The pupillary dilation that occurs following use of many antidepressant drugs including desvenlafaxine may trigger an angle closure attack in a patient with anatomically narrow angles who does not have a patent iridectomy. Avoid use of antidepressants, including desvenlafaxine, in patients with untreated anatomically narrow angles.
During all MDD phase 2 and phase 3 studies, mania was reported for approximately 0.02% of patients treated with desvenlafaxine. Activation of mania/hypomania has also been reported in a small proportion of patients with major affective disorder who were treated with other marketed antidepressants. As with all antidepressants, desvenlafaxine should be used cautiously in patients with a history or family history of mania or hypomania.
Adverse reactions after discontinuation of serotonergic antidepressants, particularly after abrupt discontinuation, include: nausea, sweating, dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesia, such as electric shock sensations), tremor, anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania, tinnitus, and seizures. A gradual reduction in dosage rather than abrupt cessation is recommended whenever possible [see Dosage and Administration (2.5), Adverse Reaction (6.1)].
Cases of seizure have been reported in pre-marketing clinical studies with desvenlafaxine. Desvenlafaxine has not been systematically evaluated in patients with a seizure disorder. Patients with a history of seizures were excluded from pre-marketing clinical studies. Desvenlafaxine should be prescribed with caution in patients with a seizure disorder.
Hyponatremia may occur as a result of treatment with SSRIs and SNRIs, including desvenlafaxine. In many cases, this hyponatremia appears to be the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Cases with serum sodium lower than 110 mmol/L have been reported. Elderly patients may be at greater risk of developing hyponatremia with SSRIs and SNRIs. Also, patients taking diuretics or who are otherwise volume depleted can be at greater risk [see Use in Specific Populations (8.5) and Clinical Pharmacology (12.3)].
Discontinuation of desvenlafaxine should be considered in patients with symptomatic hyponatremia and appropriate medical intervention should be instituted.
Signs and symptoms of hyponatremia include headache, difficulty concentrating, memory impairment, confusion, weakness, and unsteadiness, which can lead to falls. Signs and symptoms associated with more severe and/or acute cases have included hallucination, syncope, seizure, coma, respiratory arrest, and death.
Interstitial lung disease and eosinophilic pneumonia associated with venlafaxine (the parent drug of desvenlafaxine) therapy have been rarely reported. The possibility of these adverse events should be considered in patients treated with desvenlafaxine who present with progressive dyspnea, cough, or chest discomfort. Such patients should undergo a prompt medical evaluation, and discontinuation of desvenlafaxine should be considered.
The following adverse reactions are discussed in greater detail in other sections of the label.
- Hypersensitivity [see Contraindications (4)]
- Suicidal Thoughts and Behaviors in Pediatric and Young Adult Patients [see Warnings and Precautions (5.1)]
- Serotonin Syndrome [see Warnings and Precautions (5.2)]
- Elevated Blood Pressure [see Warnings and Precautions (5.3)]
- Increased Risk of Bleeding [see Warnings and Precautions (5.4)]
- Angle Closure Glaucoma [see Warnings and Precautions (5.5)]
- Activation of Mania/Hypomania [see Warnings and Precautions (5.6)]
- Discontinuation Syndrome [see Warnings and Precautions (5.7)]
- Seizure [see Warnings and Precautions (5.8)]
- Hyponatremia [see Warnings and Precautions (5.9)]
- Interstitial Lung Disease and Eosinophilic Pneumonia [see Warnings and Precautions (5.10)]
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in clinical practice.
Desvenlafaxine was evaluated for safety in 8,394 patients diagnosed with major depressive disorder who participated in multiple-dose pre-marketing studies, representing 2,784 patient-years of exposure. Of the total 8,394 patients exposed to at least one dose of desvenlafaxine; 2,116 were exposed to desvenlafaxine for 6 months, representing 1,658 patient-years of exposure, and 421 were exposed for one year, representing 416 patient-years of exposure.
Adverse reactions reported as reasons for discontinuation of treatment
In the pre-marketing pooled 8-week placebo-controlled studies in patients with MDD, 1,834 patients were exposed to desvenlafaxine (50 to 400 mg). Of the 1,834 patients, 12% discontinued treatment due to an adverse reaction, compared with 3% of the 1,116 placebo-treated patients. At the recommended dose of 50 mg, the discontinuation rate due to an adverse reaction for desvenlafaxine (4.1%) was similar to the rate for placebo (3.8%). For the 100 mg dose of desvenlafaxine the discontinuation rate due to an adverse reaction was 8.7%.
The most common adverse reactions leading to discontinuation in at least 2% and at a rate greater than placebo of the desvenlafaxine treated patients in the short-term studies, up to 8 weeks, were: nausea (4%); dizziness, headache and vomiting (2% each). In a longer-term study, up to 9 months, the most common was vomiting (2%).
Common adverse reactions in placebo-controlled MDD studies
The most commonly observed adverse reactions in desvenlafaxine treated MDD patients in pre-marketing pooled 8-week, placebo-controlled, fixed-dose studies (incidence ≥ 5% and at least twice the rate of placebo in the 50 or 100 mg dose groups) were: nausea, dizziness, insomnia, hyperhidrosis, constipation, somnolence, decreased appetite, anxiety, and specific male sexual function disorders.
