Venlafaxin Sandoz
SUMMARY OF PRODUCT CHARACTERISTICS
1. NAME OF THE MEDICINAL PRODUCT
Venlafaxin Sandoz 25 mg tablets
Venlafaxin Sandoz 37.5 mg tablets
Venlafaxin Sandoz 50 mg tablets
Venlafaxin Sandoz 75 mg tablets
Venlafaxin Sandoz 150 mg tablets
2. QUALITATIVE AND QUANTITATIVE COMPOSITION
Venlafaxin Sandoz 25 mg:
Each tablet contains 25 mg venlafaxine as venlafaxine hydrochloride.
Excipient(s) with known effect: one tablet contains 17.39 mg lactose (as monohydrate).
Venlafaxin Sandoz 37.5 mg:
Each tablet contains 37.5 mg venlafaxine as venlafaxine hydrochloride.
Excipient(s) with known effect: one tablet contains 26.08 mg lactose (as monohydrate).
Venlafaxin Sandoz 50 mg:
Each tablet contains 50 mg venlafaxine as venlafaxine hydrochloride.
Excipient(s) with known effect: one tablet contains 34.77 mg lactose (as monohydrate).
Venlafaxin Sandoz 75 mg:
Each tablet contains 75 mg venlafaxine as venlafaxine hydrochloride.
Excipient(s) with known effect: one tablet contains 52.16 mg lactose (as monohydrate).
Venlafaxin Sandoz 150 mg:
Each tablet contains 150 mg venlafaxine as venlafaxine hydrochloride.
Excipient(s) with known effect: one tablet contains 104.31 mg lactose (as monohydrate).
For the full list of excipients, see section 6.1.
3. PHARMACEUTICAL FORM
Tablet
Venlafaxin Sandoz 25 mg:
Pale, red-brown or brownish, oblong tablet coded 2with a size of approximately 8.4 x 3.9 mm.
Venlafaxin Sandoz 37.5 mg:
Pale, red-brown or brownish, oblong tablet coded 3 with a size of approximately 10.3 x 4.5 mm.
Venlafaxin Sandoz 50 mg:
Pale, red-brown or brownish, oblong tablet, scored and coded 5 on each half with a size of approximately 11.5 x 5.0 mm. The tablet can be divided into equal doses.
Venlafaxin Sandoz 75 mg:
Pale, red-brown or brownish, oblong tablet, scored and coded 7 on each half with a size of approximately 13.8 x 5.6 mm.The tablet can be divided into equal doses.
Venlafaxin Sandoz 150 mg:
Pale, red-brown or brownish, oblong tablet, scored and coded 15 on each half with a size of approximately 18.0 x 7.3 mm.The tablet can be divided into equal doses.
4. Clinical particulars
4.1 Therapeutic indications
Treatment of major depressive episodes.
For prevention of recurrence of major depressive episodes.
4.2 Posology and method of administration
Posology
Major depressive episodes
The recommended starting dose of immediate-release venlafaxine is 75 mg/day in two or three divided doses taken with food. Patients not responding to the initial 75 mg/day dose may benefit from dose increases up to a maximum dose of 375 mg/day. Dosage increases can be made at intervals of 2 weeks or more. If clinically warranted due to symptom severity, dose increases can be made at more frequent intervals, but not less than 4 days.
Because of the risk of dose-related adverse effects, dose increments should be made only after a clinical evaluation (see section 4.4). The lowest effective dose should be maintained.
Patients should be treated for a sufficient period of time, usually several months or longer. Treatment should be reassessed regularly on a case-by-case basis. Longer-term treatment may also be appropriate for prevention of recurrence of major depressive episodes (MDE). In most of the cases, the recommended dose in prevention of recurrence of MDE is the same as the one used during the current episode.
Antidepressive medicinal products should continue for at least six months following remission.
Elderly
No specific dose adjustments of venlafaxine are considered necessary based on patient age alone.However, caution should be exercised in treating the elderly (e.g., due to the possibility of renal impairment, the potential for changes in neurotransmitter sensitivity and affinity occurring with aging). The lowest effective dose should always be used, and patients should be carefully monitored when an increase in the dose is required.
Paediatric population
Venlafaxine is not recommended for use in children and adolescents.
Controlled clinical studies in children and adolescents with major depressive disorder failed to demonstrate efficacy and do not support the use of venlafaxine in these patients (see sections 4.4 and 4.8).
The efficacy and safety of venlafaxine for other indications in children and adolescents under the age of 18 have not been established.
Hepatic impairment
In patients with mild and moderate hepatic impairment, in general a 50% dose reduction should be considered. However, due to inter-individual variability in clearance, individualisation of dosage may be desirable.
There are limited data in patients with severe hepatic impairment. Caution is advised, and a dose reduction by more than 50% should be considered. The potential benefit should be weighed against the risk in the treatment of patients with severe hepatic impairment.
Renal impairment
Although no change in dosage is necessary for patients with glomerular filtration rate (GFR) between 30‑70 ml/minute, caution is advised. For patients that require haemodialysis and in patients with severe renal impairment (GFR < 30 ml/min), the dose should be reduced by 50%. Because of inter‑individual variability in clearance in these patients, individualisation of dosage may be desirable.
