CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. CarcinogenesisTumors were not increased by venlafaxine treatment in mice or rats. Venlafaxine was given by oral gavage to mice for 18 months at doses up to 120 mg/kg per day, which was 1.7 times the maximum recommended human dose on mg/m2 basis. Venlafaxine was also given to rats by oral gavage for 24 months at doses up to 120 mg/kg per day. In rats receiving the 120 mg/kg dose, plasma concentrations of venlafaxine at necropsy were times (male rats) and times (female rats) the plasma concentrations of patients receiving the maximum recommended human dose. Plasma levels of the O-desmethyl metabolite (ODV) were lower in rats than in patients receiving the maximum recommended dose. O-desmethylvenlafaxine (ODV), the major human metabolite of venlafaxine, administered by oral gavage to mice and rats for years did not increase the incidence of tumors in either study. Mice received ODV at dosages up to 500/300 mg/kg/day (dosage lowered after 45 weeks of dosing). The exposure at the 300 mg/kg/day dose is times that of human dose of 225 mg/day. Rats received ODV at dosages up to 300 mg/kg/day (males) or 500 mg/kg/day (females). The exposure at the highest dose is approximately (males) or 11 (females) times that of human dose of 225 mg/day.MutagenesisVenlafaxine and the major human metabolite, ODV, were not mutagenic in the Ames reverse mutation assay in Salmonella bacteria or the Chinese hamster ovary/HGPRT mammalian cell forward gene mutation assay. Venlafaxine was also not mutagenic or clastogenic in the in vitro BALB/c-3T3 mouse cell transformation assay, the sister chromatid exchange assay in cultured Chinese hamster ovary cells, or in the in vivo chromosomal aberration assay in rat bone marrow. ODV was not clastogenic in the in vitro Chinese hamster ovary cell chromosomal aberration assay or in the in vivo chromosomal aberration assay in rats.Impairment of FertilityReproduction and fertility studies of venlafaxine in rats showed no adverse effects of venlafaxine on male or female fertility at oral doses of up to times the maximum recommended human dose of 225 mg/day on mg/m2 basis. However, reduced fertility was observed in study in which male and female rats were treated with O-desmethylvenlafaxine (ODV), the major human metabolite of venlafaxine, prior to and during mating and gestation. This occurred at an ODV exposure (AUC) approximately to times that associated with human venlafaxine dose of 225 mg/day.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. The exact mechanism of the antidepressant action of venlafaxine in humans is unknown, but is thought to be related to the potentiation of serotonin and norepinephrine in the central nervous system, through inhibition of their reuptake. Non-clinical studies have demonstrated that venlafaxine and its active metabolite, ODV, are potent and selective inhibitors of neuronal serotonin and norepinephrine reuptake and weak inhibitors of dopamine reuptake.. 12.2 Pharmacodynamics. Venlafaxine and ODV have no significant affinity for muscarinic-cholinergic, H1-histaminergic, or 1-adrenergic receptors in vitro. Pharmacologic activity at these receptors is hypothesized to be associated with the various anticholinergic, sedative, and cardiovascular effects seen with other psychotropic drugs. Venlafaxine and ODV do not possess monoamine oxidase (MAO) inhibitory activity.Cardiac Electrophysiology The effect of venlafaxine on the QT interval was evaluated in randomized, double-blind, placebo-and positive-controlled three-period crossover thorough QT study in 54 healthy adult subjects. No significant QT prolongation effect of venlafaxine 450 mg was detected.. 12.3 Pharmacokinetics. Steady-state concentrations of venlafaxine and ODV in plasma are attained within days of oral multiple-dose therapy. Venlafaxine and ODV exhibited linear kinetics over the dose range of 75 mg to 450 mg per day. Mean +- SD steady-state plasma clearance of venlafaxine and ODV is 1.3 +- 0.6 and 0.4 +- 0.2 L/h/kg, respectively; apparent elimination half-life is +- and 11 +- hours, respectively; and apparent (steady-state) volume of distribution is 7.5 +- 3.7 and 5.7 +- 1.8 L/kg, respectively. Venlafaxine and ODV are minimally bound at therapeutic concentrations to plasma proteins (27% and 30%, respectively).Absorption and DistributionVenlafaxine is well absorbed and extensively metabolized in the liver. ODV is the major active metabolite. On the basis of mass balance studies, at least 92% of single oral dose of venlafaxine is absorbed. The absolute bioavailability of venlafaxine is approximately 45%.Administration of venlafaxine hydrochloride extended-release capsules (150 mg once daily) generally resulted in lower Cmax and later Tmax values than for venlafaxine tablets (immediate release) administered twice daily (Table 16). When equal daily doses of venlafaxine were administered as either an immediate-release tablet or the extended-release capsule, the exposure to both venlafaxine and ODV was similar for the two treatments, and the fluctuation in plasma concentrations was slightly lower with the venlafaxine hydrochloride extended-release capsule. Therefore, venlafaxine hydrochloride extended-release capsules provide slower rate of absorption, but the same extent of absorption compared with the immediate-release tablet.Table 16: Comparison of Cmax and Tmax Values for Venlafaxine and ODV Following Oral Administration of Venlafaxine Hydrochloride Extended-release Capsules and Venlafaxine Tablets (Immediate Release) Venlafaxine ODV Cmax (ng/mL) Tmax (h) Cmax (ng/mL) Tmax (h) Venlafaxine Hydrochloride Extended-release Capsules (150 mg once daily) 150 5.5 260 Venlafaxine Tablets (75 mg twice daily) 225 290 Food did not affect the bioavailability of venlafaxine or its active metabolite, ODV. Time of administration (AM versus PM) did not affect the pharmacokinetics of venlafaxine and ODV from the 75 mg venlafaxine hydrochloride extended-release capsule.Venlafaxine is not highly bound to plasma proteins; therefore, administration of venlafaxine hydrochloride extended-release capsules to patient taking another drug that is highly protein-bound should not cause increased free concentrations of the other drug.Metabolism and EliminationFollowing absorption, venlafaxine undergoes extensive presystemic metabolism in the liver, primarily to ODV, but also to N-desmethylvenlafaxine, N,O-didesmethylvenlafaxine, and other minor metabolites. In vitro studies indicate that the formation of ODV is catalyzed by CYP2D6; this has been confirmed in clinical study showing that patients with low CYP2D6 levels (poor metabolizers) had increased levels of venlafaxine and reduced levels of ODV compared to people with normal CYP2D6 levels (extensive metabolizers) [see Use in Specific Populations (8.7 )]. Approximately 87% of venlafaxine dose is recovered in the urine within 48 hours as unchanged venlafaxine (5%), unconjugated ODV (29%), conjugated ODV (26%), or other minor inactive metabolites (27%). Renal elimination of venlafaxine and its metabolites is thus the primary route of excretion.