Table 2 shows the incidence of common adverse reactions that occurred in ≥2% of desvenlafaxine treated MDD patients and twice the rate of placebo at any dose in the pre-marketing pooled 8-week, placebo-controlled, fixed dose clinical studies
Table 2: Common Adverse Reactions (≥ 2% in any Fixed-Dose Group and Twice the Rate of Placebo) in Pre-marketing Pooled MDD 8-Week Placebo-Controlled Studies
|Percentage of Patients Reporting Reaction|
|System Organ Class Preferred Term||Placebo (n=636)||50 mg (n=317)||100 mg (n=424)||200 mg (n=307)||400 mg (n=317)|
|Blood pressure increased||1||1||1||2||2|
|General disorders and administration site conditions|
|Metabolism and nutrition disorders|
|Nervous system disorders|
|Disturbance in attention||<1||<1||1||2||1|
|Renal and urinary disorders|
|Respiratory, thoracic and mediastinal disorders|
|Skin and subcutaneous tissue disorders|
Sexual function adverse reactions
Table 3 shows the incidence of sexual function adverse reactions that occurred in ≥ 2% of desvenlafaxine treated MDD patients in any fixed-dose group (pre-marketing pooled 8-week, placebo-controlled, fixed -dose, clinical studies).
Table 3: Sexual Function Adverse Reactions (≥ 2% in Men or Women in any Desvenlafaxine Group) During the On-Therapy Period
|Placebo (n=239)||50 mg (n=108)||100 mg (n=157)||200 mg (n=131)||400 mg (n=154)|
|Placebo (n=397)||50 mg (n=209)||100 mg (n=267)||200 mg (n=176)||400 mg (n=163)|
Other adverse reactions observed in premarketing and postmarketing clinical studies
Other infrequent adverse reactions, not described elsewhere in the label, occurring at an incidence of < 2% in MDD patients treated with desvenlafaxine were:
Cardiac disorders – Tachycardia.
General disorders and administration site conditions – Asthenia.
Investigations – Weight increased, liver function test abnormal, blood prolactin increased.
Musculoskeletal and connective tissue disorders – Musculoskeletal stiffness.
Nervous system disorders – Syncope, convulsion, dystonia.
Psychiatric disorders – Depersonalization, bruxism.
Renal and urinary disorders – Urinary retention.
Skin and subcutaneous tissue disorders – Rash, alopecia, photosensitivity reaction, angioedema.
In clinical studies, there were uncommon reports of ischemic cardiac adverse reactions, including myocardial ischemia, myocardial infarction, and coronary occlusion requiring revascularization; these patients had multiple underlying cardiac risk factors. More patients experienced these events during desvenlafaxine treatment as compared to placebo.
Laboratory, ECG and vital sign changes observed in MDD clinical studies
The following changes were observed in pre-marketing placebo-controlled, short-term MDD studies with desvenlafaxine.
Elevations in fasting serum total cholesterol, LDL (low density lipoproteins) cholesterol, and triglycerides occurred in the controlled studies. Some of these abnormalities were considered potentially clinically significant.
The percentage of patients who exceeded a predetermined threshold value is shown in Table 4.
|Table 4: Incidence (%) of Patients With Lipid Abnormalities of Potential Clinical Significance*|
|Placebo||50 mg||100 mg||200 mg||400 mg|
|*(Increase of ≥50 mg/dl and an absolute value of ≥261 mg/dl)|
|*(Increase ≥50 mg/dl and an absolute value of ≥190 mg/dl)|
|*(Fasting: ≥327 mg/dl)|
Proteinuria, greater than or equal to trace, was observed in the pre-marketing fixed-dose controlled studies (see Table 5). This proteinuria was not associated with increases in BUN or creatinine and was generally transient. Table 5: Incidence (%) of Patients with Proteinuria in the Fixed-dose Clinical Studies
|Placebo||50 mg||100 mg||200 mg||400 mg|
Vital sign changes
Table 6 summarizes the changes that were observed in placebo-controlled, short-term, pre-marketing studies with desvenlafaxine in patients with MDD (doses 50 to 400 mg).
Table 6: Mean Changes in Vital Signs at Final on Therapy for All Short-term, Fixed-dose Controlled Studies
|Placebo||50 mg||100 mg||200 mg||400 mg|
|Supine systolic bp (mm Hg)||-1.4||1.2||2||2.5||2.1|
|Supine diastolic bp (mm Hg)||-0.6||0.7||0.8||1.8||2.3|
|Supine pulse (bpm)||-0.3||1.3||1.3||0.9||4.1|
Treatment with desvenlafaxine at all doses from 50 mg per day to 400 mg per day in controlled studies was associated with sustained hypertension, defined as treatment-emergent supine diastolic blood pressure (SDBP) ≥90 mm Hg and ≥10 mm Hg above baseline for 3 consecutive on-therapy visits (see Table 7). Analyses of patients in desvenlafaxine pre-marketing short-term controlled studies who met criteria for sustained hypertension revealed a consistent increase in the proportion of patients who developed sustained hypertension. This was seen at all doses with a suggestion of a higher rate at 400 mg per day.
Table 7: Proportion of Patients with Sustained Elevation of Supine Diastolic Blood Pressure
|Treatment Group||Proportion of Patients with Sustained Hypertension|
|Desvenlafaxine 50 mg per day||1.3%|
|Desvenlafaxine 100 mg per day||0.7%|
|Desvenlafaxine 200 mg per day||1.1%|
|Desvenlafaxine 400 mg per day||2.3%|
In the pre-marketing short-term, placebo-controlled clinical studies with doses of 50 to 400 mg, systolic orthostatic hypotension (decrease ≥30 mm Hg from supine to standing position) occurred more frequently in patients ≥65 years of age receiving desvenlafaxine (8%, 7/87) versus placebo (2.5%, 1/40), compared to patients <65 years of age receiving desvenlafaxine (0.9%, 18/1,937) versus placebo (0.7%, 8/1,218).
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