Withdrawal symptoms seen on discontinuation of venlafaxine
Abrupt discontinuation should be avoided. When stopping treatment with Venlafaxin Sandoz the dose should be gradually reduced over a period of at least one to two weeks in order to reduce the risk of withdrawal reactions (see sections 4.4 and section 4.8). If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose, but at a more gradual rate.
Method of administration
For oral use.
It is recommended that venlafaxine immediate-release tablets be taken with food, at approximately the same time each day.
Patients treated with venlafaxine immediate‑release tablets may be switched to venlafaxine prolonged‑release capsules at the nearest equivalent daily dosage. For example, venlafaxine immediate‑release tablets 37.5 mg twice daily may be switched to venlafaxine prolonged‑release capsules 75 mg once daily. Individual dosage adjustments may be necessary.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
Concomitant treatment with irreversible monoamine oxidase inhibitors (MAOIs) is contraindicated due to the risk of serotonin syndrome with symptoms such as agitation, tremor and hyperthermia. Venlafaxine must not be initiated for at least 14 days after discontinuation of treatment with an irreversible MAOI.
Venlafaxine must be discontinued for at least 7 days before starting treatment with an irreversible MAOI (see sections 4.4 and 4.5).
4.4 Special warnings and precautions for use
Suicide/suicidal thoughts or clinical worsening
Depression is associated with an increased risk of suicidal thoughts, self-harm and suicide (suicide-related events). This risk persists until significant remission occurs. As improvement may not occur during the first few weeks or more of treatment, patients should be closely monitored until such improvement occurs. It is general clinical experience that the risk of suicide may increase in the early stages of recovery.
Other psychiatric conditions for which venlafaxine is prescribed can also be associated with an increased risk of suicide-related events. In addition, these conditions may be co-morbid with major depressive disorder. The same precautions observed when treating patients with major depressive disorder should therefore be observed when treating patients with other psychiatric disorders.
Patients with a history of suicide-related events, or those exhibiting a significant degree of suicidal ideation prior to commencement of treatment, are known to be at greater risk of suicidal thoughts or suicide attempts, and should receive careful monitoring during treatment. A meta-analysis of placebo-controlled clinical trials of antidepressant drugs in adult patients with psychiatric disorders showed an increased risk of suicidal behaviour with antidepressants compared to placebo in patients less than 25 years old.
Close supervision of patients, and in particular those at high risk, should accompany drug therapy, especially in early treatment and following dose changes. Patients (and caregivers of patients) should be alerted about the need to monitor for any clinical worsening, suicidal behaviour or thoughts and unusual changes in behaviour, and to seek medical advice immediately if these symptoms present.
Paediatric population
Venlafaxin Sandoz
should not be used in the treatment
of children and adolescents under the age of 18 years.
Suicide-related behaviours (suicide attempt and suicidal thoughts)
and hostility (predominantly aggression, oppositional behaviour and
anger) were more frequently observed in clinical trials among
children and adolescents treated with antidepressants compared to
those treated with placebo. If, based on clinical need, a decision
to treat is nevertheless taken, the patient should be carefully
monitored for the appearance of suicidal symptoms. In addition,
long-term safety data in children and adolescents concerning
growth, maturation and cognitive and behavioural development are
lacking.
Serotonin syndrome
As with other serotonergic agents, serotonin syndrome, of a potentially life‑threatening condition, may occur with venlafaxine treatment, particularly with concomitant use of other agents that may affect the serotonergic neurotransmitter system (including triptans, SSRIs, SNRIs, lithium, sibutramine, St.John’s Wort [Hypericum perforatum], fentanyland its analogues, tramadol, dextromethorphan, tapentadol, pethidine, methadone and pentazocine), with medicinal agents that impair metabolism of serotonin (such as MAOIs e.g. methylene blue), with serotonin precursors (such as tryptophan supplements) or with antipsychotics or other dopamine antagonists (see sections 4.3 and 4.5).
Serotonin syndrome symptoms may include mental status changes (e.g., agitation, hallucinations, coma), autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (e.g., hyperreflexia, incoordination) and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhoea). Serotonin syndrome in its most severe form, can resemble NMS, which includes hyperthermia, muscle rigidity, autonomic instability with possible rapid fluctuation of vital signs and mental status changes.
If concomitant treatment with venlafaxine and other agents that may affect the serotonergic and/or dopaminergic neurotransmitter systems is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases.
The concomitant use of venlafaxine with serotonin precursors (such as tryptophan supplements) is not recommended.
Narrow-angle glaucoma
Mydriasis may occur in association with venlafaxine. It is recommended that patients with raised intraocular pressure or patients at risk for acute narrow-angle glaucoma (angle-closure glaucoma) be closely monitored.