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES. 14.1 Major Depressive Disorder. The efficacy of venlafaxine hydrochloride extended-release capsules as treatment for Major Depressive Disorder (MDD) was established in two placebo-controlled, short-term (8 weeks for study 1; 12 weeks for study 2), flexible-dose studies, with doses starting at 75 mg per day and ranging to 225 mg per day in adult outpatients meeting DSM-III-R or DSM-IV criteria for MDD. In moderately depressed outpatients, the initial dose of venlafaxine was 75 mg per day. In both studies, venlafaxine hydrochloride extended-release capsules demonstrated superiority over placebo on the primary efficacy measure defined as change from baseline in the HAM-D-21 total score to the endpoint visit, venlafaxine hydrochloride extended-release capsules also demonstrated superiority over placebo on the key secondary efficacy endpoint, the Clinical Global Impressions (CGI) Severity of Illness scale. Examination of gender subsets of the population studied did not reveal any differential responsiveness on the basis of gender.A 4-week study of inpatients meeting DSM-III-R criteria for MDD with melancholia utilizing venlafaxine tablets in range of 150 mg to 375 mg per day (divided in three-times-a-day schedule) demonstrated superiority of venlafaxine hydrochloride tablets over placebo based on the HAM-D-21 total score. The mean dose in completers was 350 mg per day (study 3).In longer-term study, adult outpatients with MDD who had responded during an 8-week open-label study on venlafaxine hydrochloride extended-release capsules (75 mg, 150 mg, or 225 mg, once daily every morning) were randomized to continuation of their same venlafaxine hydrochloride extended-release capsule dose or to placebo, for up to 26 weeks of observation for relapse. Response during the open-label phase was defined as CGI Severity of Illness text score of <= and HAM-D-21 total score of <= 10 at the day 56 evaluation. Relapse during the double-blind phase was defined as follows: (1) reappearance of major depressive disorder as defined by DSM-IV criteria and CGI Severity of Illness text score of >= (moderately ill), (2) consecutive CGI Severity of Illness text scores of >= 4, or (3) final CGI Severity of Illness text score of >= for any patient who withdrew from the study for any reason. Patients receiving continued venlafaxine hydrochloride extended-release capsule treatment experienced statistically significantly lower relapse rates over the subsequent 26 weeks compared with those receiving placebo (study 4).In second longer term trial, adult outpatients with MDD, recurrent type, who had responded (HAM-D-21 total score <= 12 at the day 56 evaluation) and continued to be improved [defined as the following criteria being met for days 56 through 180: (1) no HAM-D-21 total score >= 20; (2) no more than HAM-D-21 total scores 10, and (3) no single CGI Severity of Illness text score >= (moderately ill)] during an initial 26 weeks of treatment on venlafaxine tablets [100 mg to 200 mg per day, on twice daily schedule] were randomized to continuation of their same venlafaxine tablet dose or to placebo. The follow-up period to observe patients for relapse, defined as CGI Severity of Illness text score >= 4, was for up to 52 weeks. Patients receiving continued venlafaxine tablet treatment experienced statistically significantly lower relapse rates over the subsequent 52 weeks compared with those receiving placebo (study 5). Table 17: Major Depressive Disorder Studies Study number Treatment Group Primary Efficacy Measure: HAM-D Score Mean Baseline Score (SD) LS Mean Change from Baseline Placebo Subtracted Differencea (95% CI) Study Venlafaxine Hydrochloride Extended-release Capsules (75 to 225 mg/day) Placebo 24.5 23.6 -11.7 -7.24 -4.45 (-6.66, -2.25) Study Venlafaxine Hydrochloride Extended-release Capsules (75 to 225 mg/day) 24.5 -15.11 -6.40 (-8.45, -4.34) Placebo 24.9 -8.71 Study Venlafaxine Immediate Release Tablets (150 to 375 mg/day) Placebo 28.2 (0.5) 28.6 (0.6) -14.9 -4.7 -10.2 (-14.4, -6.0) SD: standard deviation; LS Mean: least-squares mean; CI: confidence interval.a Difference (drug minus placebo) in least-squares mean change from baseline Doses statistically significantly superior to placebo. 14.2 Generalized Anxiety Disorder. The efficacy of venlafaxine hydrochloride extended-release capsules as treatment for Generalized Anxiety Disorder (GAD) was established in two 8-week, placebo-controlled, fixed-dose studies (75 mg to 225 mg per day), one 6-month, placebo-controlled, flexible-dose study (75 mg to 225 mg per day), and one 6-month, placebo-controlled, fixed-dose study (37.5 mg, 75 mg, and 150 mg per day) in adult outpatients meeting DSM-IV criteria for GAD.In one 8-week study, venlafaxine hydrochloride extended-release capsules demonstrated superiority over placebo for the 75 mg, 150 mg, and 225 mg per day doses as measured by the Hamilton Rating Scale for Anxiety (HAM-A) total score, both the HAM-A anxiety and tension texts, and the Clinical Global Impressions (CGI) scale. However, the 75 mg and 150 mg per day doses were not as consistently effective as the highest dose (study 1). second 8-week study evaluating doses of 75 mg and 150 mg per day and placebo showed that both doses were more effective than placebo on some of these same outcomes; however, the 75 mg per day dose was more consistently effective than the 150 mg per day dose (study 2). dose-response relationship for effectiveness in GAD was not clearly established in the 75 mg to 225 mg per day dose range studied.Two 6-month studies, one evaluating venlafaxine hydrochloride extended-release capsule doses of 37.5 mg, 75 mg, and 150 mg per day (study 3) and the other evaluating venlafaxine hydrochloride extended-release capsules doses of 75 mg to 225 mg per day (study 4), showed that daily doses of 75 mg or higher were more effective than placebo on the HAM-A total, both the HAM-A anxiety and tension texts, and the CGI scale during months of treatment. While there was also evidence for superiority over placebo for the 37.5 mg per day dose, this dose was not as consistently effective as the higher doses.Examination of gender subsets of the population studied did not reveal any differential responsiveness on the basis of gender.Table 18: Generalized Anxiety Disorder Studies Study Number Treatment Group Primary Efficacy Measure: HAM-A Score Mean Baseline Score (SD) LS Mean Change from Baseline (SE) Placebo Subtracted Differencea (95% CI) Study Ven XR 75 mg Ven XR 150 mg Ven XR 225 mg 24.7 24.5 23.6 -11.1 (0.95) -11.7 (0.87) -12.1 (0.81) -1.5 (-3.8, 0.8) -2.2 (-4.5, 0.1) -2.6 (-4.9, -0.3) Placebo 24.1 -9.5 (0.85) Study Ven XR 75 mg Ven XR 150 mg 23.7 23.0 -10.6 (0.82) -9.8 (0.86) -2.6 (-4.6, -0.5) -1.7 (-3.8, 0.3) Placebo 23.7 -8.0 (0.73) Study Ven XR 37.5 mg Ven XR 75 mg Ven XR 150 mg 26.6 (0.4) 26.3 (0.4) 26.3 (0.4) -13.8 -15.5 -16.4 -2.8 (-5.1, -0.6) -4.6 (-6.9, -2.3) -5.5 (-7.8, -3.1) Placebo 26.7 (0.5) -11.0 Study Ven XR 75 to 225 mg 25.0 -13.4 (0.79) 4.7 (-6.6, -2.9) Placebo 24.9 -8.7 (0.70) SD: standard deviation; SE: standard error; LS Mean: least-squares mean; CI: confidence interval.a Difference (drug minus placebo) in least-squares mean change from baseline Doses statistically significantly superior to placebo. 14.3 Social Anxiety Disorder (also known as Social Phobia). The efficacy of venlafaxine hydrochloride extended-release capsules as treatment for Social Anxiety Disorder (SAD) was established in four double-blind, parallel-group, 12-week, multicenter, placebo-controlled, flexible-dose studies (studies to 4) and one double-blind, parallel-group, 6-month, placebo-controlled, fixed/flexible-dose study, which included doses in range of 75 mg to 225 mg per day in adult outpatients meeting DSM-IV criteria for SAD (study 5).In these five studies, venlafaxine hydrochloride extended-release capsules were statistically significantly more effective than placebo on change from baseline to endpoint on the Liebowitz Social Anxiety Scale (LSAS) total score. There was no evidence for any greater effectiveness of the 150 mg to 225 mg per day group compared to the 75 mg per day group in the 6-month study.Examination of subsets of the population studied did not reveal any differential responsiveness on the basis of gender. There was insufficient information to determine the effect of age or race on outcome in these studies.Table 19: Social Anxiety Disorder Studies Study Number Treatment Group Primary Efficacy Measure: LSAS Score Mean Baseline Score (SD) LS Mean Change from Baseline (SE) Placebo Subtracted Differencea (95% CI) Study Ven XR (75 to 225 mg) Placebo 91.1 86.7 -31.0 (2.22) -19.9 (2.22) 11.2 (-5.3, -17.1) Study Ven XR (75 to 225 mg) Placebo 90.8 87.4 -32.8 (2.69) -22.1 (2.66) -10.7 (-3.7, -17.6) Study Ven XR (75 to 225 mg) Placebo 83.2 83.6 -36.0 (2.35) -19.1 (2.40) -16.9 (-22.6, -11.2) -12.7 (-6.5, -19.0) Study Ven XR (75 to 225 mg) 86.2 -35.0 (2.64) -14.6 (-21.8, -7.4) Placebo 86.1 -22.2 (2.47) Study Ven XR 75 mg Ven XR (150 to 225 mg) 91.8 86.2 -38.1 (3.16) -37.6 (3.05) -14.6 (-21.8, -7.4) -14.1 (-21.3, -6.9) Placebo 89.3 -23.5 (3.08) SD: standard deviation; SE: standard error; LS Mean: least-squares mean; CI: confidence interval.a Difference (drug minus placebo) in least-squares mean change from baseline Doses statistically significantly superior to placebo. 14.4 Panic Disorder. The efficacy of venlafaxine hydrochloride extended-release capsules as treatment for Panic Disorder (PD) was established in two double-blind, 12-week, multicenter, placebo-controlled studies in adult outpatients meeting DSM-IV criteria for PD, with or without agoraphobia. Patients received fixed doses of 75 mg or 150 mg per day in one study (study 1) and 75 mg or 225 mg per day in the other study (study 2).Efficacy was assessed on the basis of outcomes in three variables: (1) percentage of patients free of full-symptom panic attacks on the Panic and Anticipatory Anxiety Scale (PAAS); (2) mean change from baseline to endpoint on the Panic Disorder Severity Scale (PDSS) total score; and (3) percentage of patients rated as responders (much improved or very much improved) on the Clinical Global Impressions (CGI) Improvement scale. In these two studies, venlafaxine hydrochloride extended-release capsules were statistically significantly more effective than placebo (for each fixed dose) on all three endpoints, but dose-response relationship was not clearly established.Examination of subsets of the population studied did not reveal any differential responsiveness on the basis of gender. There was insufficient information to determine the effect of age or race on outcome in these studies.In longer term study (study 3), adult outpatients meeting DSM-IV criteria for PD who had responded during 12-week open phase with venlafaxine hydrochloride extended-release capsules (75 mg to 225 mg per day) were randomly assigned to continue the same venlafaxine hydrochloride extended-release capsules dose (75 mg, 150 mg, or 225 mg) or switch to placebo for observation for relapse under double-blind conditions. Response during the open phase was defined as <= full-symptom panic attack per week during the last weeks of the open phase and CGI Improvement score of (very much improved) or (much improved). Relapse during the double-blind phase was defined as having or more full-symptom panic attacks per week for consecutive weeks or having discontinued due to loss of effectiveness as determined by the investigators during the study. Randomized patients were in response status for mean time of 34 days prior to being randomized. In the randomized phase following the 12-week open-label period, patients receiving continued venlafaxine hydrochloride extended-release capsules experienced statistically significantly longer time to relapse.Table 20: Panic Disorder Studies Study Number Treatment Group Primary Efficacy Measure: Whether Free of Full-symptom Panic Attacks Percent of patients Free of Full symptom panic attack Adjusted Odds Ratioa to placebo Adjusted Odds Ratioa 95% Confidence Interval Study Ven XR 75 mg Ven XR 150 mg Placebo 54.1% (85/157) 61.4% (97/158) 34.4% (53/154) 2.268 3.035 -- (1.43, 3.59) (1.91, 4.82) -- Study Ven XR 75 mg Ven XR 225 mg Placebo 64.1% (100/156) 70.0% (112/160) 46.5% (73/157) 2.350 2.890 -- (1.46, 3.78) (1.80, 4.64) -- Odds ratio (drug to placebo) in terms of probability of free of full-symptom panic attacks based on logistic regression model. 95%CI: 95% confidence interval without adjusting for multiple dose arms. Doses statistically significantly superior to placebo.. 14.5 Pediatric Patients. Two placebo-controlled studies in 766 pediatric patients with MDD and two placebo-controlled studies in 793 pediatric patients with GAD have been conducted with venlafaxine hydrochloride extended-release capsules, and the data were not sufficient to support claim for use in pediatric patients.

ABUSE SECTION.

9.2 Abuse. While venlafaxine has not been systematically studied in clinical studies for its potential for abuse, there was no indication of drug-seeking behavior in the clinical studies. However, it is not possible to predict on the basis of premarketing experience the extent to which CNS-active drug will be misused, diverted, and/or abused once marketed. Consequently, physicians should carefully evaluate patients for history of drug abuse and follow such patients closely, observing them for signs of misuse or abuse of venlafaxine (e.g., development of tolerance, incrementation of dose, drug-seeking behavior).

ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following adverse reactions are discussed in greater detail in other sections of the label:Hypersensitivity [see Contraindications (4.1)] Suicidal Thoughts and Behaviors in Children, Adolescents, and Adults [see Warnings and Precautions (5.1)] Serotonin Syndrome [see Warnings and Precautions (5.2)] Elevations in Blood Pressure [see Warnings and Precautions (5.3)] Abnormal Bleeding [see Warnings and Precautions (5.4)] Angle Closure Glaucoma [see Warnings and Precautions (5.5)] Activation of Mania/Hypomania [see Warnings and Precautions (5.6)] Discontinuation Syndrome [see Warnings and Precautions (5.7)] Seizure [see Warnings and Precautions (5.8)] Hyponatremia [see Warnings and Precautions (5.9)] Weight and Height changes in Pediatric Patients [see Warnings and Precautions (5.10)] Appetite Changes in Pediatric Patients [see Warnings and Precautions (5.11)] Interstitial Lung Disease and Eosinophilic Pneumonia [see Warnings and Precautions (5.12)] Sexual Dysfunction [see Warnings and Precautions (5.13)] Hypersensitivity [see Contraindications (4.1)] Suicidal Thoughts and Behaviors in Children, Adolescents, and Adults [see Warnings and Precautions (5.1)] Serotonin Syndrome [see Warnings and Precautions (5.2)] Elevations in Blood Pressure [see Warnings and Precautions (5.3)] Abnormal Bleeding [see Warnings and Precautions (5.4)] Angle Closure Glaucoma [see Warnings and Precautions (5.5)] Activation of Mania/Hypomania [see Warnings and Precautions (5.6)] Discontinuation Syndrome [see Warnings and Precautions (5.7)] Seizure [see Warnings and Precautions (5.8)] Hyponatremia [see Warnings and Precautions (5.9)] Weight and Height changes in Pediatric Patients [see Warnings and Precautions (5.10)] Appetite Changes in Pediatric Patients [see Warnings and Precautions (5.11)] Interstitial Lung Disease and Eosinophilic Pneumonia [see Warnings and Precautions (5.12)] Sexual Dysfunction [see Warnings and Precautions (5.13)] Most common adverse reactions (incidence >= 5% and at least twice the rate of placebo): nausea, somnolence, dry mouth, sweating, abnormal ejaculation, anorexia, constipation, erectile dysfunction, and libido decreased (6.1).To report SUSPECTED ADVERSE REACTIONS, contact Teva at 1-888-838-2872 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.. 6.1 Clinical Studies Experience. Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.Most Common Adverse ReactionsThe most commonly observed adverse reactions in the clinical study database in venlafaxine hydrochloride extended-release capsule treated patients in MDD, GAD, SAD, and PD (incidence >= 5% and at least twice the rate of placebo) were: nausea (30.0%), somnolence (15.3%), dry mouth (14.8%), sweating (11.4%), abnormal ejaculation (9.9%), anorexia (9.8%), constipation (9.3%), impotence (5.3%) and decreased libido (5.1%).Adverse Reactions Reported as Reasons for Discontinuation of TreatmentCombined across short-term, placebo-controlled premarketing studies for all indications, 12% of the 3,558 patients who received venlafaxine hydrochloride extended-release capsules (37.5 mg to 225 mg) discontinued treatment due to an adverse experience, compared with 4% of the 2,197 placebo-treated patients in those studies.The most common adverse reactions leading to discontinuation in >= 1% of the venlafaxine hydrochloride extended-release capsule treated patients in the short-term studies (up to 12 weeks) across indications are shown in Table 7.Table 7: Incidence (%) of Patients Reporting Adverse Reactions Leading to Discontinuation in Placebo-controlled Clinical Studies (up to 12 Weeks Duration) Body System Adverse Reaction Venlafaxine Hydrochloride Extended-release Capsules = 3,558 Placebo = 2,197 Body as whole Asthenia 1.7 0.5 Headache 1.5 0.8 Digestive system Nausea 4.3 0.4 Nervous system Dizziness 2.2 0.8 Insomnia 2.1 0.6 Somnolence 1.7 0.3 Skin and appendages 1.5 0.6 Sweating 1.0 0.2 Common Adverse Reactions in Placebo-controlled StudiesThe number of patients receiving multiple doses of venlafaxine hydrochloride extended-release capsules during the premarketing assessment for each approved indication is shown in Table 8. The conditions and duration of exposure to venlafaxine in all development programs varied greatly, and included (in overlapping categories) open and double-blind studies, uncontrolled and controlled studies, inpatient (venlafaxine tablets only) and outpatient studies, fixed-dose, and titration studies.Table 8: Patients Receiving Venlafaxine Hydrochloride Extended-release Capsules in Premarketing Clinical Studies Indication Venlafaxine Hydrochloride Extended-release Capsules MDD 705a GAD 1,381 SAD 819 PD 1,314 In addition, in the premarketing assessment of venlafaxine tablets, multiple doses were administered to 2,897 patients in studies for MDD.The incidences of common adverse reactions (those that occurred in >= 2% of venlafaxine hydrochloride extended-release capsule treated patients [357 MDD patients, 1,381 GAD patients, 819 SAD patients, and 1,001 PD patients] and more frequently than placebo) in venlafaxine hydrochloride extended-release capsule treated patients in short-term, placebo-controlled, fixed- and flexible-dose clinical studies (doses 37.5 mg to 225 mg per day) are shown in Table 9.The adverse reaction profile did not differ substantially between the different patient populations.Table 9: Common Adverse Reactions: Percentage of Patients Reporting Adverse Reactions (>= 2% and placebo) in Placebo-controlled Studies (up to 12 Weeks Duration) across All Indications Body System Venlafaxine Hydrochloride Extended-release Capsules Placebo Adverse Reaction = 3,558 = 2,197 Body as whole Asthenia 12.6 7.8 Cardiovascular system Hypertension 3.4 2.6 Palpitation 2.2 2.0 Vasodilatation 3.7 1.9 Digestive system Anorexia 9.8 2.6 Constipation 9.3 3.4 Diarrhea 7.7 7.2 Dry mouth 14.8 5.3 Nausea 30.0 11.8 Vomiting 4.3 2.7 Nervous system Abnormal dreams 2.9 1.4 Dizziness 15.8 9.5 Insomnia 17.8 9.5 Libido decreased 5.1 1.6 Nervousness 7.1 5.0 Paresthesia 2.4 1.4 Somnolence 15.3 7.5 Tremor 4.7 1.6 Respiratory system Yawn 3.7 0.2 Skin and appendages Sweating (including night sweats) 11.4 2.9 Special senses Abnormal vision 4.2 1.6 Urogenital system Abnormal ejaculation/orgasm (men)a 9.9 0.5 Anorgasmia (men)a 3.6 0.1 Anorgasmia (women)b 2.0 0.2 Impotence (men)a 5.3 1.0 Percentages based on the number of men (venlafaxine hydrochloride extended-release capsules, = 1,440; placebo, = 923)b Percentages based on the number of women (venlafaxine hydrochloride extended-release capsules, = 2,118; placebo, = 1,274)Other Adverse Reactions Observed in Clinical StudiesBody as whole- Photosensitivity reaction, chillsCardiovascular system- Postural hypotension, syncope, hypotension, tachycardiaDigestive system- Gastrointestinal hemorrhage [see Warnings and Precautions (5.4)], bruxismHemic/Lymphatic system- Ecchymosis [see Warnings and Precautions (5.4)] Metabolic/Nutritional- Hypercholesterolemia, weight gain [see Warnings and Precautions (5.10)], weight loss [see Warnings and Precautions (5.10)] Nervous system- Seizures [see Warnings and Precautions (5.8)], manic reaction [see Warnings and Precautions (5.6)], agitation, confusion, akathisia, hallucinations, hypertonia, myoclonus, depersonalization, apathySkin and appendages- Urticaria, pruritus, rash, alopeciaSpecial senses- Mydriasis, abnormality of accommodation, tinnitus, taste perversionUrogenital system- Urinary retention, urination impaired, urinary incontinence, urinary frequency increased, menstrual disorders associated with increased bleeding or increased irregular bleeding (e.g., menorrhagia, metrorrhagia). 6.2 Vital Sign Changes. In placebo-controlled premarketing studies, there were increases in mean blood pressure (see Table 10). Across most indications, dose-related increase in mean supine systolic and diastolic blood pressure was evident in patients treated with venlafaxine hydrochloride extended-release capsules. Across all clinical studies in MDD, GAD, SAD and PD, 1.4% of patients in the venlafaxine hydrochloride extended-release capsules groups experienced an increase in SDBP of >= 15 mm Hg along with blood pressure >= 105 mm Hg, compared to 0.9% of patients in the placebo groups. Similarly, 1% of patients in the venlafaxine hydrochloride extended-release capsules groups experienced an increase in SSBP of >= 20 mm Hg with blood pressure >= 180 mm Hg, compared to 0.3% of patients in the placebo groups.Table 10: Final On-therapy Mean Changes From Baseline in Supine Systolic (SSBP) and Diastolic (SDBP) Blood Pressure (mm Hg) in Placebo-controlled Studies Indication (Duration) Venlafaxine Hydrochloride Extended-release Capsules Placebo <= 75 mg per day 75 mg per day SSBP SDBP SSBP SDBP SSBP SDBP MDD (8 to 12 weeks) -0.28 0.37 2.93 3.56 -1.08 -0.10 GAD (8 weeks) -0.28 0.02 2.40 1.68 -1.26 -0.92 (6 months) 1.27 -0.69 2.06 1.28 -1.29 -0.74 SAD (12 weeks) -0.29 -1.26 1.18 1.34 -1.96 -1.22 (6 months) -0.98 -0.49 2.51 1.96 -1.84 -0.65 PD (10 to 12 weeks) -1.15 0.97 -0.36 0.16 -1.29 -0.99 Venlafaxine hydrochloride extended-release capsule treatment was associated with sustained hypertension (defined as treatment-emergent Supine Diastolic Blood Pressure [SDBP] >= 90 mm Hg and >= 10 mm Hg above baseline for three consecutive on-therapy visits (see Table 11). An insufficient number of patients received mean doses of venlafaxine hydrochloride extended-release capsules over 300 mg per day in clinical studies to fully evaluate the incidence of sustained increases in blood pressure at these higher doses.Table 11: Sustained Elevations in SDBP in Venlafaxine Hydrochloride Extended-release Capsules Premarketing Studies Indication Dose Range (mg per day) Incidence (%) MDD 75 to 375 19/705 (3) GAD 37.5 to 225 5/1011 (0.5) SAD 75 to 225 5/771 (0.6) PD 75 to 225 9/973 (0.9) Venlafaxine hydrochloride extended-release capsules were associated with mean increases in pulse rate compared with placebo in premarketing placebo-controlled studies (see Table 12) [see Warnings and Precautions (5.3, 5.4)]. Table 12: Approximate Mean Final On-therapy Increase in Pulse Rate (beats/min) in Venlafaxine Hydrochloride Extended-release Capsules Premarketing Placebo-controlled Studies (up to 12 Weeks Duration) Indication (Duration) Venlafaxine Hydrochloride Extended-release Capsules Placebo MDD (12 weeks) 1 GAD (8 weeks) < SAD (12 weeks) 1 PD (12 weeks) < . 6.3 Laboratory Changes. Serum CholesterolVenlafaxine hydrochloride extended-release capsules were associated with mean final increases in serum cholesterol concentrations compared with mean final decreases for placebo in premarketing MDD, GAD, SAD and PD clinical studies (Table 13).Table 13: Mean Final On-therapy Changes in Cholesterol Concentrations (mg/dL) in Venlafaxine Hydrochloride Extended-release Capsules Premarketing Studies Indication (Duration) Venlafaxine Hydrochloride Extended-release Capsules Placebo MDD (12 weeks) +1.5 -7.4 GAD (8 weeks) (6 months) +1.0 +2.3 -4.9 -7.7 SAD (12 weeks) (6 months) +7.9 +5.6 -2.9 -4.2 PD (12 weeks) 5.8 -3.7 Venlafaxine hydrochloride extended-release capsules treatment for up to 12 weeks in premarketing placebo-controlled trials for major depressive disorder was associated with mean final on-therapy increase in serum cholesterol concentration of approximately 1.5 mg/dL compared with mean final decrease of 7.4 mg/dL for placebo. Venlafaxine hydrochloride extended-release capsule treatment for up to weeks and up to months in premarketing placebo-controlled GAD trials was associated with mean final on-therapy increases in serum cholesterol concentration of approximately 1.0 mg/dL and 2.3 mg/dL, respectively while placebo subjects experienced mean final decreases of 4.9 mg/dL and 7.7 mg/dL, respectively. Venlafaxine hydrochloride extended-release capsule treatment for up to 12 weeks and up to months in premarketing placebo-controlled Social Anxiety Disorder trials was associated with mean final on-therapy increases in serum cholesterol concentration of approximately 7.9 mg/dL and 5.6 mg/dL, respectively, compared with mean final decreases of 2.9 mg/dL and 4.2 mg/dL, respectively, for placebo. Venlafaxine hydrochloride extended-release capsule treatment for up to 12 weeks in premarketing placebo-controlled panic disorder trials was associated with mean final on-therapy increases in serum cholesterol concentration of approximately 5.8 mg/dL compared with mean final decrease of 3.7 mg/dL for placebo.Patients treated with venlafaxine tablets (immediate release) for at least months in placebo-controlled 12-month extension trials had mean final on-therapy increase in total cholesterol of 9.1 mg/dL compared with decrease of 7.1 mg/dL among placebo-treated patients. This increase was duration dependent over the study period and tended to be greater with higher doses. Clinically relevant increases in serum cholesterol, defined as 1) final on-therapy increase in serum cholesterol >= 50 mg/dL from baseline and to value >= 261 mg/dL, or 2) an average on-therapy increase in serum cholesterol >= 50 mg/dL from baseline and to value >= 261 mg/dL, were recorded in 5.3% of venlafaxine-treated patients and 0.0% of placebo-treated patients.Serum TriglyceridesVenlafaxine hydrochloride extended-release capsules were associated with mean final on-therapy increases in fasting serum triglycerides compared with placebo in premarketing clinical studies of SAD and PD up to 12 weeks (pooled data) and months duration (Table 14).Table 14: Mean Final On-therapy Increases in Triglyceride Concentrations (mg/dL) in Venlafaxine Hydrochloride Extended-release Capsules Premarketing Studies Indication (Duration) Venlafaxine Hydrochloride Extended-release Capsules Placebo SAD (12 weeks) 8.2 0.4 SAD (6 months) 11.8 1.8 PD (12 weeks) 5.9 0.9 PD (6 months) 9.3 0.3 6.4 Pediatric Patients. In general, the adverse reaction profile of venlafaxine (in placebo-controlled clinical studies) in children and adolescents (ages to 17) was similar to that seen for adults. As with adults, decreased appetite, weight loss, increased blood pressure, and increased serum cholesterol were observed [see Warnings and Precautions (5.3, 5.10, 5.11) and Use in Specific Populations (8.4)].In pediatric clinical studies, the adverse reaction, suicidal ideation, was observed.Particularly, the following adverse reactions were observed in pediatric patients: abdominal pain, agitation, dyspepsia, ecchymosis, epistaxis, and myalgia.. 6.5 Adverse Reactions Identified During Postapproval Use. The following adverse reactions have been identified during postapproval use of venlafaxine hydrochloride extended-release capsules. Because these reactions are reported voluntarily from population of uncertain size, it is not always possible to reliably estimate their frequency or establish causal relationship to drug exposure:Body as whole- Anaphylaxis, angioedemaCardiovascular system- QT prolongation, ventricular fibrillation, ventricular tachycardia (including torsade de pointes), takotsubo cardiomyopathyDigestive system- PancreatitisHemic/Lymphatic system- Mucous membrane bleeding [see Warnings and Precautions (5.4)], blood dyscrasias (including agranulocytosis, aplastic anemia, neutropenia and pancytopenia), prolonged bleeding time, thrombocytopeniaMetabolic/Nutritional- Hyponatremia [see Warnings and Precautions (5.9)], Syndrome of Inappropriate Antidiuretic Hormone (SIADH) secretion [see Warnings and Precautions (5.9)], abnormal liver function tests, hepatitis, prolactin increasedMusculoskeletal- RhabdomyolysisNervous system- Neuroleptic Malignant Syndrome (NMS) [see Warnings and Precautions (5.2)], serotonergic syndrome [see Warnings and Precautions (5.2)], delirium, extrapyramidal reactions (including dystonia and dyskinesia), impaired coordination and balance, tardive dyskinesia Respiratory system- Dyspnea, interstitial lung disease, pulmonary eosinophilia [see Warnings and Precautions (5.12)] Skin and appendages- Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiformeSpecial senses- Angle-closure glaucoma [see Warnings and Precautions (5.5)].

BOXED WARNING SECTION.

WARNING: SUICIDAL THOUGHTS AND BEHAVIORS. Antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients over age 24; there was reduction in risk with antidepressant use in patients aged 65 and older [see Warnings and Precautions (5.1)]. In patients of all ages who are started on antidepressant therapy monitor closely for clinical worsening and emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber [see Warnings and Precautions (5.1) and Patient Counseling Information (17)].Venlafaxine Hydrochloride Extended-release Capsules are not approved for use in pediatric patients [see Use in Specific Populations (8.4)]. WARNING: SUICIDAL THOUGHTS AND BEHAVIORS See full prescribing information for complete boxed warning.Increased risk of suicidal thinking and behavior in children, adolescents and young adults taking antidepressants (5.1)Monitor for worsening and emergence of suicidal thoughts and behaviors (5.1)Venlafaxine hydrochloride extended-release capsules are not approved for use in pediatric patients (8.4). Increased risk of suicidal thinking and behavior in children, adolescents and young adults taking antidepressants (5.1). Monitor for worsening and emergence of suicidal thoughts and behaviors (5.1). Venlafaxine hydrochloride extended-release capsules are not approved for use in pediatric patients (8.4).

