Nurses Compass
Drug Guide
Levomilnacipran
Classification
Therapeutic: Antidepressant, Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)
Pharmacological: Selective serotonin and norepinephrine reuptake inhibitor
FDA Approved Indications
- Major depressive disorder
Mechanism of Action
Levomilnacipran inhibits the reuptake of serotonin and norepinephrine, increasing their levels in the synaptic cleft, which helps alleviate depressive symptoms.
Dosage and Administration
Adult: Start with 20 mg once daily; can be titrated up to 40-120 mg/day based on response and tolerability. Usually takes at least 2 weeks to see full effect.
Pediatric: Not approved for pediatric use.
Geriatric: Begin at the lower end of dosing range, monitor closely for side effects.
Renal Impairment: Dose adjustment may be necessary; consult product labeling.
Hepatic Impairment: Use with caution; no specific dosage adjustment provided.
Pharmacokinetics
Absorption: Well-absorbed after oral administration.
Distribution: Widely distributed; protein binding approximately 15%.
Metabolism: Minimal hepatic metabolism; primarily excreted unchanged.
Excretion: Renal excretion (~50-60%), some in feces.
Half Life: About 12 hours, allowing once or twice daily dosing.
Contraindications
- Hypersensitivity to levomilnacipran or other SNRIs.
- Concurrent use with monoamine oxidase inhibitors (MAOIs).
Precautions
- History of hypertension, bipolar disorder, seizures, or narrow-angle glaucoma. Use with caution in patients with a history of serotonin syndrome or bleeding risk. Can increase blood pressure; monitor blood pressure regularly. Possible increased risk of suicidal thoughts in young adults and adolescents.
Adverse Reactions - Common
- Nausea (Common)
- Dry mouth (Common)
- Headache (Common)
- Increased blood pressure (Common)
Adverse Reactions - Serious
- Serotonin syndrome (Rare)
- Hypertensive crisis or increased blood pressure (Less common)
- QT prolongation (Rare)
Drug-Drug Interactions
- Serotonergic drugs (e.g., SSRIs, SNRIs, triptans) - risk of serotonin syndrome
- Blood pressure medications - possible increased effect
- MAOIs - contraindicated
Drug-Food Interactions
N/ADrug-Herb Interactions
N/ANursing Implications
Assessment: Monitor blood pressure regularly; assess for suicidal ideation; monitor for signs of serotonin syndrome.
Diagnoses:
- Risk for hypertension
- Imbalanced nutrition: less than body requirements due to nausea
- Risk for suicidal ideation
Implementation: Start at recommended dose; titrate cautiously; instruct patient to report side effects.
Evaluation: Effectiveness in alleviating depressive symptoms and tolerability of side effects.
Patient/Family Teaching
- Take medication exactly as prescribed.
- Do not abruptly stop medication.
- Avoid alcohol and illicit drugs.
- Report signs of increased blood pressure, serotonin syndrome (agitation, hallucinations, rapid heart rate), or worsening depression.
Special Considerations
Black Box Warnings:
- Increased risk of suicidal thoughts and behaviors in children, adolescents, and young adults.
- Serotonin syndrome risk when combined with serotonergic agents.
Genetic Factors: Genetic polymorphisms may affect drug metabolism and response.
Lab Test Interference: May affect blood pressure measurements.
Overdose Management
Signs/Symptoms: Nausea, vomiting, increased blood pressure, tachycardia, seizures, serotonin syndrome symptoms.
Treatment: Supportive care, activated charcoal if ingestion is recent, symptomatic treatment, and monitoring. Hemodialysis may be considered in severe cases.
Storage and Handling
Storage: Store at room temperature, away from moisture and heat.
Stability: Stable for manufacturer-recommended shelf life.