milnacipran
milnacipran
(mil-na-sip-ran) milnacipran,Savella
(trade name)Classification
Therapeutic: antifibromyalgia agentsPharmacologic: selective norepinephrine reuptake inhibitors
Indications
Action
Therapeutic effects
Pharmacokinetics
Time/action profile (↓ in pain)
| ROUTE | ONSET | PEAK | DURATION |
|---|---|---|---|
| PO | 1 wk | unknown | unknown |
Contraindications/Precautions
Adverse Reactions/Side Effects
Central nervous system
- neuroleptic malignant syndrome (life-threatening)
- suicidal thoughts (life-threatening)
- dizziness
- headache
- insomnia
Cardiovascular
- hypertension
- tachycardia
Fluid and Electrolyte
- hyponatremia
Gastrointestinal
- constipation
- dry mouth
- ↑ liver enzymes
- nausea
- vomiting
Dermatologic
- hot flushes
- hyperhidrosis
Miscellaneous
- serotonin syndrome (life-threatening)
Interactions
Drug-Drug interaction
Concurrent use with MAO inhibitors may result in serious, potentially fatal reactions; wait at least 14 days following discontinuation of MAO inhibitor before initiation of milnacipran. Wait at least 5 days after discontinuing milnacipran before initiation of MAO inhibitor.Concurrent use of serotonergic drugs (including triptans, lithium, and tramadol ) may ↑ the risk of serotinin syndrome; also ↑ risk of coronary vasoconstriction and hypertension.Concurrent use of NSAIDs, aspirin, or other drugs that affect coagulation may ↑ the risk of bleeding.May ↓ antihypertensive effectiveness of clonidine.↑ risk of hypertension and arrhythmias with epinephrine or norepinephrine.↑ risk of euphoria and hypotension when switching from clomipramine.Concurrent use with digoxin may result in adverse hemodynamics, including hypotension and tachycardia; avoid concurrent use with IV digoxin.Route/Dosage
Renal Impairment
Oral (Adults) CCr 5–29 mL/min—maintenance dose is 25 mg twice daily; some patients may require up to 50 mg twice daily depending on response.Availability
Nursing implications
Nursing assessment
- Assess intensity, quality, and location of pain periodically during therapy. May require several weeks for effects to be seen.
- Monitor BP and heart rate before and periodically during therapy. Treat pre-existing hypertension and cardiac disease prior to therapy. Sustained hypertension may be dose related; decrease dose or discontinue therapy if this occurs.
- Monitor closely for changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression.
- Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, convulsions, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control). Report symptoms immediately.
- Lab Test Considerations: May cause ↑ ALT, AST, and bilirubin.
- May cause hyponatremia.
Potential Nursing Diagnoses
Chronic pain (Indications)Risk for suicide (Adverse Reactions)
Implementation
- Oral: May be administered without regard to meals; may be more tolerable if taken with food.
Patient/Family Teaching
- Instruct patient to take milnacipran as directed at the same time each day. Take missed doses as soon as possible unless time for next dose. Do not stop abruptly; must be decreased gradually. Advise patient to read the Medication Guide prior to therapy and with each Rx refill.
- Encourage patient and family to be alert for emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia, hypomania, mania, worsening of depression and suicidal ideation, especially during early antidepressant therapy. Assess symptoms on a day-to-day basis as changes may be abrupt. If these symptoms occur, notify health care professional.
- May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
- Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications. Avoid use of aspirin, NSAIDs, and warfarin due to increased risk for bleeding.
- Instruct patient to notify health care professional if signs of liver damage (pruritus, dark urine, jaundice, right upper quadrant tenderness, unexplained "flu-like" symptoms) or hyponatremia (headache, difficulty concentrating, memory impairment, confusion, weakness, unsteadiness), hyponatremia (headache, difficulty concentrating, memory impairment, confusion, weakness, unsteadiness, falls), rash, or serotonin syndrome (mental status changes: agitation, hallucinations, coma; autonomic instability: tachycardia, labile BP, hyperthermia; neuromuscular aberrations: hyperreflexia, incoordination; and/or gastrointestinal symptoms: nausea, vomiting, diarrhea) occur.
- Advise patient to avoid taking alcohol during milnacipran therapy.
- Instruct patient to notify health care professional if pregnancy is planned or suspected or if breast feeding. Encourage patients who become pregnant while taking milnacipran to enroll in the pregnancy registry by calling 1–800–643–3010 or by e-mail at registries@kendall.com.
- Encourage patient to maintain routine follow-up visits with health care provider to determine effectiveness.
Evaluation/Desired Outcomes
- Reduction in pain and soreness associated with fibromyalgia.