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. Hypersensitivity to venlafaxine hydrochloride, desvenlafaxine succinate, or any excipients in the venlafaxine hydrochloride extended-release capsules formulation (4.1).Do not use with an MAOI or within 14 days of stopping an MAOI. Allow days after stopping venlafaxine hydrochloride extended-release capsules before starting an MAOI, because of the risk of serotonin syndrome (4.2, 5.2, 7.3).. Hypersensitivity to venlafaxine hydrochloride, desvenlafaxine succinate, or any excipients in the venlafaxine hydrochloride extended-release capsules formulation (4.1).. Do not use with an MAOI or within 14 days of stopping an MAOI. Allow days after stopping venlafaxine hydrochloride extended-release capsules before starting an MAOI, because of the risk of serotonin syndrome (4.2, 5.2, 7.3).. 4.1 Hypersensitivity. Hypersensitivity to venlafaxine hydrochloride, desvenlafaxine succinate or to any excipients in the formulation. 4.2 Concomitant Use with Monoamine Oxidase Inhibitors (MAOIs). The use of MAOIs (intended to treat psychiatric disorders) concomitantly with venlafaxine hydrochloride extended-release capsules or within days of discontinuing treatment with venlafaxine hydrochloride extended-release capsules is contraindicated because of an increased risk of serotonin syndrome. The use of venlafaxine hydrochloride extended-release capsules within 14 days of discontinuing treatment with an MAOI (intended to treat psychiatric disorders) is also contraindicated [see Dosage and Administration (2.9), Warnings and Precautions (5.2), and Drug Interactions (7.2)].Starting venlafaxine hydrochloride extended-release capsules in patient who is being treated with an MAOI such as linezolid or intravenous methylene blue is also contraindicated, because of an increased risk of serotonin syndrome [see Dosage and Administration (2.9), Warnings and Precautions (5.2), and Drug Interactions (7.3)].

CONTROLLED SUBSTANCE SECTION.

9.1 Controlled Substance. Venlafaxine hydrochloride extended-release capsules are not controlled substance.

DEPENDENCE SECTION.

9.3 Dependence. In vitro studies revealed that venlafaxine has virtually no affinity for opiate, benzodiazepine, phencyclidine (PCP), or N-methyl-D-aspartic acid (NMDA) receptors.Venlafaxine was not found to have any significant CNS stimulant activity in rodents. In primate drug discrimination studies, venlafaxine showed no significant stimulant or depressant abuse liability. Discontinuation effects have been reported in patients receiving venlafaxine [see Dosage and Administration (2.8)].

DESCRIPTION SECTION.

11 DESCRIPTION. Venlafaxine Hydrochloride Extended-release Capsules, USP are an extended-release capsule for once-a-day oral administration that contains venlafaxine hydrochloride, USP SNRI.Venlafaxine is designated (R/S)-1-[2-(dimethylamino)-1-(4-methoxyphenyl)ethyl] cyclohexanol hydrochloride or (+-)-1-[- [(dimethylamino)methyl]-p-methoxybenzyl] cyclohexanol hydrochloride and has the molecular formula of C17H27NO2 HCl. Its molecular weight is 313.86. The structural formula is shown as follows:Venlafaxine hydrochloride, USP is white to off-white crystalline solid with solubility of 572 mg/mL in water (adjusted to ionic strength of 0.2 with sodium chloride). Its octanol:water (0.2 sodium chloride) partition coefficient is 0.43. Drug release is controlled by diffusion through the coating membrane on the spheroids and is not pH dependent. Capsules contain venlafaxine hydrochloride, USP equivalent to 37.5 mg, 75 mg, or 150 mg venlafaxine. Inactive ingredients consist of black iron oxide, dibutyl sebacate, ethylcellulose, gelatin, polyethylene glycol, povidone, propylene glycol, shellac, sugar spheres (which contain sucrose and corn starch), sunset yellow FCF FD&C yellow 6, talc, and titanium dioxide. The 37.5 mg capsules also contain D&C yellow 10 and potassium hydroxide, the 75 mg capsules also contain D&C yellow 10 and may contain potassium hydroxide, and the 150 mg capsules also contain potassium hydroxide. Structural formula for venlafaxine hydrochloride.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. Venlafaxine hydrochloride extended-release capsules should be administered in single dose with food, either in the morning or in the evening at approximately the same time each day [see Clinical Pharmacology (12.3)]. Each capsule should be swallowed whole with fluid and not divided, crushed, chewed, or placed in water or it may be administered by carefully opening the capsule and sprinkling the entire contents on spoonful of applesauce. This drug/food mixture should be swallowed immediately without chewing and followed with glass of water to ensure complete swallowing of the pellets (spheroids).. Indication Starting Dose Target Dose Maximum Dose MDD (2.1) 37.5 to 75 mg/day 75 mg/day 225 mg/day GAD (2.2) 37.5 to 75 mg/day 75 mg/day 225 mg/day SAD (2.3) 75 mg/day 75 mg/day 75 mg/day PD (2.4) 37.5 mg/day 75 mg/day 225 mg/day Take once daily with food (2). Capsules should be taken whole; do not divide, crush, chew, or dissolve (2).When discontinuing treatment, reduce the dose gradually (2.8, 5.7).Renal impairment: reduce the total daily dose by 25% to 50% in patients with renal impairment. Reduce the total daily dose by 50% or more in patients undergoing dialysis or with severe renal impairment (2.6).Hepatic impairment: reduce the daily dose by 50% in patients with mild to moderate hepatic impairment. In patients with severe hepatic impairment or hepatic cirrhosis, it may be necessary to reduce the dose by more than 50% (2.6). Take once daily with food (2). Capsules should be taken whole; do not divide, crush, chew, or dissolve (2).. When discontinuing treatment, reduce the dose gradually (2.8, 5.7).. Renal impairment: reduce the total daily dose by 25% to 50% in patients with renal impairment. Reduce the total daily dose by 50% or more in patients undergoing dialysis or with severe renal impairment (2.6).. Hepatic impairment: reduce the daily dose by 50% in patients with mild to moderate hepatic impairment. In patients with severe hepatic impairment or hepatic cirrhosis, it may be necessary to reduce the dose by more than 50% (2.6). 2.1 Major Depressive Disorder. For most patients, the recommended starting dose for venlafaxine hydrochloride extended-release capsules is 75 mg per day, administered in single dose. For some patients, it may be desirable to start at 37.5 mg per day for to days to allow new patients to adjust to the medication before increasing to 75 mg per day. Patients not responding to the initial 75 mg per day dose may benefit from dose increases to maximum of 225 mg per day. Dose increases should be in increments of up to 75 mg per day, as needed, and should be made at intervals of not less than days, since steady-state plasma levels of venlafaxine and its major metabolites are achieved in most patients by day [see Clinical Pharmacology (12.3)]. In the clinical studies establishing efficacy, upward titration was permitted at intervals of weeks or more.It should be noted that, while the maximum recommended dose for moderately depressed outpatients is also 225 mg per day for venlafaxine tablets (immediate-release), more severely depressed inpatients in one study of the development program for that product responded to mean dose of 350 mg per day (range of 150 mg to 375 mg per day). Whether or not higher doses of venlafaxine hydrochloride extended-release capsules are needed for more severely depressed patients is unknown; however, the experience with venlafaxine hydrochloride extended-release capsules doses higher than 225 mg per day is very limited.. 2.2 Generalized Anxiety Disorder. For most patients, the recommended starting dose for venlafaxine hydrochloride extended-release capsules is 75 mg per day, administered in single dose. For some patients, it may be desirable to start at 37.5 mg per day for to days to allow new patients to adjust to the medication before increasing to 75 mg per day. Patients not responding to the initial 75 mg per day dose may benefit from dose increases to maximum of 225 mg per day. Dose increases should be in increments of up to 75 mg per day, as needed, and should be made at intervals of not less than days, since steady-state plasma levels of venlafaxine and its major metabolites are achieved in most patients by day [see Clinical Pharmacology (12.3)]. 2.3 Social Anxiety Disorder (Social Phobia). The recommended dose is 75 mg per day, administered in single dose. There was no evidence that higher doses confer any additional benefit.. 2.4 Panic Disorder. The recommended starting dose is 37.5 mg per day of venlafaxine hydrochloride extended-release capsules for days. Patients not responding to 75 mg per day may benefit from dose increases to maximum of approximately 225 mg per day. Dose increases should be in increments of up to 75 mg per day, as needed, and should be made at intervals of not less than days.. 2.5 Switching Patients from Venlafaxine Tablets. Depressed patients who are currently being treated at therapeutic dose with venlafaxine tablets (immediate release) may be switched to venlafaxine hydrochloride extended-release capsules at the nearest equivalent dose (mg per day), e.g., 37.5 mg venlafaxine twice day to 75 mg venlafaxine hydrochloride extended-release capsules once daily. However, individual dosage adjustments may be necessary.. 2.6 Specific Populations. Patients with Hepatic ImpairmentThe total daily dose should be reduced by 50% in patients with mild (Child-Pugh 5 to 6) to moderate (Child-Pugh 7 to 9) hepatic impairment. In patients with severe hepatic impairment (Child-Pugh 10 to 15) or hepatic cirrhosis, it may be necessary to reduce the dose by 50% or more [see Use in Specific Populations (8.7)].Patients with Renal ImpairmentThe total daily dose should be reduced by 25% to 50% in patients with mild (CLcr 60 to 89 mL/min) or moderate (CLcr 30 to 59 mL/min) renal impairment. In patients undergoing hemodialysis or with severe renal impairment (CLcr 30 mL/min), the total daily dose should be reduced by 50% or more. Because there was much individual variability in clearance between patients with renal impairment, individualization of dosage may be desirable in some patients [see Use in Specific Populations (8.7)]. 2.7 Maintenance Treatment. There is no body of evidence available from controlled studies to indicate how long patients with MDD, GAD, SAD, or PD should be treated with venlafaxine hydrochloride extended-release capsules.It is generally agreed that acute episodes of MDD require several months or longer of sustained pharmacological therapy beyond response to the acute episode. Venlafaxine hydrochloride extended-release capsules/venlafaxine tablets have demonstrated continuation of response in clinical studies up to 52 weeks, at the same dose at which patients responded during the initial treatment [see Clinical Studies (14.1)]. It is not known whether or not the dose of venlafaxine hydrochloride extended-release capsules needed for maintenance treatment is identical to the dose needed to achieve an initial response. Patients should be periodically reassessed to determine the need for maintenance treatment and the appropriate dose for such treatment.In patients with GAD and SAD, venlafaxine hydrochloride extended-release capsules have been shown to be effective in 6-month clinical studies. The need for continuing medication in patients with GAD and SAD who improve with venlafaxine hydrochloride extended-release capsule treatment should be periodically reassessed.In clinical study for PD, patients continuing venlafaxine hydrochloride extended-release capsules at the same dose at which they responded during the initial 12 weeks of treatment experienced statistically significantly longer time to relapse than patients randomized to placebo [see Clinical Studies (14.4)]. The need for continuing medication in patients with PD who improve with venlafaxine hydrochloride extended-release capsule treatment should be periodically reassessed.. 2.8 Discontinuing Venlafaxine Hydrochloride Extended-release Capsules. gradual reduction in the dose, rather than abrupt cessation, is recommended when discontinuing therapy with venlafaxine hydrochloride extended-release capsules. In clinical studies with venlafaxine hydrochloride extended-release capsules, tapering was achieved by reducing the daily dose by 75 mg at one-week intervals. Individualization of tapering may be necessary [see Warnings and Precautions (5.7)]. In some patients, discontinuation may need to occur over period of several months.. 2.9 Switching Patients to or from Monoamine Oxidase Inhibitor (MAOI) Intended to Treat Psychiatric Disorders. At least 14 days should elapse between discontinuation of an MAOI (intended to treat psychiatric disorders) and initiation of therapy with venlafaxine hydrochloride extended-release capsules. In addition, at least days should be allowed after stopping venlafaxine hydrochloride extended-release capsules before starting an MAOI intended to treat psychiatric disorders [see Contraindications (4.2), Warnings and Precautions (5.2), and Drug Interactions (7.2)].Use of Venlafaxine Hydrochloride Extended-release Capsules with other MAOIs such as Linezolid or Intravenous Methylene BlueDo not start venlafaxine hydrochloride extended-release capsules in patient who is being treated with linezolid or intravenous methylene blue, because there is an increased risk of serotonin syndrome. In patient who requires more urgent treatment of psychiatric condition, other interventions, including hospitalization should be considered [see Contraindications (4.2)].In some cases, patient already receiving venlafaxine hydrochloride extended-release capsule therapy may require urgent treatment with linezolid or intravenous methylene blue. If acceptable alternatives to linezolid or intravenous methylene blue are not available and the potential benefits of linezolid or intravenous methylene blue treatment are judged to outweigh the risks of serotonin syndrome in particular patient, venlafaxine hydrochloride extended-release capsules should be stopped promptly, and linezolid or intravenous methylene blue can be administered. Monitor the patient for symptoms of serotonin syndrome for days or until 24 hours after the last dose of linezolid or intravenous methylene blue, whichever comes first. Therapy with venlafaxine hydrochloride extended-release capsules can be resumed 24 hours after the last dose of linezolid or intravenous methylene blue [see Warnings and Precautions (5.2)].The risk of administering methylene blue by non-intravenous routes (such as oral tablets or by local injection) or in intravenous doses much lower than mg/kg concomitantly with venlafaxine hydrochloride extended-release capsules is unclear. The clinician should, nevertheless, be aware of the possibility of emergent symptoms of serotonin syndrome with such use [see Warnings and Precautions (5.2)].

