fluvoxaMINE

General

Pronunciation
floo-VOKS-a-meen [Pronunciation]

Trade Name(s)

• Luvox

• Luvox CR

Genetic Implications

Pregnancy Category
Category C

Ther. class.
antidepressants
antiobsessive agents

Pharm. class.
selective serotonin reuptake inhibitors ssris

Indications

Obsessive-compulsive disorder (OCD).

Unlabelled Use(s):

• Depression.

• Generalized anxiety disorder (GAD).

• Social anxiety disorder (SAD).

• Post-traumatic stress disorder (PTSD).

Action

Inhibits the reuptake of serotonin in the CNS.

Therapeutic Effect(s):
Decrease in obsessive-compulsive behaviors.

Pharmacokinetics

Absorption: 53% absorbed after oral administration.

Distribution: Excreted in breast milk; enters the CNS. Remainder of distribution not known.

Metabolism and Excretion: Mostly metabolized by the liver (CYP2D6 isoenzyme); the CYP2D6 enzyme system exhibits genetic polymorphism; ~7% of population may be poor metabolizers (PMs) and may have significantly ↑fluvoxamine concentrations and an ↑ risk of adverse effects.

Half-life: 13.6–15.6 hr.

TIME/ACTION PROFILE (improvement on obsessive-compulsive behaviors)

ROUTE	ONSET	PEAK	DURATION
PO	within 2–3 wk	several mo	unknown

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity to fluvoxamine or other SSRIs;

• Concurrent use of MAOIs (or within 14 days of discontinuing fluvoxamine), alosetron, pimozide, thioridazine, or tizanidine.

Use Cautiously in:

• Impaired hepatic function;

• Risk of suicide (may ↑ risk of suicide attempt/ideation especially during early treatment or dose adjustment);

• OB: Neonates exposed to SSRI in third trimester may develop drug discontinuation syndrome including respiratory distress, feeding difficulty, and irritability;

• Lactation: Discontinue drug or bottle-feed;

• Pedi: May ↑ risk of suicide attempt/ideation especially during early treatment or dose adjustment; may be greater in children and adolescents (safety not established in children <18 yr [controlled–release] and <8 yr [immediate-release]);

• Pedi: Safety not established in children <8 yr (for immediate-release);

• Geri: May have ↑ sensitivity; recommend lower initial dose and slower dosage titration.

Adverse Reactions/Side Effects

CNS: NEUROLEPTIC MALIGNANT SYNDROME, SUICIDAL THOUGHTS, sedation, dizziness, drowsiness, headache, insomnia, nervousness, weakness, agitation, anxiety, apathy, emotional lability, manic reactions, mental depression, psychotic reactions, syncope.

EENT: sinusitis.

Resp: cough, dyspnea.

CV: edema, hypertension, palpitations, postural hypotension, tachycardia, vasodilation.

GI: constipation, diarrhea, dry mouth, dyspepsia, nausea, anorexia, dysphagia, ↑ liver enzymes, flatulence, vomiting.

GU: ↓ libido/sexual dysfunction.

Derm: ↑ sweating.

Metabolic: weight gain, weight loss.

MS: hypertonia, myoclonus/twitching.

Neuro: hypokinesia/hyperkinesia, tremor.

Misc: SEROTONIN SYNDROME, allergic reactions, chills, flu-like symptoms, tooth disorder/caries, yawning.

*CAPITALS indicates life-threatening.
*italic indicates most frequent.

Interactions

Drug-Drug

• Serious, potentially fatal reactions (serotonin syndrome) may occur with MAO inhibitors .

• Smoking may ↓ effectiveness of fluvoxamine.

• Concurrent use with tricyclic antidepressants may ↑ plasma levels of fluvoxamine.

• Drugs that affect serotonergic neurotransmitter systems, including linezolid , tramadol , and triptans, ↑ risk of serotonin syndrome.

• ↓ metabolism and may ↑ effects of some beta blockers ( propranolol ), alosetron (avoid concurrent use), some benzodiazepines (avoid concurrent diazepam ), carbamazepine , methadone , lithium , theophylline (↓ dose to 33% of usual dose), ramelteon (avoid concurrent use), warfarin , and l-tryptophan .

