Serotonin and Norepinephrine Reuptake Inhibitors SNRIs

Venlafaxine (Effexor®) = 150 mg for norepinephrine. Start at 37.5 mg QD advancing every 3-5 days. Must reach =150 mg/day to obtain the norepinephrine reuptake inhibition effect. Differs from other agents in that it lacks anticholinergic, antiadrenergic, and antihistaminergic side effects.

Duloxetine (Cymbalta®) 30 mg/day advancing to 60-120 mg/day. Approved for use in diabetic neuropathy and postherpetic neuralgia but is commonly used in neuropathic pain syndromes associated with situational depression as an adjunct to the anticonvulsants and opioids. It has the advantage of limited anticholinergic effects, and the onset of analgesia occurs within a few days instead of several weeks.

Bupropion (Wellbutrin®SR, Zyban®) 150-300 mg/day. Wellbutrin SR is given BID (Wellbutrin XL is given QD). Bupropion is an atypical antidepressant that acts as a nore-pinephrine and dopamine reuptake inhibitor, and nicotinic antagonist. Bupropion lowers seizure threshold in higher doses. However, at the recommended dose the risk of seizures is comparable to that observed for other antidepressants. Bupropion is an effective antidepressant on its own but it is particularly popular as an add-on medication in the cases of incomplete response to the first-line SSRI antidepressant. It also seems to be effective in patients who have a history of alcohol or substance abuse who require long-term opioid therapy for chronic pain.

Trazadone (Desyrel®®) 50-300 mg/day (avoid in men due to risk of priapism). A favorable response in association with other adjunctive drugs and again particularly useful to restore evening sleep given at night.

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