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS. Venlafaxine Hydrochloride Extended-release Capsules, USP are available in the following strengths:37.5 mg capsules light-gray opaque cap/buff opaque body with 93 and 7384 on both body and cap. 75 mg capsules buff opaque cap/buff opaque body with 93 and 7385 on both body and cap. 150 mg capsules light-orange opaque cap/light-orange opaque body with 93 and 7386 on both body and cap. 37.5 mg capsules light-gray opaque cap/buff opaque body with 93 and 7384 on both body and cap. 75 mg capsules buff opaque cap/buff opaque body with 93 and 7385 on both body and cap. 150 mg capsules light-orange opaque cap/light-orange opaque body with 93 and 7386 on both body and cap. Venlafaxine hydrochloride extended-release capsules are available as 37.5 mg, 75 mg and 150 mg strengths (3).Each capsule contains venlafaxine hydrochloride equivalent to 37.5 mg, 75 mg or 150 mg of venlafaxine (3).. Venlafaxine hydrochloride extended-release capsules are available as 37.5 mg, 75 mg and 150 mg strengths (3).. Each capsule contains venlafaxine hydrochloride equivalent to 37.5 mg, 75 mg or 150 mg of venlafaxine (3).

DRUG ABUSE AND DEPENDENCE SECTION.

9 DRUG ABUSE AND DEPENDENCE. 9.1 Controlled Substance. Venlafaxine hydrochloride extended-release capsules are not controlled substance.. 9.2 Abuse. While venlafaxine has not been systematically studied in clinical studies for its potential for abuse, there was no indication of drug-seeking behavior in the clinical studies. However, it is not possible to predict on the basis of premarketing experience the extent to which CNS-active drug will be misused, diverted, and/or abused once marketed. Consequently, physicians should carefully evaluate patients for history of drug abuse and follow such patients closely, observing them for signs of misuse or abuse of venlafaxine (e.g., development of tolerance, incrementation of dose, drug-seeking behavior).. 9.3 Dependence. In vitro studies revealed that venlafaxine has virtually no affinity for opiate, benzodiazepine, phencyclidine (PCP), or N-methyl-D-aspartic acid (NMDA) receptors.Venlafaxine was not found to have any significant CNS stimulant activity in rodents. In primate drug discrimination studies, venlafaxine showed no significant stimulant or depressant abuse liability. Discontinuation effects have been reported in patients receiving venlafaxine [see Dosage and Administration (2.8)].

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS. Serotonergic Drugs (e.g., MAOIs, triptans, SSRIs, other SNRIs, linezolid, lithium, tramadol, or St. Johns wort): Potential for serotonin syndrome. Careful patient observation is advised (4.2, 5.2, 7.3).. Serotonergic Drugs (e.g., MAOIs, triptans, SSRIs, other SNRIs, linezolid, lithium, tramadol, or St. Johns wort): Potential for serotonin syndrome. Careful patient observation is advised (4.2, 5.2, 7.3).. 7.1 Central Nervous System (CNS)-Active Drugs. The risk of using venlafaxine in combination with other CNS-active drugs has not been systematically evaluated. Consequently, caution is advised when venlafaxine hydrochloride extended-release capsules are taken in combination with other CNS-active drugs.. 7.2 Monoamine Oxidase Inhibitors. Adverse reactions, some of which were serious, have been reported in patients who have recently been discontinued from an MAOI and started on antidepressants with pharmacological properties similar to venlafaxine hydrochloride extended-release capsules (SNRIs or SSRIs), or who have recently had SNRI or SSRI therapy discontinued prior to initiation of an MAOI [see Dosage and Administration (2.9), Contraindications (4.2) and Warnings and Precautions (5.2)]. 7.3 Serotonergic Drugs. Based on the mechanism of action of venlafaxine hydrochloride extended-release capsules and the potential for serotonin syndrome, caution is advised when venlafaxine hydrochloride extended-release capsules are coadministered with other drugs that may affect the serotonergic neurotransmitter systems, such as triptans, SSRIs, other SNRIs, linezolid (an antibiotic which is reversible non-selective MAOI), lithium, tramadol, or St. Johns wort. If concomitant treatment with venlafaxine hydrochloride extended-release capsules and these drugs is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases. The concomitant use of venlafaxine hydrochloride extended-release capsules with tryptophan supplements is not recommended [see Dosage and Administration (2.9), Contraindications (4.2), and Warnings and Precautions (5.2)].. 7.4 Drugs that Interfere with Hemostasis (e.g., NSAIDs, Aspirin, and Warfarin). Serotonin release by platelets plays an important role in hemostasis. The use of psychotropic drugs that interfere with serotonin reuptake is associated with the occurrence of upper gastrointestinal bleeding and concurrent use of an NSAID or aspirin may potentiate this risk of bleeding [see Warnings and Precautions (5.4)]. Altered anticoagulant effects, including increased bleeding, have been reported when SSRIs and SNRIs are coadministered with warfarin. Patients receiving warfarin therapy should be carefully monitored when venlafaxine hydrochloride extended-release capsules are initiated or discontinued.. 7.5 Weight Loss Agents. The safety and efficacy of venlafaxine therapy in combination with weight loss agents, including phentermine, have not been established. Coadministration of venlafaxine hydrochloride extended-release capsules and weight loss agents is not recommended. Venlafaxine hydrochloride extended-release capsules are not indicated for weight loss alone or in combination with other products.. 7.6 Effects of Other Drugs on Venlafaxine Hydrochloride Extended-release Capsules. Figure 1: Effect of interacting drugs on the pharmacokinetics of venlafaxine and active metabolite O-desmethylvenlafaxine (ODV).Abbreviations: ODV, O-desmethylvenlafaxine; AUC, area under the curve; Cmax, peak plasma concentrations; EMs, extensive metabolizers; PMs, poor metabolizers No dose adjustment on coadministration with CYP2D6 inhibitors (Fig and Metabolism Section 12.3). Figure 1. 7.7 Effects of Venlafaxine Hydrochloride Extended-release Capsules on Other Drugs. Figure 2: Effect of venlafaxine on the pharmacokinetics interacting drugs and their active metabolites.Abbreviations: AUC, area under the curve; Cmax, peak plasma concentrations; OH, hydroxyl Data for 2-OH desipramine were not plotted to enhance clarity; the fold change and 90% CI for Cmax and AUC of 2-OH desipramine were 6.6 (5.5, 7.9) and 4.4 (3.8, 5.0), respectively.Note:: Administration of venlafaxine in stable regimen did not exaggerate the psychomotor and psychometric effects induced by ethanol in these same subjects when they were not receiving venlafaxine.. Figure 2. 7.8 Drug-Laboratory Test Interactions. False-positive urine immunoassay screening tests for phencyclidine (PCP) and amphetamine have been reported in patients taking venlafaxine. This is due to lack of specificity of the screening tests. False positive test results may be expected for several days following discontinuation of venlafaxine therapy. Confirmatory tests, such as gas chromatography/mass spectrometry, will distinguish venlafaxine from PCP and amphetamine.

GERIATRIC USE SECTION.

8.5 Geriatric Use. The percentage of patients in clinical studies for venlafaxine hydrochloride extended-release capsules for MDD, GAD, SAD, and PD who were 65 years of age or older are shown in Table 15.Table 15: Percentage (and Number of Patients Studied) of Patients 65 Years of Age and Older by Indicationa Indication Venlafaxine Hydrochloride Extended-release Capsules MDD (14/357) GAD (77/1,381) SAD (10/819) PD (16/1,001) In addition, in the premarketing assessment of venlafaxine tablets (immediate release), 12% (357/2,897) of patients were >= 65 years of age. No overall differences in effectiveness or safety were observed between geriatric patients and younger patients, and other reported clinical experience generally has not identified differences in response between the elderly and younger patients. However, greater sensitivity of some older individuals cannot be ruled out. SSRIs and SNRIs, including venlafaxine hydrochloride extended-release capsules, have been associated with cases of clinically significant hyponatremia in elderly patients, who may be at greater risk for this adverse event [see Warnings and Precautions (5.9)].The pharmacokinetics of venlafaxine and ODV are not substantially altered in the elderly [see Clinical Pharmacology (12.3)] (see Figure 3). No dose adjustment is recommended for the elderly on the basis of age alone, although other clinical circumstances, some of which may be more common in the elderly, such as renal or hepatic impairment, may warrant dose reduction [see Dosage and Administration (2.6)].

HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING. Venlafaxine Hydrochloride Extended-release Capsules, USP are available as follows:37.5 mg light-gray opaque cap/buff opaque body with 93 and 7384 on both body and cap. They are available in bottles of 30 (NDC 0093-7384-56), 90 (NDC 0093-7384-98), and 500 (NDC 0093-7384-05). 75 mg buff opaque cap/buff opaque body with 93 and 7385 on both body and cap. They are available in bottles of 30 (NDC 0093-7385-56), 90 (NDC 0093-7385-98), and 500 (NDC 0093-7385-05).150 mg light-orange opaque cap/light-orange opaque body with 93 and 7386 on both body and cap. They are available in bottles of 30 (NDC 0093-7386-56), 90 (NDC 0093-7386-98), and 500 (NDC 0093-7386-05).Store at 20 to 25C (68 to 77F) [see USP Controlled Room Temperature].Dispense in tight, light-resistant container as defined in the USP, with child-resistant closure (as required).KEEP THIS AND ALL MEDICATIONS OUT OF THE REACH OF CHILDREN.

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE. Venlafaxine hydrochloride extended-release capsules are serotonin and norepinephrine reuptake inhibitor (SNRI) indicated for the treatment of:Major Depressive Disorder (MDD)Generalized Anxiety Disorder (GAD)Social Anxiety Disorder (SAD)Panic Disorder (PD) Major Depressive Disorder (MDD). Generalized Anxiety Disorder (GAD). Social Anxiety Disorder (SAD). Panic Disorder (PD) 1.1 Major Depressive Disorder. Venlafaxine hydrochloride extended-release capsules are indicated for the treatment of major depressive disorder (MDD). Efficacy was established in three short-term (4, 8, and 12 weeks) and two long-term, maintenance trials.. 1.2 Generalized Anxiety Disorder. Venlafaxine hydrochloride extended-release capsules are indicated for the treatment of Generalized Anxiety Disorder (GAD). Efficacy was established in two 8-week and two 26-week placebo-controlled trials.. 1.3 Social Anxiety Disorder. Venlafaxine hydrochloride extended-release capsules are indicated for the treatment of Social Anxiety Disorder (SAD), also known as social phobia. Efficacy was established in four 12-week and one 26-week, placebo-controlled trials.. 1.4 Panic Disorder. Venlafaxine hydrochloride extended-release capsules are indicated for the treatment of Panic Disorder (PD), with or without agoraphobia. Efficacy was established in two 12-week placebo-controlled trials.