Blood pressure
Dose-related increases in blood pressure have been commonly reported with venlafaxine. In some cases, severely elevated blood pressure requiring immediate treatment has been reported in postmarketing experience. All patients should be carefully screened for high blood pressure and pre-existing hypertension should be controlled before initiation of treatment. Blood pressure should be reviewed periodically, after initiation of treatment and after dose increases. Caution should be exercised in patients whose underlying conditions might be compromised by increases in blood pressure, e.g., those with impaired cardiac function.
Heart rate
Increases in heart rate can occur, particularly with higher doses. Caution should be exercised in patients whose underlying conditions might be compromised by increases in heart rate.
Cardiac disease and risk of arrhythmia
Venlafaxine has not been evaluated in patients with a recent history of myocardial infarction or unstable heart disease. Therefore, it should be used with caution in these patients.
In postmarketing experience, cases of QTc prolongation, Torsades de Pointes (TdP), ventricular tachycardia, and fatal cardiac arrhythmias have been reported with the use of venlafaxine, especially in overdose or in patients with other risk factors for QTc prolongation/TdP. The balance of risks and benefits should be considered before prescribing venlafaxine to patients at high risk of serious cardiac arrhythmia or QTc prolongation.
Convulsions
Convulsions may occur with venlafaxine therapy. As with all antidepressants, venlafaxine should be introduced with caution in patients with a history of convulsions,and concerned patients should be closely monitored. Treatment should be discontinued in any patient who develops seizures.
Hyponatraemia
Cases of hyponatraemia and/or the Syndrome of Inappropriate Antidiuretic Hormone (SIADH) secretion may occur with venlafaxine. This has most frequently been reported in volume-depleted or dehydrated patients. Elderly patients, patients taking diuretics, and patients who are otherwise volume‑depleted may be at greater risk for this event.
Abnormal bleeding
Medicinal products that inhibit serotonin uptake may lead to reduced platelet function. TBleeding events related to SSRI and SNRI use have ranged from ecchymoses, hematomas, epistaxis, and petechiae togastrointestinal and life-threatening haemorrhages. The risk of haemorrhagemay be increased in patients taking venlafaxine. As with other serotonin-reuptake inhibitors, venlafaxine should be used cautiously in patients predisposed to bleeding, including patients on anticoagulants and platelet inhibitors.
Serum cholesterol
Clinically relevant increases in serum cholesterol were recorded in 5.3% of venlafaxine-treated patients and 0.0% of placebo-treated patients treated for at least 3 months in placebo-controlled clinical trials. Measurement of serum cholesterol levels should be considered during long-term treatment.
Co-administration with weight loss agents
The safety and efficacy of venlafaxine therapy in combination with weight loss agents, including phentermine, have not been established. Co-administration of venlafaxine and weight loss agents is not recommended. Venlafaxine is not indicated for weight loss alone or in combination with other products.
Mania/hypomania
Mania/hypomania may occur in a small proportion of patients with mood disorders who have received antidepressants, including venlafaxine. As with other antidepressants, venlafaxine should be used cautiously in patients with a history or family history of bipolar disorder.
Aggression
Aggression may occur in a small number of patients who have received antidepressants, including venlafaxine. This has been reported under initiation, dose changes and discontinuation of treatment.
As with other antidepressants, venlafaxine should be used cautiously in patients with a history of aggression.
Discontinuation of treatment
Withdrawal symptoms, when treatment is discontinued, are
common, particularly if discontinuation is abrupt (see section
4.8). In clinical trials,
adverse events seen on treatment discontinuation (tapering and
post-tapering) occurred in approximately 31% of patients treated
with venlafaxine and 17% of patients taking placebo.
The risk of withdrawal symptoms may be dependent on several factors, including the duration and dose of therapy and the rate of dose reduction. Dizziness, sensory disturbances (including paraesthesia), sleep disturbances (including insomnia and intense dreams), agitation or anxiety, nausea and/or vomiting, tremor and headache are the most commonly reported reactions. Generally, these symptoms are mild to moderate, however, in some patients they may be severe in intensity. They usually occur within the first few days of discontinuing treatment, but there have been very rare reports of such symptoms in patients who have inadvertently missed a dose. Generally, these symptoms are self-limiting and usually resolve within 2 weeks, though in some individuals they may be prolonged (2-3 months or more). It is therefore advised that venlafaxine should be gradually tapered when discontinuing treatment over a period of several weeks or months, according to the patient’s needs (see section 4.2).
Akathisia/psychomotor restlessness
The use of venlafaxine has been associated with the development of akathisia, characterised by a subjectively unpleasant or distressing restlessness and need to move often accompanied by an inability to sit or stand still. This is most likely to occur within the first few weeks of treatment. In patients who develop these symptoms, increasing the dose may be detrimental.
Dry mouth
Dry mouth is reported in 10% of patients treated with venlafaxine. This may increase the risk of caries, and patients should be advised upon the importance of dental hygiene.
Diabetes
In patients with diabetes, treatment with an SSRI or venlafaxine may alter glycaemic control. Insulin and/or oral antidiabetic dosage may need to be adjusted.
