What to Know About Fetzima (Levomilnacipran)

An Antidepressant Used to Treat Major Depressive Disorder

Doctor writing on a prescription pad

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Fetzima (levomilnacipran) is an antidepressant drug used to treat major depressive disorder (MDD) in adults. It comes in capsule form (extended release) and contains the active ingredient levomilnacipran (the generic name for the drug), which is a type of selective serotonin and norepinephrine reuptake inhibitor. SNRIs work by blocking the neurotransmitters serotonin and norepinephrine that play a vital role in mood.

Uses

Fetzima has been FDA-approved for the treatment of MDD in adults. It is not approved for use in children. Fetzima is a new version of milnacipran (Savella), a drug used to treat the symptoms of fibromyalgia. However, Fetzima should never be used for fibromyalgia.

Before Taking

Prior to prescribing Fetzima, your doctor will likely take into consideration the following factors:

  • The symptoms of MDD that you struggle with most
  • If you have thoughts of suicide or self-harm
  • What's worked for you in the past (unless this is your first major depression)
  • What's worked for other family members with MDD (genetics can play a role in how you respond to an antidepressant)
  • Other medications you are currently taking
  • Other types of non-medical treatment you're receiving, such as talk therapy
  • Other medical problems or co-occurring psychiatric conditions, including a history of bipolar disorder
  • If you are pregnant or breastfeeding or planning to become pregnant
  • Current drug or alcohol use

Talk to your healthcare provider or pharmacist to see if there is any difference in choosing the brand-name drug over the generic version, especially if your insurance covers one over the other. The FDA requires generic drugs to use the same active ingredients as their brand-name counterparts and, therefore, the risks and benefits should be the same.

Precautions and Contraindications

If you are allergic to levomilnacipran or milnacipran, you should not use Fetzima. It is also not advisable if you have narrow-angle glaucoma.

It's important to tell your doctor about all the medication you are taking, including prescription medication, over-the-counter drugs, vitamins, and supplements before taking Fetzima.

If Fetzima is mixed with a monoamine oxidase inhibitor (MAOI) it can cause a potentially life-threatening reaction. Do not take Fetzima within seven days before or 14 days after you have taken an MAOI, including the antibiotic linezolid or intravenous methylene blue.

Levomilnacipran has also been found to enhance the effects of medication known to increase bleeding (ibuprofen, warfarin, aspirin) and to increase the levels and effects of the following drugs:

  • Antibiotics: Biaxin (clarithromycin) and Zithromax (azithromycin)
  • Antifungals: Diflucan (fluconazole), Nizoral (ketoconazole), Sporanox (itraconazole)
  • HIV medications: Norvir (ritonavir), Crixivan (indinavir)
  • Medication for mood, anxiety, psychotic or thought disorders, including tricyclics, lithium, fentanyl, tryptophan, selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), buspirone, amphetamines, or antipsychotics
  • Triptans used to treat migraine headaches
  • Tramadol for moderate to severe pain
  • Diuretics (water pills)
  • Over-the-counter supplements such as tryptophan or St. John's Wort

According to the manufacturer, you should also talk to your doctor if you are pregnant, nursing, or planning to become pregnant or to breastfeed, or have any of the following health conditions:

  • High blood pressure
  • Heart problems
  • Kidney problems (Fetzima can cause renal impairment in relatively low doses)
  • Bleeding problems (the drug can increase your risk of bleeding and bruising)
  • Trouble urinating
  • Alcohol use disorder
  • Low sodium levels in your blood
  • Mania or bipolar disorder
  • Seizures or convulsions

If Fetzima doesn't work with your health history and current medications, consider asking your doctor whether a different SNRI or another type of reuptake inhibitor would work for you. Some possible options may include:

  • SNRI: Focalin (dexmethylphenidate): Cymbalta (duloxetine), Pristiq (desvenlafaxine)
  • Norepinephrine Reuptake Inhibitors (NRIs): Ludiomil (maprotiline)
  • Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs): Focalin (dexmethylphenidate)
  • Serotonin-Norepinephrine-Dopamine Reuptake Inhibitors (SNDRIs): Effexor (venlafaxine)

Dosage

Fetzima is often prescribed at a low dose (20 milligrams), which is gradually increased over two days to 40 mg per day. According to the manufacturer, the recommended dose ranges from 40 milligrams to 120 mg, however it’s up to your doctor to determine the right dose for you. 