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. See FDA-approved patient labeling (Medication Guide).Prescribers or other healthcare professionals should inform patients, their families, and their caregivers about the benefits and risks associated with treatment with venlafaxine hydrochloride extended-release capsules and should counsel them in their appropriate use. patient Medication Guide about Antidepressant Medicines, Depression and Other Serious Mental Illnesses, and Suicidal Thoughts or Actions is available for venlafaxine hydrochloride extended-release capsules. The prescriber or healthcare professional should instruct patients, their families, and their caregivers to read the Medication Guide and should assist them in understanding its contents. Patients should be given the opportunity to discuss the contents of the Medication Guide and to obtain answers to any questions they may have. The complete text of the Medication Guide is reprinted at the end of this document. Patients should be advised of the following issues and should be asked to alert their prescriber if these occur while taking venlafaxine hydrochloride extended-release capsules.Suicidal Thoughts and BehaviorsAdvise patients, their families and caregivers to look for the emergence of suicidality, worsening of depression, and other psychiatric symptoms (anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, psychomotor restlessness, hypomania, mania, other unusual changes in behavior), especially early during treatment and when the dose is adjusted up or down. Such symptoms should be reported to the patients prescriber or health professional, especially if they are severe, abrupt in onset, or were not part of the patients presenting symptoms. Symptoms such as these may be associated with an increased risk for suicidal thinking and behavior and indicate need for very close monitoring [see Boxed Warning and Warnings and Precautions (5.1)].Concomitant MedicationAdvise patients taking venlafaxine hydrochloride extended-release capsules not to use concomitantly other products containing venlafaxine or desvenlafaxine. Healthcare professionals should instruct patients not to take venlafaxine hydrochloride extended-release capsules with an MAOI or within 14 days of stopping an MAOI and to allow days after stopping venlafaxine hydrochloride extended-release capsules before starting an MAOI [see Contraindications (4.2)].Serotonin SyndromePatients should be cautioned about the risk of serotonin syndrome, with the concomitant use of venlafaxine hydrochloride extended-release capsules and triptans, tramadol, amphetamines, tryptophan supplements, with antipsychotics or other dopamine antagonists, or other serotonergic agents [see Warnings and Precautions (5.2) and Drug Interactions (7.3)].Elevated Blood PressureAdvise patients that they should have regular monitoring of blood pressure when taking venlafaxine hydrochloride extended-release capsules [see Warnings and Precautions (5.3)].Abnormal BleedingPatients should be cautioned about the concomitant use of venlafaxine hydrochloride extended-release capsules and NSAIDs, aspirin, warfarin, or other drugs that affect coagulation since combined use of psychotropic drugs that interfere with serotonin reuptake and these agents has been associated with an increased risk of bleeding [see Warnings and Precautions (5.4)].Angle Closure GlaucomaPatients should be advised that taking venlafaxine hydrochloride extended-release capsules can cause mild pupillary dilation, which in susceptible individuals, can lead to an episode of angle closure glaucoma. Preexisting glaucoma is almost always open-angle glaucoma because angle closure glaucoma, when diagnosed, can be treated definitively with iridectomy. Open-angle glaucoma is not risk factor for angle closure glaucoma. Patients may wish to be examined to determine whether they are susceptible to angle closure, and have prophylactic procedure (e.g., iridectomy), if they are susceptible [see Warnings and Precautions (5.5)].Activation of Mania/HypomaniaAdvise patients, their families and caregivers to observe for signs of activation of mania/hypomania [see Warnings and Precautions (5.6)].Cardiovascular/Cerebrovascular DiseaseCaution is advised in administering venlafaxine hydrochloride extended-release capsules to patients with cardiovascular, cerebrovascular, or lipid metabolism disorders [see Adverse Reactions (6.1)].Serum Cholesterol and Triglyceride ElevationAdvise patients that elevations in total cholesterol, LDL and triglycerides may occur and that measurement of serum lipids may be considered [see Warnings and Precautions (6.3)].Discontinuation SyndromeAdvise patients not to stop taking venlafaxine hydrochloride extended-release capsules without talking first with their healthcare professional. Patients should be aware that discontinuation effects may occur when stopping venlafaxine hydrochloride extended-release capsules [see Warnings and Precautions (5.7) and Adverse Reactions (6.1)].Sexual Dysfunction Advise patients that use of venlafaxine hydrochloride extended-release capsules may cause symptoms of sexual dysfunction in both male and female patients. Inform patients that they should discuss any changes in sexual function and potential management strategies with their healthcare provider [see Warnings and Precautions (5.13)].Interference with Cognitive and Motor PerformanceCaution patients about operating hazardous machinery, including automobiles, until they are reasonably certain that venlafaxine hydrochloride extended-release capsules therapy does not adversely affect their ability to engage in such activities.AlcoholAdvise patients to avoid alcohol while taking venlafaxine hydrochloride extended-release capsules [see Drug Interactions (7.6)].Allergic ReactionsAdvise patients to notify their physician if they develop allergic phenomena such as rash, hives, swelling, or difficulty breathing.PregnancyAdvise patients to notify their physician if they become pregnant or intend to become pregnant during therapy [see Use in Specific Populations (8.1)].NursingAdvise patients to notify their physician if they are breastfeeding an infant [see Use in Specific Populations (8.3)].Residual SpheroidsVenlafaxine hydrochloride extended-release capsules contain spheroids, which release the drug slowly into the digestive tract. The insoluble portion of these spheroids is eliminated, and patients may notice spheroids passing in the stool or via colostomy. Patients should be informed that the active medication has already been absorbed by the time the patient sees the spheroids.Dispense with Medication Guide available at: www.tevausa.com/medguidesManufactured In Israel By:Teva Pharmaceutical Ind. Ltd.Kfar Saba, 4410202, IsraelManufactured For:Teva Pharmaceuticals Parsippany, NJ 07054Rev. 1/2022.

LABOR & DELIVERY SECTION.

8.2 Labor and Delivery. The effect of venlafaxine on labor and delivery in humans is unknown.

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action. The exact mechanism of the antidepressant action of venlafaxine in humans is unknown, but is thought to be related to the potentiation of serotonin and norepinephrine in the central nervous system, through inhibition of their reuptake. Non-clinical studies have demonstrated that venlafaxine and its active metabolite, ODV, are potent and selective inhibitors of neuronal serotonin and norepinephrine reuptake and weak inhibitors of dopamine reuptake.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY. 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. CarcinogenesisTumors were not increased by venlafaxine treatment in mice or rats. Venlafaxine was given by oral gavage to mice for 18 months at doses up to 120 mg/kg per day, which was 1.7 times the maximum recommended human dose on mg/m2 basis. Venlafaxine was also given to rats by oral gavage for 24 months at doses up to 120 mg/kg per day. In rats receiving the 120 mg/kg dose, plasma concentrations of venlafaxine at necropsy were times (male rats) and times (female rats) the plasma concentrations of patients receiving the maximum recommended human dose. Plasma levels of the O-desmethyl metabolite (ODV) were lower in rats than in patients receiving the maximum recommended dose. O-desmethylvenlafaxine (ODV), the major human metabolite of venlafaxine, administered by oral gavage to mice and rats for years did not increase the incidence of tumors in either study. Mice received ODV at dosages up to 500/300 mg/kg/day (dosage lowered after 45 weeks of dosing). The exposure at the 300 mg/kg/day dose is times that of human dose of 225 mg/day. Rats received ODV at dosages up to 300 mg/kg/day (males) or 500 mg/kg/day (females). The exposure at the highest dose is approximately (males) or 11 (females) times that of human dose of 225 mg/day.MutagenesisVenlafaxine and the major human metabolite, ODV, were not mutagenic in the Ames reverse mutation assay in Salmonella bacteria or the Chinese hamster ovary/HGPRT mammalian cell forward gene mutation assay. Venlafaxine was also not mutagenic or clastogenic in the in vitro BALB/c-3T3 mouse cell transformation assay, the sister chromatid exchange assay in cultured Chinese hamster ovary cells, or in the in vivo chromosomal aberration assay in rat bone marrow. ODV was not clastogenic in the in vitro Chinese hamster ovary cell chromosomal aberration assay or in the in vivo chromosomal aberration assay in rats.Impairment of FertilityReproduction and fertility studies of venlafaxine in rats showed no adverse effects of venlafaxine on male or female fertility at oral doses of up to times the maximum recommended human dose of 225 mg/day on mg/m2 basis. However, reduced fertility was observed in study in which male and female rats were treated with O-desmethylvenlafaxine (ODV), the major human metabolite of venlafaxine, prior to and during mating and gestation. This occurred at an ODV exposure (AUC) approximately to times that associated with human venlafaxine dose of 225 mg/day.

NURSING MOTHERS SECTION.

8.3 Nursing Mothers. Venlafaxine and ODV have been reported to be excreted in human milk. Because of the potential for serious adverse reactions in nursing infants from venlafaxine hydrochloride extended-release capsules, decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

OVERDOSAGE SECTION.

10 OVERDOSAGE. 10.1 Human Experience. During the premarketing evaluations of venlafaxine hydrochloride extended-release capsules (for MDD, GAD, SAD, and PD) and venlafaxine tablets (for MDD), there were twenty reports of acute overdosage with venlafaxine tablets (6 and 14 reports in venlafaxine hydrochloride extended-release capsules and venlafaxine tablet patients, respectively), either alone or in combination with other drugs and/or alcohol.Somnolence was the most commonly reported symptom. Among the other reported symptoms were paresthesia of all four limbs, moderate dizziness, nausea, numb hands and feet, and hot-cold spells days after the overdose. In most cases, no signs or symptoms were associated with overdose. The majority of the reports involved ingestion in which the total dose of venlafaxine taken was estimated to be no more than several-fold higher than the usual therapeutic dose. One patient who ingested 2.75 of venlafaxine was observed to have two generalized convulsions and prolongation of QTc to 500 msec, compared with 405 msec at baseline. Mild sinus tachycardia was reported in two of the other patients.Actions taken to treat the overdose included no treatment, hospitalization and symptomatic treatment, and hospitalization plus treatment with activated charcoal. All patients recovered.In postmarketing experience, overdose with venlafaxine has occurred predominantly in combination with alcohol and/or other drugs. The most commonly reported events in overdosage include tachycardia, changes in level of consciousness (ranging from somnolence to coma), mydriasis, seizures, and vomiting. Electrocardiogram changes (e.g., prolongation of QT interval, bundle branch block, QRS prolongation), ventricular tachycardia, bradycardia, hypotension, rhabdomyolysis, vertigo, liver necrosis, serotonin syndrome, and death have been reported.Published retrospective studies report that venlafaxine overdosage may be associated with an increased risk of fatal outcomes compared to that observed with SSRI antidepressant products, but lower than that for tricyclic antidepressants. Epidemiological studies have shown that venlafaxine-treated patients have higher preexisting burden of suicide risk factors than SSRI-treated patients. The extent to which the finding of an increased risk of fatal outcomes can be attributed to the toxicity of venlafaxine in overdosage, as opposed to some characteristic(s) of venlafaxine-treated patients, is not clear. Prescriptions for venlafaxine hydrochloride extended-release capsules should be written for the smallest quantity of capsules consistent with good patient management, in order to reduce the risk of overdose. 10.2 Management of Overdosage. Consult Certified Poison Control Center for up-to-date guidance and advice (1-800-222-1222 or www.poison.org). In case of an overdose, provide supportive care, including close medical supervision and monitoring. Treatment should consist of those general measures employed in the management of overdosage with any drug. Consider the possibility of multiple drug overdose. Ensure an adequate airway, oxygenation, and ventilation. Monitor cardiac rhythm and vital signs. Provide supportive and symptomatic measures.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

Package/Label Display Panel. NDC 0093-7384-56Venlafaxine Hydrochloride Extended-release Capsules, USP37.5 mgSEALED FOR YOUR PROTECTIONPHARMACIST: Dispense the accompanying Medication Guide to each patient.Rx only30 CAPSULES. 37.5mg30s.

PEDIATRIC USE SECTION.

8.4 Pediatric Use. Two placebo-controlled trials in 766 pediatric patients with MDD and two placebo-controlled trials in 793 pediatric patients with GAD have been conducted with venlafaxine hydrochloride extended-release capsules, and the data were not sufficient to support claim for use in pediatric patients.Anyone considering the use of venlafaxine hydrochloride extended-release capsules in child or adolescent must balance the potential risks with the clinical need [see Boxed Warning, Warnings and Precautions (5.1, 5.10, 5.11) and Adverse Reactions (6.4)].Although no studies have been designed to primarily assess venlafaxine hydrochloride extended-release capsuless impact on the growth, development, and maturation of children and adolescents, the studies that have been done suggest that venlafaxine hydrochloride extended-release capsules may adversely affect weight and height [see Warnings and Precautions (5.10)]. Should the decision be made to treat pediatric patient with venlafaxine hydrochloride extended-release capsules, regular monitoring of weight and height is recommended during treatment, particularly if treatment is to be continued long-term [see Warnings and Precautions (5.10, 5.11)]. The safety of venlafaxine hydrochloride extended-release capsule treatment for pediatric patients has not been systematically assessed for chronic treatment longer than six months in duration. In the studies conducted in pediatric patients (ages to 17), the occurrence of blood pressure and cholesterol increases considered to be clinically relevant in pediatric patients was similar to that observed in adult patients. Consequently, the precautions for adults apply to pediatric patients [see Warnings and Precautions (5.3, 6.3)].

