TaperCommunitymilnacipran
Boxed Warning
Suicidality risk in children, adolescents, and young adults under 25 during initial treatment.
Milnacipran is a serotonin-norepinephrine reuptake inhibitor (SNRI) approved in the US for fibromyalgia management. It has a roughly 3:1 selectivity for norepinephrine over serotonin reuptake inhibition.
12.5mg, 25mg, 50mg, 100mg
Tablets: 12.5mg, 25mg, 50mg, 100mg; Titration pack: 12.5mg and 25mg tablets
Category C (risk cannot be ruled out)
Dual reuptake inhibitor of serotonin and norepinephrine with preferential activity at the norepinephrine transporter (NET > SERT, approximately 3:1 ratio).
SNRI approved for fibromyalgia (not depression in the US). Short half-life requires twice-daily dosing. Taper gradually — abrupt discontinuation causes withdrawal syndrome.
Reduce dose gradually over at least 1–2 weeks. Consider smaller dose reductions at lower doses. Short half-life means symptoms can emerge within 24 hours of missed dose.
Toxicity
Serotonin syndrome risk. Hypertension and tachycardia. Hepatotoxicity reported rarely.
Pharmacokinetics
Well absorbed (85–90% bioavailability). Tmax ~2–4 hours. Food does not affect AUC but delays Tmax.
~400 L
Hepatic — primarily conjugation (glucuronidation), not significantly CYP-mediated. Active desethyl metabolite.
Renal (55% unchanged, 24% as glucuronide conjugate).
13%
~60 L/hr
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