Venlafaxine
Classification: AATC code: N06AX16
Summary
No clinically significant differences in effect of venlafaxine have been reported. Conflicting results on sex differences in pharmacokinetics of venlafaxine have been reported. Observational therapeutic drug monitoring studies have shown that women had higher dose corrected serum levels of venlafaxine.
Additional information
Depression is almost twice as common in women as in men [1]. Women have an earlier age of onset and increased duration of depressive episodes. Differences in neurobiology [2, 3], hormones, inflammatory markers, diagnostic tools, or health seeking behavior [4, 5] may be of importance. Although depression is more prevalent in women, most preclinical studies on depression have used male animals [2].
Women are two to three times more likely to suffer from an anxiety disorder [1]. Sex differences in symptomatology and comorbidity may be due to genetic, hormonal, neurodevelopmental, environmental, and neurobiological factors [6].
Pharmacokinetics and dosing
In a pharmacokinetic study where patients (18 men, 18 women) first received a single dose 50 mg venlafaxine and later a 50 mg dose every 8 hours for 5 days, only minimal sex differences were observed. After the single dose, women had higher Cmax and AUC of the metabolite O-desmetylvenlafaxine (ODV), while men had longer ODV Tmax. When multiple dosing, women had faster venlafaxine renal clearance and men had longer ODV half-life [7]. In another pharmacokinetic study (14 men, 21 women) with 300 mg/day, women showed a reduced ODV/venlafaxine ratio for the (-)-enantiomer of ODV after 14 days, but no sex differences were observed for the (+)-enantiomer. Similar results were seen after 28 days [8]. Several therapeutic drug monitoring studies (about 60% women ) have shown that women had higher concentrations of venlafaxine and its metabolites [9-14]. According to the manufacturer, no sex differences in the pharmacokinetics of venlafaxine and its metabolite ODV are expected and no sex differentiation in dosing are recommended [15]. Published pharmacokinetic studies support similar dosing in men and women [7, 8].
Effects
Men and women with major depressive disorders have shown similar treatment response of venlafaxine in randomized, double-blind, controlled trials (in all 1058 men, 2059 women) [16, 17]. Treatment response of venlafaxine was also examined in patients with posttraumatic stress disorder in a pooled analysis (271 men, 416 women), but no significant sex differences were observed [18].
Adverse effects
Isolated cases of Torsade de Pointes ventricular tachycardia have been reported in association with venlafaxine overdose, the risk is generally higher in women [19].
Reproductive health issues
Regarding teratogenic aspects, please consult Janusmed Drugs and Birth Defects (in Swedish, Janusmed fosterpåverkan).
Other information
A small British study (48 men, 46 women) examining the choice of antidepressant treatment in relation to suicide risk showed that less venlafaxine was prescribed to men than women. Patients received monotherapy treatment for depression of which 6 men and 19 women were treated with venlafaxine [20].
Prescription history during the first year after the introduction of mirtazapine, sertraline and venlafaxine has been collected from 20 pharmacies in the Netherlands. No sex differences between men and women were observed [21]. Drug utilization of ten commonly prescribed antidepressants during the period 2009-2014 in Sweden, Denmark, Germany, and Spain were analyzed in a large register study (in total 4,833,774 initiators included). Women comprised the majority of initiators for all antidepressants studied. In Sweden, 70.2% of the initiators on venlafaxine were women [22]. However, male sex has been associated with a greater risk of treatment drop-out than women, reports a Spanish study based on prescription data. Patients who had received at least one antidepressant drug were included (in all 7525 patients) [23].
Updated: 2022-06-13
Date of litterature search: 2021-06-17
References
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- Klamerus KJ, Parker VD, Rudolph RL, Derivan AT, Chiang ST. Effects of age and gender on venlafaxine and O-desmethylvenlafaxine pharmacokinetics. Pharmacotherapy. 1996;16:915-23. PubMed
- Gex-Fabry M, Rudaz S, Balant-Gorgia AE, Brachet A, Veuthey JL, Balant LP et al. Steady-state concentration of venlafaxine enantiomers: model-based analysis of between-patient variability. Eur J Clin Pharmacol. 2002;58:323-31. PubMed
- Reis M, Aamo T, Spigset O, Ahlner J. Serum concentrations of antidepressant drugs in a naturalistic setting: compilation based on a large therapeutic drug monitoring database. Ther Drug Monit. 2009;31:42-56. PubMed
- Reis M, Lundmark J, Björk H, Bengtsson F. Therapeutic drug monitoring of racemic venlafaxine and its main metabolites in an everyday clinical setting. Ther Drug Monit. 2002;24:545-53. PubMed
- Unterecker S, Hiemke C, Greiner C, Haen E, Jabs B, Deckert J et al. The effect of age, sex, smoking and co-medication on serum levels of venlafaxine and O-desmethylvenlafaxine under naturalistic conditions. Pharmacopsychiatry. 2012;45:229-35. PubMed
- Hansen MR, Kuhlmann IB, Pottegård A, Damkier P. Therapeutic Drug Monitoring of Venlafaxine in an Everyday Clinical Setting: Analysis of Age, Sex and Dose Concentration Relationships. Basic Clin Pharmacol Toxicol. 2017;121(4):298-302. PubMed
- Sigurdsson HP, Hefner G, Ben-Omar N, Köstlbacher A, Wenzel-Seifert K, Hiemke C et al. Steady-state serum concentrations of venlafaxine in patients with late-life depression Impact of age, sex and BMI. J Neural Transm (Vienna). 2015;122(5):721-9. PubMed
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- Entsuah AR, Huang H, Thase ME. Response and remission rates in different subpopulations with major depressive disorder administered venlafaxine, selective serotonin reuptake inhibitors, or placebo. J Clin Psychiatry. 2001;62:869-77. PubMed
- Rothbaum BO, Davidson JR, Stein DJ, Pedersen R, Musgnung J, Tian XW et al. A pooled analysis of gender and trauma-type effects on responsiveness to treatment of PTSD with venlafaxine extended release or placebo. J Clin Psychiatry. 2008;69:1529-39. PubMed
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Reviewed by: Diana Rydberg
Approved by: Karin Schenck-Gustafsson