PHARMACODYNAMICS SECTION.

12.2 Pharmacodynamics. Venlafaxine and ODV have no significant affinity for muscarinic-cholinergic, H1-histaminergic, or 1-adrenergic receptors in vitro. Pharmacologic activity at these receptors is hypothesized to be associated with the various anticholinergic, sedative, and cardiovascular effects seen with other psychotropic drugs. Venlafaxine and ODV do not possess monoamine oxidase (MAO) inhibitory activity.Cardiac Electrophysiology The effect of venlafaxine on the QT interval was evaluated in randomized, double-blind, placebo-and positive-controlled three-period crossover thorough QT study in 54 healthy adult subjects. No significant QT prolongation effect of venlafaxine 450 mg was detected.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. Steady-state concentrations of venlafaxine and ODV in plasma are attained within days of oral multiple-dose therapy. Venlafaxine and ODV exhibited linear kinetics over the dose range of 75 mg to 450 mg per day. Mean +- SD steady-state plasma clearance of venlafaxine and ODV is 1.3 +- 0.6 and 0.4 +- 0.2 L/h/kg, respectively; apparent elimination half-life is +- and 11 +- hours, respectively; and apparent (steady-state) volume of distribution is 7.5 +- 3.7 and 5.7 +- 1.8 L/kg, respectively. Venlafaxine and ODV are minimally bound at therapeutic concentrations to plasma proteins (27% and 30%, respectively).Absorption and DistributionVenlafaxine is well absorbed and extensively metabolized in the liver. ODV is the major active metabolite. On the basis of mass balance studies, at least 92% of single oral dose of venlafaxine is absorbed. The absolute bioavailability of venlafaxine is approximately 45%.Administration of venlafaxine hydrochloride extended-release capsules (150 mg once daily) generally resulted in lower Cmax and later Tmax values than for venlafaxine tablets (immediate release) administered twice daily (Table 16). When equal daily doses of venlafaxine were administered as either an immediate-release tablet or the extended-release capsule, the exposure to both venlafaxine and ODV was similar for the two treatments, and the fluctuation in plasma concentrations was slightly lower with the venlafaxine hydrochloride extended-release capsule. Therefore, venlafaxine hydrochloride extended-release capsules provide slower rate of absorption, but the same extent of absorption compared with the immediate-release tablet.Table 16: Comparison of Cmax and Tmax Values for Venlafaxine and ODV Following Oral Administration of Venlafaxine Hydrochloride Extended-release Capsules and Venlafaxine Tablets (Immediate Release) Venlafaxine ODV Cmax (ng/mL) Tmax (h) Cmax (ng/mL) Tmax (h) Venlafaxine Hydrochloride Extended-release Capsules (150 mg once daily) 150 5.5 260 Venlafaxine Tablets (75 mg twice daily) 225 290 Food did not affect the bioavailability of venlafaxine or its active metabolite, ODV. Time of administration (AM versus PM) did not affect the pharmacokinetics of venlafaxine and ODV from the 75 mg venlafaxine hydrochloride extended-release capsule.Venlafaxine is not highly bound to plasma proteins; therefore, administration of venlafaxine hydrochloride extended-release capsules to patient taking another drug that is highly protein-bound should not cause increased free concentrations of the other drug.Metabolism and EliminationFollowing absorption, venlafaxine undergoes extensive presystemic metabolism in the liver, primarily to ODV, but also to N-desmethylvenlafaxine, N,O-didesmethylvenlafaxine, and other minor metabolites. In vitro studies indicate that the formation of ODV is catalyzed by CYP2D6; this has been confirmed in clinical study showing that patients with low CYP2D6 levels (poor metabolizers) had increased levels of venlafaxine and reduced levels of ODV compared to people with normal CYP2D6 levels (extensive metabolizers) [see Use in Specific Populations (8.7 )]. Approximately 87% of venlafaxine dose is recovered in the urine within 48 hours as unchanged venlafaxine (5%), unconjugated ODV (29%), conjugated ODV (26%), or other minor inactive metabolites (27%). Renal elimination of venlafaxine and its metabolites is thus the primary route of excretion.

PREGNANCY SECTION.

8.1 Pregnancy. Teratogenic Effects Venlafaxine did not cause malformations in offspring of rats or rabbits given doses up to 2.5 times (rat) or times (rabbit) the maximum recommended human daily dose on mg/m2 basis. However, in rats, there was decrease in pup weight, an increase in stillborn pups, and an increase in pup deaths during the first days of lactation, when dosing began during pregnancy and continued until weaning. The cause of these deaths is not known. These effects occurred at 2.5 times (mg/m2) the maximum human daily dose. The no effect dose for rat pup mortality was 0.25 times the human dose on mg/m2 basis. In reproductive developmental studies in rats and rabbits with O-desmethylvenlafaxine (ODV), the major human metabolite of venlafaxine, evidence of teratogenicity was not observed at exposure margins of 13 in rats and 0.3 in rabbits. There are no adequate and well-controlled studies in pregnant women. Venlafaxine hydrochloride extended-release capsules should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.Non-teratogenic EffectsNeonates exposed to venlafaxine hydrochloride extended-release capsules, other SNRIs, or SSRIs, late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. Such complications can arise immediately upon delivery. Reported clinical findings have included respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying. These features are consistent with either direct toxic effect of SSRIs and SNRIs, or possibly drug discontinuation syndrome. It should be noted, that in some cases the clinical picture is consistent with serotonin syndrome [see Warnings and Precautions (5.2) and Drug Interactions (7.3)]. When treating pregnant woman with venlafaxine hydrochloride extended-release capsules during the third trimester, the physician should carefully consider the potential risks and benefits of treatment.

RECENT MAJOR CHANGES SECTION.

RECENT MAJOR CHANGES. Dosage and Administration, Discontinuing venlafaxine hydrochloride extended-release capsules (2.8) 11/2021Warnings and Precautions, Discontinuation Syndrome (5.7) 11/2021Warnings and Precautions, Sexual Dysfunction (5.13) 9/2021.

SPL MEDGUIDE SECTION.