Drug-Laboratory Test Interactions
False-positive urine immunoassay screening tests for phencyclidine (PCP) and amphetamine have been reported in patients taking venlafaxine. This is due to lack of specificity of the screening tests. False positive test results may be expected for several days following discontinuation of venlafaxine therapy. Confirmatory tests, such as gas chromatography/mass spectrometry, will distinguish venlafaxine from PCP and amphetamine.
Lactose intolerance
Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
4.5 Interaction with other medicinal products and other forms of interaction
Monoamine Oxidase Inhibitors (MAOI)
Irreversible non-selective MAOIs
Venlafaxine must not be used in combination with irreversible non-selective MAOIs. Venlafaxine must not be initiated for at least 14 days after discontinuation of treatment with an irreversible non‑selective MAOI. Venlafaxine must be discontinued for at least 7 days before starting treatment with an irreversible non‑selective MAOI (see sections 4.3 and 4.4).
Reversible, selective MAO-A inhibitor (moclobemide)
Due to the risk of serotonin syndrome, the combination of venlafaxine with a reversible and selective MAOI, such as moclobemide, is not recommended.Following treatment with a reversible MAO‑inhibitor, a shorter withdrawal period than 14 days may be used before initiation of venlafaxine treatment. It is recommended that venlafaxine should be discontinued for at least 7 days before starting treatment with a reversible MAOI (see section 4.4).
Reversible, non-selective MAOI (linezolid)
The antibiotic linezolid is a weak reversible and non-selective MAOI and should not be given to patients treated with venlafaxine (see section 4.4).
Severe adverse reactions have been reported in patients who have recently been discontinued from an MAOI and started on venlafaxine, or have recently had venlafaxine therapy discontinued prior to initiation of an MAOI. These reactions have included tremor, myoclonus, diaphoresis, nausea, vomiting, flushing, dizziness, and hyperthermia with features resembling neuroleptic malignant syndrome, seizures, and death.
Serotonin syndrome
As with other serotonergic agents, serotonin syndrome, a potentially life-threatening condition, may occur with venlafaxine treatment, particularly with concomitant use of other agents that may affect the serotonergic neurotransmitter system (including triptans, SSRIs, SNRIs, lithium, sibutramine, or St. John's wort [Hypericum perforatum], fentanyl and its analogues, tramadol, dextromethorphan, tapentadol, pethidine, methadone and pentazocine), with medicinal agents that impair metabolism of serotonin (such as MAOIs e.g. methylene blue), with serotonin precursors (such as tryptophan supplements) ) or with antipsychotics or other dopamine antagonists (see sections 4.3 and 4.4).
If concomitant treatment with venlafaxine and an SSRI, an SNRI or a serotonin receptor agonist (triptan) is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases. The concomitant use of venlafaxine with serotonin precursors (such as tryptophan supplements) is not recommended (see section 4.4).
CNS-active substances
The risk of using venlafaxine in combination with other CNS-active substances has not been systematically evaluated. Consequently, caution is advised when venlafaxine is taken in combination with other CNS-active substances.
Ethanol
Venlafaxine has been shown not to increase the impairment of mental and motor skills caused by ethanol. However, as with all CNS-active substances, patients should be advised to avoid alcohol consumption.
Drugs that prolong the QT interval
The risk of QTc prolongation and/or ventricular arrhythmias (e.g., TdP) is increased with concomitant use of other medicinal products which prolong the QTc interval. Co-administration of such medicinal products should be avoided (see section 4.4).
Relevant classes include:
-
class Ia and III antiarrhythmics (e.g. quinidine, amiodarone, sotalol, dofetilide)
-
some antipsychotics (e.g. thioridazine)
-
some macrolides (e.g. erythromycin)
-
some antihistamines
-
some quinolone antibiotics (e.g. moxifloxacin)
The above list is not exhaustive and other individual medicinal products known to significantly increase QT interval should be avoided.
Effect of other medicinal products on venlafaxine
Ketoconazole (CYP3A4 inhibitor)
A pharmacokinetic study with ketoconazole in CYP2D6 extensive (EM) and poor metabolisers (PM) resulted in higher AUC of venlafaxine (70% and 21% in CYP2D6 PM and EM subjects, respectively) and O‑desmethylvenlafaxine (33% and 23% in CYP2D6 PM and EM subjects, respectively) following administration of ketoconazole. Concomitant use of CYP3A4 inhibitors (e.g., atazanavir, clarithromycin, indinavir, itraconazole, voriconazole, posaconazole, ketoconazole, nelfinavir, ritonavir, saquinavir, telithromycin) and venlafaxine may increase levels of venlafaxine and O‑desmethylvenlafaxine. Therefore, caution is advised if a patient’s therapy includes a CYP3A4 inhibitor and venlafaxine concomitantly.
Effect of venlafaxine on other medicinal products
Lithium
Serotonin syndrome may occur with the concomitant use of venlafaxine and lithium (see Serotonin syndrome).
Diazepam
Venlafaxine has no effects on the pharmacokinetics and pharmacodynamics of diazepam and its active metabolite, desmethyldiazepam. Diazepam does not appear to affect the pharmacokinetics of either venlafaxine or O‑desmethylvenlafaxine. It is unknown whether a pharmacokinetic and/or pharmacodynamic interaction with other benzodiazepines exists.