Always check your prescription and ask your doctor or pharmacist if you have any questions regarding dosage.

How to Take and Store

Take your prescription on the schedule and follow the exact dosage your doctor prescribed.

The manufacturer recommends taking Fetzima daily, at the same time each day, with or without food. It's best to swallow the capsule whole; do not open and sprinkle in food, crush, or chew. It's best to store Fetzima at room temperature ( 77°F) and to keep out of the reach of children.

If you miss a dose, take the missed dose as soon as you remember. If it is almost time for the next dose, skip the missed dose and take your next dose at the regular time. Do not take two doses of Fetzima at the same time. 

If you take too much (more than 120 mg) or suspect an overdose, call 911 or the Poison Control Center at 1-800-222-1222.

Side Effects

As with any prescription medication, there are certain side effects that you may experience while using Fetzima.

Common

The most common adverse side effects reported by people taking Fetzima include:

  • Nausea
  • Vomiting
  • Constipation
  • Excessive sweating (hyperhidrosis)
  • Increased or irregular heart rate (tachycardia)
  • Erectile dysfunction
  • Heart palpitations

This is only a partial list of possible side effects for this medication. You should ask your doctor or pharmacist if you require additional information.

Severe

Certain side effects, although they are quite rare, do require more serious consideration if they occur. You should seek out prompt medical assistance if you experience any of the following:

  • High blood pressure
  • Increased heart rate
  • Abnormal bleeding or bruising
  • Visual problems
  • Difficulty with urination
  • Mania or hypomania: Symptoms include increased energy, sleep problems, racing thoughts, impulsive behavior, grandiose thoughts, elevated mood, irritability and rapid, excessive talking.
  • Seizures or convulsions
  • Low sodium in the blood: Symptoms include headache, weakness, confusion, and problems with thinking, concentration, or memory.
  • Suicidal thoughts or actions or worsening depression
  • Serotonin syndrome: Symptoms include agitation, hallucinations, changes in consciousness, coordination problems, twitching muscles, rapid heartbeat, high or low blood pressure, sweating or fever, nausea, vomiting, diarrhea or muscle rigidity.
  • Severe allergic reaction: Symptoms include breathing difficulty, facial swelling, rash, hives, or blisters.

If you experience any of the more severe side effects listed above, it is imperative that you seek out medical assistance immediately to avoid damage to your health or possibly fatal outcomes.

Warnings and Interactions

Fetzima is not recommended if you are pregnant or breastfeeding (it's unknown if the drug passes through breastmilk), so you should contact your doctor immediately if you become pregnant while taking the drug.

Fetzima can cause sleepiness or impact your ability to make decisions, think clearly, or react quickly. Do not drive or operate heavy machinery until you know how the drug affects you.

Like all antidepressants, Fetzima has a black-box warning of an increased risk of suicidal thoughts or actions in some children, teenagers, or young adults within the first few months of treatment.

Pay close attention to any sudden changes in mood, behavior, thoughts, or feelings, especially when first starting the medication. If you do experience these sudden changes, report them to your doctor immediately.

It's also important to keep schedule visits with your healthcare provider to discuss any ongoing symptoms or side effects. Do not try and stop the medication on your own. Although your first impulse when you experience intolerable side effects may be to stop taking your medication, it is never a good idea to discontinue your antidepressant without first consulting with your doctor.

Your depression may return or even become worse if you suddenly stop taking your antidepressant. In addition, you run the risk of experiencing what is known as discontinuation syndrome, which includes a set of unpleasant symptoms such as nausea, fatigue, headaches, strange neurological sensations, and muscle aches.

Your doctor will be able to best advise you about methods to better cope with or eliminate side effects or whether it's a good idea to switch to a different antidepressant that will present fewer problems for you.

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