28 capsule P £31.88 DT = £3.90
▶ Apclaven XL (Torrent Pharma (UK) Ltd)
Venlafaxine (as Venlafaxine hydrochloride) 37.5 mg Apclaven XL
37.5mg capsules | 28 capsule P s DT = £5.25
Venlafaxine (as Venlafaxine hydrochloride) 75 mg Apclaven XL
75mg capsules | 28 capsule P s DT = £2.60
Venlafaxine (as Venlafaxine hydrochloride) 150 mg Apclaven XL
150mg capsules | 28 capsule P s DT = £3.90
Venlafaxine (as Venlafaxine hydrochloride) 75 mg Depefex XL
75mg capsules | 28 capsule P £10.40 DT = £2.60
Venlafaxine (as Venlafaxine hydrochloride) 150 mg Depefex XL
150mg capsules | 28 capsule P £17.40 DT = £3.90
Venlafaxine (as Venlafaxine hydrochloride) 75 mg Efexor XL 75mg
capsules | 28 capsule P £22.08 DT = £2.60
Venlafaxine (as Venlafaxine hydrochloride) 150 mg Efexor XL
150mg capsules | 28 capsule P £36.81 DT = £3.90
Venlafaxine (as Venlafaxine hydrochloride) 225 mg Efexor XL
225mg capsules | 28 capsule P £47.11 DT = £47.11
▶ Majoven XL (Bristol Laboratories Ltd)
Venlafaxine (as Venlafaxine hydrochloride) 37.5 mg Majoven XL
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