Imipramine
Venlafaxine did not affect the pharmacokinetics of imipramine and 2‑OH‑imipramine. There was a dose‑dependentincrease of 2‑OH‑desipramine AUC by 2.5 to 4.5‑foldwhen venlafaxine 75 mg to 150 mg daily was administered. Imipramine did not affect the pharmacokinetics of venlafaxine and O‑desmethylvenlafaxine.The clinical significance of this interaction is unknown. Caution should be exercised with co‑administration of venlafaxine and imipramine.
Haloperidol
A pharmacokinetic study with haloperidol has shown a 42% decrease in total oral clearance, a 70% increase in AUC, an 88% increase in Cmax, but no change in half-life for haloperidol. This should be taken into account in patients treated with haloperidol and venlafaxine concomitantly. The clinical significance of this interaction is unknown.
Risperidone
Venlafaxine increased the risperidone AUC by 50%, but did not significantly alter the pharmacokinetic profile of the total active moiety (risperidone plus 9‑hydroxyrisperidone). The clinical significance of this interaction is unknown.
Metoprolol
Concomitant administration of venlafaxine and metoprolol to healthy volunteers in a pharmacokinetic interaction study for both medicinal products resulted in an increase of plasma concentrations of metoprolol by approximately 30-40% without altering the plasma concentrations of its active metabolite, α‑hydroxymetoprolol. The clinical relevance of this finding in hypertensive patients is unknown. Metoprolol did not alter the pharmacokinetic profile of venlafaxine or its active metabolite, O‑desmethylvenlafaxine. Caution should be exercised with co‑administration of venlafaxine and metoprolol.
Indinavir
A pharmacokinetic study with indinavir has shown a 28% decrease in AUC and a 36% decrease in Cmaxfor indinavir. Indinavir did not affect the pharmacokinetics of venlafaxine and O‑desmethylvenlafaxine. The clinical significance of this interaction is unknown.
4.6 Fertility, pregnancy and lactation
Pregnancy
There are no adequate data from the use of venlafaxine in pregnant women.
Studies in animals have shown reproductive toxicity (see section 5.3). The potential risk for humans is unknown. Venlafaxine must only be administered to pregnant women if the expected benefits outweigh any possible risk.
As with other serotonin reuptake inhibitors (SSRIs/SNRIs), discontinuation symptoms may occur in the newborns if venlafaxine is used until or shortly before birth. Some newborns exposed to venlafaxine late in the third trimester have developed complications requiring tube-feeding, respiratory support or prolonged hospitalisation. Such complications can arise immediately upon delivery.
The following symptoms may be observed in neonates if the mother has used an SSRI/SNRI late in pregnancy: irritability, tremor, hypotonia, persistent crying, and difficulty in sucking or in sleeping. These symptoms may be due to either serotonergic effects or exposure symptoms. In the majority of cases, these complications are observed immediately or within 24 hours after partus.
Epidemiological data have suggested that the use of SSRIs in pregnancy, particularly in late pregnancy, may increase the risk of persistent pulmonary hypertension in the newborn (PPHN). Although no studies have investigated an association of PPHN to SNRI treatment, this potential risk cannot be ruled out with venlafaxine taking into account the related mechanism of action (inhibition of the reuptake of serotonin).
Breast-feeding
Venlafaxine and its active metabolite, O-desmethylvenlafaxine, are excreted in breast milk.There have been post-marketing reports of breast-fed infants who experienced crying, irritability, and abnormal sleep patterns. Symptoms consistent with venlafaxine drug discontinuation have also been reported after stopping breast-feeding. A risk to the suckling child cannot beexcluded. Therefore, a decision to continue/discontinue breast‑feeding or to continue/discontinue therapy with Venlafaxin Sandoz should be made, taking into account the benefit of breast‑feeding to the child and the benefit of Venlafaxin Sandoz therapy to the woman.
Fertility
Reduced fertility was observed in a study in which both male and female rats were exposed to O-desmethylvenlafaxine. The human relevance of this finding is unknown (see section 5.3).
4.7 Effects on ability to drive and use machines
Any psychoactive medicinal product may impair judgment, thinking, and motor skills. Therefore, any patient receiving venlafaxine should be cautioned about their ability to drive or operate hazardous machinery.
4.8 Undesirable effects
Summary of the safety profile
Adverse reactions reported as very common (>1/10) in clinical studies were nausea, dry mouth, headache and sweating (including night sweats).
Tabulated list of adverse reactions
Adverse reactions are listed below by system organ class,frequency category and decreasing order of medical seriousness within each frequency category.
