TaperCommunitylevomilnacipran
Boxed Warning
Suicidality risk in children, adolescents, and young adults under 25 during initial treatment.
Levomilnacipran is the more pharmacologically active enantiomer of milnacipran. It is an SNRI approved for major depressive disorder with approximately 2:1 selectivity for norepinephrine over serotonin reuptake inhibition.
20mg, 40mg, 80mg, 120mg
Extended-release capsules: 20mg, 40mg, 80mg, 120mg
Category C (risk cannot be ruled out)
Potent dual reuptake inhibitor of serotonin and norepinephrine with preferential norepinephrine activity (NET > SERT, approximately 2:1 ratio). The active S-enantiomer of milnacipran.
Active enantiomer of milnacipran with stronger norepinephrine reuptake inhibition. Extended-release formulation allows once-daily dosing. Taper gradually over weeks.
Reduce dose gradually. Consider stepping down by one dose level (e.g., 120→80→40→20) every 1–2 weeks. Extended-release capsules should not be crushed or opened.
Toxicity
Serotonin syndrome risk. Blood pressure and heart rate increases. Urinary hesitation.
Pharmacokinetics
Well absorbed, bioavailability ~92%. Tmax ~6–8 hours (extended-release). Food does not affect AUC.
387–473 L
Hepatic via CYP3A4 (major) with minor contribution from CYP2C8, CYP2C19, CYP2D6, and CYP2J2. Desethyl metabolite (inactive).
Renal (58% unchanged).
22%
~21 L/hr
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