• ↑ risk of bleeding with NSAIDS , aspirin , clopidogrel , or warfarin .

• ↑ blood levels and risk of toxicity from clozapine (dosage adjustments may be necessary).

Route/Dosage

• PO (Adults): Immediate release–50 mg daily at bedtime; ↑ by 50 mg q 4–7 days until desired effect is achieved. If daily dose >100 mg, give in two equally divided doses or give a larger dose at bedtime (not to exceed 300 mg/day); Controlled release–100 mg at bedtime; ↑ by 50 mg q 7 days until desired effect is achieved, not to exceed 300 mg/day..

• PO (Children 8–17 yr): Immediate release–25 mg at bedtime, may ↑ by 25 mg/day q 4–7 days (not to exceed 200 mg/day; daily doses >50 mg should be given in divided doses with a larger dose at bedtime)..

Hepatic Impairment

• PO (Adults): Immediate release–25 mg daily at bedtime initially, slower titration and longer dosing intervals should be used..

Availability

• Tablets: 25 mg, 50 mg, 100 mg

• Controlled-release capsules: 100 mg, 150 mg

Assessment

• Monitor mood changes. Assess patient for frequency of obsessive-compulsive behaviors. Note degree to which these thoughts and behaviors interfere with daily functioning. Inform health care professional if patient demonstrates significant increase in anxiety, nervousness, or insomnia.

• Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults ≤24 yrs. After starting therapy, children, adolescents, and young adults should be seen by health care professional at least weekly for 4 wk, every 3 wk for next 4 wk, and on advice of health care professional thereafter.

• Monitor appetite and nutritional intake. Weigh weekly. Report significant changes in weight. Adjust diet as tolerated to support nutritional status.

• Assess for serotonin syndrome (mental changes [agitation, hallucinations, coma], autonomic instability [tachycardia, labile BP, hyperthermia], neuromuscular aberations [hyperreflexia, incoordination], and/or GI symptoms [nausea, vomiting, diarrhea]), especially in patients taking other serotonergic drugs (SSRIs, SNRIs, triptans).

Toxicity and Overdose

• Common symptoms of toxicity include drowsiness, vomiting, diarrhea, and dizziness. Coma, tachycardia, bradycardia, hypotension, ECG abnormalities, liver function abnormalities, and convulsions may also occur. Treatment is symptomatic and supportive.

Potential Nursing Diagnoses

• Ineffective coping (Indications)

• Risk for injury (Side Effects)

Implementation

• Do not confuse fluvoxamine with fluphenazine or flavoxate. Do not confuse Luvox with Lasix (furosemide).

• Taper to avoid withdrawal effects. Reduce dose by 50% for 3 days, then reduce by 50% for 3 days, then discontinue.

• PO: Initial therapy is administered as a single bedtime dose. May be increased every 4–7 days as tolerated.

» Fluvoxamine may be given without regard to meals. Do not open, break, crush, or chew controlled-release capsules.

Patient/Family Teaching

• Instruct patient to take fluvoxamine as directed. Do not skip or double up on missed doses. Improvement in symptoms may be noticed in 2–3 wk, but medication should be continued as directed.

• May cause drowsiness and dizziness. Caution patient to avoid driving and other activities requiring alertness until response to medication is known.

• Advise patient, family, and caregivers to look for suicidality, especially during early therapy or dose changes. Notify health care professional immediately if thoughts about suicide or dying, attempts to commit suicide, new or worse depression or anxiety, agitation or restlessness, panic attacks, insomnia, new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior or if symptoms of serotonin syndrome occur.

• Advise patient to avoid alcohol or other CNS depressants during therapy and to consult health care professional before taking other medications with fluvoxamine.

• Instruct female patients to notify health care professional if breastfeeding or if pregnancy is planned or suspected.

• Advise patient to notify health care professional if rash or hives occur or if headache, nausea, anorexia, anxiety, or insomnia persists.

• Advise patient to avoid use of caffeine (chocolate, tea, cola).

• Emphasize the importance of follow-up exams to monitor progress.