milnacipran, Savella

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GENERIC NAME: milnacipran


DRUG CLASS AND MECHANISM: Milnacipran is a selective serotonin and norepinephrine reuptake inhibitor (SNRI) used for treating pain associated with fibromyalgia. It is similar to duloxetine (Cymbalta), venlafaxine (Effexor), and desvenlafaxine (Pristiq). Milnacipran affects neurotransmitters, the chemicals that nerves within the brain make and release in order to communicate with one another. Neurotransmitters either travel across the space between nerves and attach to receptors on the surface of nearby nerves or they attach to receptors on the surface of the nerves that produced them, to be taken up by the nerve and released again (a process referred to as re-uptake).

Serotonin and norepinephrine are two neurotransmitters released by nerves in the brain. Milnacipran prevents the reuptake of serotonin and epinephrine by nerves after they have been released. Since uptake is an important mechanism for removing released neurotransmitters and terminating their actions on adjacent nerves, the reduced uptake caused by milnacipran increases the effect of serotonin and norepinephrine in the brain. The mechanism responsible for its effectiveness for treating fibromyalgia is not known, but it also is thought to involve its effects on serotonin and norepinephrine in the brain. Milnacipran was approved by the FDA in January 2009.



PREPARATIONS: Tablets: 12.5, 25, 50, and 100 mg

STORAGE: Milnacipran should be stored at room temperature, 15- 30 C (59-86 F).

PRESCRIBED FOR: Milnacipran is used for the treatment of pain associated with fibromyalgia. In studies of adults (18-74 years old), milnacipran provided better pain relief than placebo (sugar pill). Some patients may experience relief as early as 1 week after treatment begins.

DOSING: The recommended dose is 50-100 mg twice daily. It may be administered with or without food, but food improves the ability to tolerate this medication.

DRUG INTERACTIONS: Milnacipran should not be used in combination with a monoamine oxidase inhibitor (MAOI) such as phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan), and selegiline (Eldepryl), or within 14 days of discontinuing the MAOI. At least 5 days should be allowed after stopping milnacipran before starting an MAOI. Combinations of SNRIs and MAOIs may lead to serious, sometimes fatal, reactions including very high body temperature, rigidity, rapid fluctuations of heart rate and blood pressure, extreme agitation progressing to delirium and coma. Similar reactions may occur if milnacipran is combined with antipsychotics, tricyclic antidepressants or other drugs that affect serotonin in the brain [for example, tryptophan and sumatriptan (Imitrex)].

Combining milnacipran with epinephrine or norepinephrine may lead to high blood pressure and abnormal heart beats because milnacipran increases epinephrine and norepinephrine.

Combining milnacipran with aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), warfarin (Coumadin) or other drugs that are associated with bleeding may increase the risk of bleeding, because milnacipran is associated with bleeding.

PREGNANCY: There are no adequate studies in pregnant women. Milnacipran should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

NURSING MOTHERS: It is not known if milnacipran is excreted in human breast milk. Because the safety of milnacipran in infants is not known, nursing while taking milnacipran is not recommended.

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