Frequencies are defined as: very common (1/10), common (1/100 to 1/10), uncommon (1/1,000 to 1/100), rare (1/10,000 to 1/1,000), very rare (1/10,000), not known (cannot be estimated from the available data).
|
System organ class |
Very Common |
Common |
Uncommon |
Rare |
Very Rare |
Not Known |
|
Blood and lymphatic system disorders |
|
|
|
Agranulocytosis*, Aplastic anaemia*, Pancytopaenia*, Neutropaenia* |
Thrombocytopaenia* |
|
|
Immune system disorders |
|
|
|
Anaphylactic reaction* |
|
|
|
Endocrine disorders |
|
|
|
Inappropriate antidiuretic hormone secretion* |
Blood prolactin increased* |
|
|
Metabolism and nutrition disorders |
|
Decreased appetite |
|
Hyponatraemia* |
|
|
|
Psychiatric disorders |
Insomnia |
Confusional state*, Depersonalisation*, Abnormal dreams, Nervousness, Libido decreased, Agitation*, Anorgasmia |
Mania, Hypomania, Hallucination, Derealization, Abnormal orgasm, Bruxism*, Apathy |
Delirium* |
|
Suicidal ideation and suicidal behavioursa, Aggressionb |
|
Nervous system disorders |
Headachec*, Dizziness, Sedation |
Akathisia*, Tremor, Paraesthesia, Dysgeusia |
Syncope, Myoclonus, balance disorder*, Coordination abnormal, Dyskinesia* |
Neuroleptic Malignant Syndrome (NMS)*, Serotonin syndrome*, Convulsion, Dystonia* |
tardive dyskinaesia* |
|
|
Eye disorders |
|
Visual impairment, Accommodation disorder, including vision blurred, Mydriasis |
|
Angle‑closure glaucoma* |
|
|
|
Ear and labyrinth disorders |
|
Tinnitus* |
|
|
|
Vertigo |
|
Cardiac disorders |
|
Tachycardia, Palpitations* |
|
Torsade de Pointes*, Ventricular tachycardia, Ventricular fibrillation, Electrocardiogram QT prolonged* |
|
|
|
Vascular disorders |
|
Hypertension, Hot flush |
Orthostatic hypotension, Hypotension* |
|
|
|
|
Respiratory, thoracic and mediastinal disorders |
|
Dyspnoea*, Yawning |
|
Interstitial lung disease*, Pulmonary eosinophilia* |
|
|
|
Gastrointestinal disorders |
Nausea, Dry mouth, Constipation |
diarrhoea*, Vomiting |
Gastrointestinal haemorrhage* |
Pancreatitis* |
|
|
|
Hepatobiliary disorders |
|
|
Liver function test abnormal* |
Hepatitis* |
|
|
|
Skin and subcutaneous tissue disorders |
Hyperhidrosis* (including night sweats)* |
Rash, Pruritus* |
Urticaria*, Alopecia*, Ecchymosis, Angioedema*, Photosensitivity reaction |
Stevens-Johnson syndrome*, Toxic epidermal necrolysis*, Erythema multiforme |
|
|
|
Musculoskeletal and connective tissue disorders |
|
Hypertonia |
|
Rhabdomyolysis* |
|
|
|
Renal and urinary disorders |
|
Urinary hesitation, Urinary retention, Pollakiuria* |
Urinary incontinence* |
|
|
|
|
Reproductive system and breast disorders |
|
Menorrhagia*, Metrorrhagia*, Erectile dysfunction, Ejaculation disorder |
|
|
|
|
|
General disorders and administration site conditions |
|
Fatigue, Asthenia, Chills* |
|
|
Mucosal haemorrhage* |
|
|
Investigations |
|
Weight decreased, Weight increased, Blood Cholesterol increased |
|
|
Bleeding time prolonged* |
|
*ADR identified post-marketing
a Cases of suicidal ideation and suicidal behaviours have been reported during venlafaxine therapy or early after treatment discontinuation (see section 4.4).
b See section 4.4.
c In pooled clinical trials, the incidence of headache with venlafaxine and placebo were similar.
Discontinuation of treatment
Discontinuation of venlafaxine (particularly when abrupt) commonly leads to withdrawal symptoms. Dizziness, sensory disturbances (including paraesthesia), sleep disturbances (including insomnia and intense dreams), agitation or anxiety, nausea and/or vomiting, tremor, vertigo, headache and flu syndrome are the most commonly reported reactions. Generally, these events are mild to moderate and are self‑limiting; however, in some patients, they may be severe and/or prolonged. It is therefore advised that when venlafaxine treatment is no longer required, gradual discontinuation by dose tapering should be carried out (see sections 4.2 and 4.4).
Paediatric population
In general, the adverse reaction profile of venlafaxine (in placebo-controlled clinical trials) in children and adolescents (ages 6 to 17) was similar to that seen for adults. As with adults, decreased appetite, weight loss, increased blood pressure, and increased serum cholesterol were observed (see section 4.4).
In paediatric clinical trials the adverse reaction suicidal ideation was observed. There were also increased reports of hostility and, especially in major depressive disorder, self-harm.
Particularly, the following adverse reactions were observed in paediatric patients: abdominal pain, agitation, dyspepsia, ecchymosis, epistaxis, and myalgia.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the national reporting system listed in [To be completed nationally].
4.9 Overdose
In postmarketing experience, overdose with venlafaxine was reported predominantly in combination with alcohol and/or other medicinal products. The most commonly reported events in overdose include tachycardia, changes in level of consciousness (ranging from somnolence to coma), mydriasis, convulsion, and vomiting. Other reported events include electrocardiographic changes (e.g., prolongation of QT interval, bundle branch block, QRS prolongation), ventricular tachycardia, bradycardia, hypotension, vertigo, and death.
Published retrospective studies report that venlafaxine overdosage may be associated with an increased risk of fatal outcomes compared to that observed with SSRI antidepressant products, but lower than that for tricyclic antidepressants. Epidemiological studies have shown that venlafaxine-treated patients have a higher burden of suicide risk factors than SSRI patients. The extent to which the finding of an increased risk of fatal outcomes can be attributed to the toxicity of venlafaxine in overdosage, as opposed to some characteristics of venlafaxine-treated patients, is not clear. Prescriptions for venlafaxine should be written for the smallest quantity of the medicinal product consistent with good patient management in order to reduce the risk of overdose.
Recommended treatment
General supportive and symptomatic measures are recommended; cardiac rhythm and vital signs must be monitored. When there is a risk of aspiration, induction of emesis is not recommended. Gastric lavage may be indicated if performed soon after ingestion or in symptomatic patients. Administration of activated charcoal may also limit absorption of the active substance. Forced diuresis, dialysis, hemoperfusion and exchange transfusion are unlikely to be of benefit. No specific antidotes for venlafaxine are known.
5. PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic
group: Other antidepressants
ATC code: N06A X16
Mechanism of action
The mechanism of venlafaxine's antidepressant action in humans is believed to be associated with its potentiation of neurotransmitter activity in the central nervous system. Preclinical studies have shown that venlafaxine and its major metabolite, O‑desmethylvenlafaxine (ODV), are inhibitors of serotonin and noradrenaline reuptake. Venlafaxine also weakly inhibits dopamine uptake. Venlafaxine and its active metabolite reduce β‑adrenergic responsiveness after both acute (single dose) and chronic administration. Venlafaxine and ODV are very similar with respect to their overall action on neurotransmitter reuptake and receptor binding.
Venlafaxine has virtually no affinity for rat brain muscarinic, cholinergic, H1‑histaminergic or α1‑adrenergic receptors in vitro. Pharmacological activity at these receptors may be related to various side effects seen with other antidepressant medicinal products, such as anticholinergic, sedative and cardiovascular side effects.
Venlafaxine does not possess monoamine oxidase (MAO) inhibitory activity.
In vitrostudies revealed that venlafaxine has virtually no affinity for opiate or benzodiazepine sensitive receptors.
Clinical efficacy and safety
Major depressive episodes
The efficacy of venlafaxine immediate-release as a treatment for major depressive episodes was demonstrated in five randomised, double‑blind, placebo‑controlled, short‑term trials ranging from 4 to 6 weeks duration, for doses up to 375 mg/day. The efficacy of venlafaxine prolonged‑release as a treatment for major depressive episodes was established in two placebo‑controlled, short‑term studies for 8 and 12 weeks duration, which included a dose range of 75 to 225 mg/day.
In one longer-term study, adult outpatients who had responded during an 8‑week open trial on venlafaxine prolonged‑release (75, 150, or 225 mg) were randomised to continuation of their same venlafaxine prolonged‑release dose or to placebo, for up to 26 weeks of observation for relapse.
In a second longer-term study, the efficacy of venlafaxine in prevention of recurrent depressive episodes for a 12‑month period was established in a placebo‑controlled double‑blind clinical trial in adult outpatients with recurrent major depressive episodes who had responded to venlafaxine treatment (100 to 200 mg/day, on a b.i.d. schedule) on the last episode of depression.
5.2 Pharmacokinetic properties
Venlafaxine is extensively metabolised, primarily to the active metabolite, O‑desmethylvenlafaxine (ODV). Mean ± SD plasma half-lives of venlafaxine and ODV are 5±2 hours and 11±2 hours, respectively. Steady‑state concentrations of venlafaxine and ODV are attained within 3 days of oral multiple‑dose therapy. Venlafaxine and ODV exhibit linear kinetics over the dose range of 75 mg to 450 mg/day.
Absorption
At least 92% of venlafaxine is absorbed following single oral doses of immediate-release venlafaxine. Absolute bioavailability is 40% to 45% due to presystemic metabolism. After immediate-release venlafaxine administration, the peak plasma concentrations of venlafaxine and ODV occur in 2 and 3 hours, respectively. Following the administration of venlafaxine prolonged-release capsules, peak plasma concentrations of venlafaxine and ODV are attained within 5.5 hours and 9 hours, respectively. When equal daily doses of venlafaxine are administered as either an immediate-release tablet or prolonged-release capsule, the prolonged-release capsule provides a slower rate of absorption, but the same extent of absorption compared with the immediate-release tablet. Food does not affect the bioavailability of venlafaxine and ODV.
Distribution
Venlafaxine and ODV are minimally bound at therapeutic concentrations to human plasma proteins (27% and 30%, respectively). The volume of distribution for venlafaxine at steady-state is 4.4±1.6 L/kg following intravenous administration.
Biotransformation
Venlafaxine undergoes extensive hepatic metabolism. In vitroand in vivo studies indicate that venlafaxine is biotransformed to its major active metabolite, ODV, by CYP2D6. In vitroand in vivostudies indicate that venlafaxine is metabolised to a minor, less active metabolite, N‑desmethylvenlafaxine, by CYP3A4. In vitroand in vivostudies indicate that venlafaxine is a weak inhibitor of CYP2D6. Venlafaxine did not inhibit CYP1A2, CYP2C9, or CYP3A4.
Elimination
Venlafaxine and its metabolites are excreted primarily through the kidneys. Approximately 87% of a venlafaxine dose is recovered in the urine within 48 hours as either unchanged venlafaxine (5%), unconjugated ODV (29%), conjugated ODV (26%), or other minor inactive metabolites (27%). Mean ± SD plasma steady‑state clearances of venlafaxine and ODV are 1.3±0.6 L/h/kg and 0.4±0.2 L/h/kg, respectively.
Special populations
Age and gender
Subject age and gender do not significantly affect the pharmacokinetics of venlafaxine and ODV.
CYP2D6 extensive/poor metabolisers
Plasma concentrations of venlafaxine are higher in CYP2D6 poor metabolisers than extensive metabolisers. Because the total exposure (AUC) of venlafaxine and ODV is similar in poor and extensive metabolisers, there is no need for different venlafaxine dosing regimens for these two groups.
Hepatic impairment
In Child-Pugh A (mildly hepatically impaired) and Child-Pugh B (moderately hepatically impaired) subjects, venlafaxine and ODV half-lives were prolonged compared to normal subjects. The oral clearance of both venlafaxine and ODV was reduced. A large degree of intersubject variability was noted. There are limited data in patients with severe hepatic impairment (see section 4.2).
Renal impairment
In dialysis patients, venlafaxine elimination half-life was prolonged by about 180% and clearance reduced by about 57% compared to normal subjects, while ODV elimination half-life was prolonged by about 142% and clearance reduced by about 56%. Dosage adjustment is necessary in patients with severe renal impairment and in patients that require haemodialysis(see section 4.2).
5.3 Preclinical safety data
Studies with venlafaxine in rats and mice revealed no evidence of carcinogenesis. Venlafaxine was not mutagenic in a wide range of in vitroand in vivotests.
Animal studies regarding reproductive toxicity have found in rats a decrease in pup weight, an increase in stillborn pups, and an increase in pup deaths during the first 5 days of lactation. The cause of these deaths is unknown. These effects occurred at 30 mg/kg/day, 4 timesthe human daily dose of 375 mg of venlafaxine (on an mg/kg basis). The no‑effect dose for these findings was 1.3 times the human dose. The potential risk for humans is unknown.
Reduced fertility was observed in a study in which both male and female rats were exposed to ODV. This exposure was approximately 1 to 2 times that of a human venlafaxine dose of 375 mg/day. The human relevance of this finding is unknown.
6. PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Cellulose, microcrystalline
Lactose monohydrate
Sodium starch glycolate (Type A)
Magnesium stearate
Silica, colloidal anhydrous
Iron oxide, brown (E 172)
6.2 Incompatibilities
Not applicable
6.3 Shelf life
Venlafaxin Sandoz 25 mg:30 months (tablet container and blister)
Venlafaxin Sandoz 37.5 mg : 30 months (tablet container and blister)
Venlafaxin Sandoz 50 mg: 30 months (tablet container and blister)
Venlafaxin Sandoz 75 mg: 30 months (tablet container and blister)
Venlafaxin Sandoz 150 mg:30 months (tablet container), 2 years (blister)
6.4 Special precautions for storage
Venlafaxin Sandoz 25 mg:
This medicinal product does not require any special storage conditions(tablet container and blister)
Venlafaxin Sandoz 37.5 mg:
This medicinal product does not require any special storage conditions(tablet container and blister)
Venlafaxin Sandoz 50 mg:
This medicinal product does not require any special storage conditions(tablet container and blister)
Venlafaxin Sandoz 75 mg:
This medicinal product does not require any special storage conditions(tablet container and blister)
Venlafaxin Sandoz 150 mg:
This medicinal product does not require any special storage conditions(tablet container)
Do not store above 30°C (blister)
6.5 Nature and contents of container
Polyethylene tablet container and closure (tamper evident)
Pack sizes: 28, 30, 42, 50, 56, 60, 90, 98, 100, 250 tablets
Blister (Al/PVC)
Pack sizes: 10, 14, 15, 20, 28, 30, 42, 45, 50, 56, 60, 90, 98, 98x1, 100, 100x1, 250 tablets
Not all pack sizes or pack types may be marketed.
6.6 Special precautions for disposal
No special requirements
7. MARKETING AUTHORISATION HOLDER
[To be completed nationally]
8. MARKETING AUTHORISATION NUMBER(S)
[To be completed nationally]
9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
Date of first authorization: {DD month YYYY}
Date of latest renewal: {DD month YYYY}
[To be completed nationally]
10. DATE OF REVISION OF THE TEXT
23 September 2016