MEDICATION GUIDE. Dispense with Medication Guide available at: www.tevausa.com/medguidesVenlafaxine Hydrochloride (ven la fax een hye droe klor ide) Extended-Release CapsulesRead the Medication Guide that comes with venlafaxine hydrochloride extended-release capsules before you start taking them and each time you get refill. There may be new information. This Medication Guide does not take the place of talking to your healthcare provider about your medical condition or treatment. Talk with your healthcare provider if there is something you do not understand or want to learn more about.What is the most important information should know about venlafaxine hydrochloride extended-release capsulesVenlafaxine hydrochloride extended-release capsules and other antidepressant medicines may cause serious side effects, including:1. Suicidal thoughts or actions:Venlafaxine hydrochloride extended-release capsules and other antidepressant medicines may increase suicidal thoughts or actions in some children, teenagers, or young adults within the first few months of treatment or when the dose is changed. Depression or other serious mental illnesses are the most important causes of suicidal thoughts or actions.Watch for these changes and call your healthcare provider right away if you notice:New or sudden changes in mood, behavior, actions, thoughts, or feelings, especially if severe.Pay particular attention to such changes when venlafaxine hydrochloride extended-release capsules are started or when the dose is changed.Keep all follow-up visits with your healthcare provider and call between visits if you are worried about symptoms.Call your healthcare provider right away if you have any of the following symptoms, or call 911 if an emergency, especially if they are new, worse, or worry you:attempts to commit suicideacting on dangerous impulsesacting aggressive or violentthoughts about suicide or dyingnew or worse depressionnew or worse anxiety or panic attacksfeeling agitated, restless, angry or irritabletrouble sleepingan increase in activity or talking more than what is normal for youother unusual changes in behavior or moodVisual problemseye painchanges in visionswelling or redness in or around the eyeOnly some people are at risk for these problems. You may want to undergo an eye examination to see if you are at risk and receive preventative treatment if you are.Call your healthcare provider right away if you have any of the following symptoms, or call 911 if an emergency. Venlafaxine hydrochloride extended-release capsules may be associated with these serious side effects:2. Serotonin SyndromeThis condition can be life-threatening and may include:agitation, hallucinations, coma or other changes in mental statuscoordination problems or muscle twitching (overactive reflexes)racing heartbeat, high or low blood pressuresweating or fevernausea, vomiting, or diarrheamuscle rigidity3. Changes in blood pressure. Venlafaxine hydrochloride extended-release capsules may:increase your blood pressure. Control high blood pressure before starting treatment and monitor blood pressure regularly4. Enlarged pupils (mydriasis).5. Anxiety and insomnia.6. Changes in appetite or weight.7. Manic/hypomanic episodes:greatly increased energysevere trouble sleepingracing thoughtsreckless behaviorunusually grand ideasexcessive happiness or irritabilitytalking more or faster than usual8. Low salt (sodium) levels in the blood.Elderly people may be at greater risk for this. Symptoms may include:headacheweakness or feeling unsteadyconfusion, problems concentrating or thinking or memory problems9. Seizures or convulsions.10. Abnormal bleeding: Venlafaxine hydrochloride extended-release capsules and other antidepressant medicines may increase your risk of bleeding or bruising, especially if you take the blood thinner warfarin (Coumadin(R), Jantoven(R)), non-steroidal anti-inflammatory drug (NSAIDs, like ibuprofen or naproxen), or aspirin.11. Elevated cholesterol.12. Lung disease and pneumonia: Venlafaxine hydrochloride extended-release capsules may cause rare lung problems. Symptoms include:worsening shortness of breathcoughchest discomfort13. Severe allergic reactions:trouble breathingswelling of the face, tongue, eyes or mouthrash, itchy welts (hives) or blisters, alone or with fever or joint pain.14. Sexual Problems (dysfunction). Taking serotonin and norepinephrine reuptake inhibitors (SNRIs), including venlafaxine hydrochloride extended-release capsules, may cause sexual problems. Symptoms in males may include: Delayed ejaculation or inability to have an ejaculation Decreased sex drive Problems getting or keeping an erectionSymptoms in females may include:Decreased sex drive Delayed orgasm or inability to have an orgasm Talk to your healthcare provider if you develop any changes in your sexual function or if you have any questions or concerns about sexual problems during treatment with venlafaxine hydrochloride extended-release capsules. There may be treatments your healthcare provider can suggest.Do not stop venlafaxine hydrochloride extended-release capsules without first talking to your healthcare provider. Stopping venlafaxine hydrochloride extended-release capsules too quickly or changing from another antidepressant too quickly may cause serious symptoms. Symptoms may include the following (some of which can be severe and last for long time):anxiety, irritability, aggressiveness, violent behaviorfeeling tired, restless or problems sleepingheadache, sweating, dizzinesselectric shock-like sensations, shaking, confusion, nightmaresvomiting, nausea, diarrheaproblems with eyesight such as blurred vision or trouble focusingincreased blood pressureWhat are venlafaxine hydrochloride extended-release capsulesVenlafaxine hydrochloride extended-release capsules are prescription medicine used to treat depression. It is important to talk with your healthcare provider about the risks of treating depression and also the risks of not treating it. You should discuss all treatment choices with your healthcare provider. Venlafaxine hydrochloride extended-release capsules are also used to treat:Generalized Anxiety Disorder (GAD)Social Anxiety Disorder (SAD)Panic Disorder (PD)Talk to your healthcare provider if you do not think that your condition is getting better with venlafaxine hydrochloride extended-release capsule treatment.Who should not take venlafaxine hydrochloride extended-release capsulesDo not take venlafaxine hydrochloride extended-release capsules if you:are allergic to venlafaxine hydrochloride extended-release capsules or any of the ingredients in venlafaxine hydrochloride extended-release capsules. See the end of this Medication Guide for complete list of ingredients in venlafaxine hydrochloride extended-release capsules.have uncontrolled angle-closure glaucomatake Monoamine Oxidase Inhibitor (MAOI). Ask your healthcare provider or pharmacist if you are not sure if you take an MAOI, including the antibiotic linezolid.Do not take an MAOI within days of stopping venlafaxine hydrochloride extended-release capsules unless directed to do so by your physician.Do not start venlafaxine hydrochloride extended-release capsules if you stopped taking an MAOI in the last weeks unless directed to do so by your physician.People who take venlafaxine hydrochloride extended-release capsules close in time to an MAOI may have serious or even life-threatening side effects. Get medical help right away if you have any of these symptoms:high feveruncontrolled muscle spasmsstiff musclesrapid changes in heart rate or blood pressureconfusionloss of consciousness (pass out)What should tell my healthcare provider before taking venlafaxine hydrochloride extended-release capsules Ask if you are not sure.Before starting venlafaxine hydrochloride extended-release capsules, tell your healthcare provider if you:Are taking certain drugs such as:Amphetamines Medicines used to treat migraine headaches such as:triptans Medicines used to treat mood, anxiety, psychotic or thought disorders, such as:tricyclic antidepressantslithiumSSRIsSNRIsantipsychotic drugs Medicines used to treat pain such as:tramadol Medicines used to thin your blood such as:warfarin Medicines used to treat heartburn such as:Cimetidine Over-the-counter medicines or supplements such as:Aspirin or other NSAIDsTryptophanSt. Johns Wort have heart problemshave diabeteshave liver problemshave kidney problemshave thyroid problemshave or had seizures or convulsionshave bipolar disorder or maniahave low sodium levels in your bloodhave high blood pressurehave high cholesterolhave or had bleeding problemsare pregnant or plan to become pregnant. It is not known if venlafaxine hydrochloride extended-release capsules will harm your unborn baby. Talk to your healthcare provider about the benefits and risks of treating depression during pregnancyare breastfeeding or plan to breastfeed. Some venlafaxine hydrochloride may pass into your breast milk. Talk to your healthcare provider about the best way to feed your baby while taking venlafaxine hydrochloride extended-release capsules.Tell your healthcare provider about all the medicines that you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. Venlafaxine hydrochloride extended-release capsules and some medicines may interact with each other, may not work as well, or may cause serious side effects.Your healthcare provider or pharmacist can tell you if it is safe to take venlafaxine hydrochloride extended-release capsules with your other medicines. Do not start or stop any medicine while taking venlafaxine hydrochloride extended-release capsules without talking to your healthcare provider first. If you take venlafaxine hydrochloride extended-release capsules, you should not take any other medicines that contain (venlafaxine) including: venlafaxine HCl. How should take venlafaxine hydrochloride extended-release capsulesTake venlafaxine hydrochloride extended-release capsules exactly as prescribed.Your healthcare provider may need to change the dose of venlafaxine hydrochloride extended-release capsules until it is the right dose for you.Venlafaxine hydrochloride extended-release capsules are to be taken with food.If you miss dose of venlafaxine hydrochloride extended-release capsules, 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 venlafaxine hydrochloride extended-release capsules at the same time.If you take too many venlafaxine hydrochloride extended-release capsules, call your healthcare provider or poison control center right away, or get emergency treatment.When switching from another antidepressant to venlafaxine hydrochloride extended-release capsules your doctor may want to lower the dose of the initial antidepressant first to avoid side effectsWhat should avoid while taking venlafaxine hydrochloride extended-release capsulesVenlafaxine hydrochloride extended-release capsules can cause sleepiness or may affect your ability to make decisions, think clearly, or react quickly. You should not drive, operate heavy machinery, or do other dangerous activities until you know how venlafaxine hydrochloride extended-release capsules affect you. Do not drink alcohol while using venlafaxine hydrochloride extended-release capsules.What are the possible side effects of venlafaxine hydrochloride extended-release capsulesVenlafaxine hydrochloride extended-release capsules may cause serious side effects, including:See What is the most important information should know about venlafaxine hydrochloride extended-release capsulesIncreased cholesterol- have your cholesterol checked regularlyNewborns whose mothers take venlafaxine hydrochloride extended-release capsules in the third trimester may have problems right after birth including:problems feeding and breathingseizuresshaking, jitteriness or constant crying Angle-closure glaucomaCommon possible side effects in people who take venlafaxine hydrochloride extended-release capsules include:unusual dreamssexual problemsloss of appetite, constipation, diarrhea, nausea or vomiting, or dry mouthfeeling tired, fatigued or overly sleepychange in sleep habits, problems sleepingyawningtremor or shakingdizziness, blurred visionsweatingfeeling anxious, nervous or jitteryheadacheincrease in heart rateTell your healthcare provider if you have any side effect that bothers you or that does not go away. These are not all the possible side effects of venlafaxine hydrochloride extended-release capsules. For more information, ask your healthcare provider or pharmacist.CALL YOUR DOCTOR FOR MEDICAL ADVICE ABOUT SIDE EFFECTS. YOU MAY REPORT SIDE EFFECTS TO THE FDA AT 1-800-FDA-1088.How should store venlafaxine hydrochloride extended-release capsules Store venlafaxine hydrochloride extended-release capsules at room temperature between 68F and 77F (20C to 25C). Keep venlafaxine hydrochloride extended-release capsules in dry place. Keep venlafaxine hydrochloride extended-release capsules and all medicines out of the reach of children. General information about venlafaxine hydrochloride extended-release capsulesMedicines are sometimes prescribed for purposes other than those listed in Medication Guide. Do not use venlafaxine hydrochloride extended-release capsules for condition for which they were not prescribed. Do not give venlafaxine hydrochloride extended-release capsules to other people, even if they have the same condition. They may harm them.This Medication Guide summarizes the most important information about venlafaxine hydrochloride extended-release capsules. If you would like more information, talk with your healthcare provider. You may ask your healthcare provider or pharmacist for information about venlafaxine hydrochloride extended-release capsules that is written for healthcare professionals.For more information about venlafaxine hydrochloride extended-release capsules call 1-888-838-2872.What are the ingredients in venlafaxine hydrochloride extended-release capsulesActive ingredient: venlafaxine hydrochloride.Inactive ingredients: black iron oxide, dibutyl sebacate, ethylcellulose, gelatin, polyethylene glycol, povidone, propylene glycol, shellac, sugar spheres (which contain sucrose and corn starch), sunset yellow FCF FD&C yellow 6, talc, and titanium dioxide. The 37.5 mg capsules also contain D&C yellow 10 and potassium hydroxide, the 75 mg capsules also contain D&C yellow 10 and may contain potassium hydroxide, and the 150 mg capsules also contain potassium hydroxide.Brands listed are trademarks of their respective owners.This Medication Guide has been approved by the U.S. Food and Drug Administration for all antidepressants.Manufactured In Israel By:Teva Pharmaceutical Ind. Ltd.Kfar Saba, 4410202, IsraelManufactured For:Teva Pharmaceuticals Parsippany, NJ 07054Rev. 1/2022. Venlafaxine hydrochloride extended-release capsules and other antidepressant medicines may increase suicidal thoughts or actions in some children, teenagers, or young adults within the first few months of treatment or when the dose is changed. Depression or other serious mental illnesses are the most important causes of suicidal thoughts or actions.. Watch for these changes and call your healthcare provider right away if you notice:. New or sudden changes in mood, behavior, actions, thoughts, or feelings, especially if severe.. Pay particular attention to such changes when venlafaxine hydrochloride extended-release capsules are started or when the dose is changed.. attempts to commit suicide. acting on dangerous impulses. acting aggressive or violent. thoughts about suicide or dying. new or worse depression. new or worse anxiety or panic attacks. feeling agitated, restless, angry or irritable. trouble sleeping. an increase in activity or talking more than what is normal for you. other unusual changes in behavior or mood. Visual problemseye painchanges in visionswelling or redness in or around the eye. eye pain. changes in vision. swelling or redness in or around the eye. agitation, hallucinations, coma or other changes in mental status. coordination problems or muscle twitching (overactive reflexes). racing heartbeat, high or low blood pressure. sweating or fever. nausea, vomiting, or diarrhea. muscle rigidity. increase your blood pressure. Control high blood pressure before starting treatment and monitor blood pressure regularly. greatly increased energy. severe trouble sleeping. racing thoughts. reckless behavior. unusually grand ideas. excessive happiness or irritability. talking more or faster than usual. headache. weakness or feeling unsteady. confusion, problems concentrating or thinking or memory problems. worsening shortness of breath. cough. chest discomfort. trouble breathing. swelling of the face, tongue, eyes or mouth. rash, itchy welts (hives) or blisters, alone or with fever or joint pain.. Delayed ejaculation or inability to have an ejaculation Decreased sex drive Problems getting or keeping an erection. Decreased sex drive Delayed orgasm or inability to have an orgasm anxiety, irritability, aggressiveness, violent behavior. feeling tired, restless or problems sleeping. headache, sweating, dizziness. electric shock-like sensations, shaking, confusion, nightmares. vomiting, nausea, diarrhea. problems with eyesight such as blurred vision or trouble focusing. increased blood pressure. Generalized Anxiety Disorder (GAD). Social Anxiety Disorder (SAD). Panic Disorder (PD). are allergic to venlafaxine hydrochloride extended-release capsules or any of the ingredients in venlafaxine hydrochloride extended-release capsules. See the end of this Medication Guide for complete list of ingredients in venlafaxine hydrochloride extended-release capsules.. have uncontrolled angle-closure glaucoma. take Monoamine Oxidase Inhibitor (MAOI). Ask your healthcare provider or pharmacist if you are not sure if you take an MAOI, including the antibiotic linezolid.. Do not take an MAOI within days of stopping venlafaxine hydrochloride extended-release capsules unless directed to do so by your physician.. Do not start venlafaxine hydrochloride extended-release capsules if you stopped taking an MAOI in the last weeks unless directed to do so by your physician.. high fever. uncontrolled muscle spasms. stiff muscles. rapid changes in heart rate or blood pressure. confusion. loss of consciousness (pass out). Are taking certain drugs such as:Amphetamines Medicines used to treat migraine headaches such as:triptans Medicines used to treat mood, anxiety, psychotic or thought disorders, such as:tricyclic antidepressantslithiumSSRIsSNRIsantipsychotic drugs Medicines used to treat pain such as:tramadol Medicines used to thin your blood such as:warfarin Medicines used to treat heartburn such as:Cimetidine Over-the-counter medicines or supplements such as:Aspirin or other NSAIDsTryptophanSt. Johns Wort Amphetamines. Medicines used to treat migraine headaches such as:triptans triptans. Medicines used to treat mood, anxiety, psychotic or thought disorders, such as:tricyclic antidepressantslithiumSSRIsSNRIsantipsychotic drugs tricyclic antidepressants. lithium. SSRIs. SNRIs. antipsychotic drugs. Medicines used to treat pain such as:tramadol tramadol. Medicines used to thin your blood such as:warfarin warfarin. Medicines used to treat heartburn such as:Cimetidine Cimetidine. Over-the-counter medicines or supplements such as:Aspirin or other NSAIDsTryptophanSt. Johns Wort Aspirin or other NSAIDs. Tryptophan. St. Johns Wort. have heart problems. have diabetes. have liver problems. have kidney problems. have thyroid problems. have or had seizures or convulsions. have bipolar disorder or mania. have low sodium levels in your blood. have high blood pressure. have high cholesterol. have or had bleeding problems. are pregnant or plan to become pregnant. It is not known if venlafaxine hydrochloride extended-release capsules will harm your unborn baby. Talk to your healthcare provider about the benefits and risks of treating depression during pregnancy. are breastfeeding or plan to breastfeed. Some venlafaxine hydrochloride may pass into your breast milk. Talk to your healthcare provider about the best way to feed your baby while taking venlafaxine hydrochloride extended-release capsules.. Take venlafaxine hydrochloride extended-release capsules exactly as prescribed.. Venlafaxine hydrochloride extended-release capsules are to be taken with food.. If you miss dose of venlafaxine hydrochloride extended-release capsules, 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 venlafaxine hydrochloride extended-release capsules at the same time.. If you take too many venlafaxine hydrochloride extended-release capsules, call your healthcare provider or poison control center right away, or get emergency treatment.. When switching from another antidepressant to venlafaxine hydrochloride extended-release capsules your doctor may want to lower the dose of the initial antidepressant first to avoid side effects. See What is the most important information should know about venlafaxine hydrochloride extended-release capsules. Increased cholesterol- have your cholesterol checked regularly. Newborns whose mothers take venlafaxine hydrochloride extended-release capsules in the third trimester may have problems right after birth including:problems feeding and breathingseizuresshaking, jitteriness or constant crying problems feeding and breathing. seizures. shaking, jitteriness or constant crying. Angle-closure glaucoma. unusual dreams. sexual problems. loss of appetite, constipation, diarrhea, nausea or vomiting, or dry mouth. feeling tired, fatigued or overly sleepy. change in sleep habits, problems sleeping. yawning. tremor or shaking. dizziness, blurred vision. sweating. feeling anxious, nervous or jittery. headache. increase in heart rate. Store venlafaxine hydrochloride extended-release capsules at room temperature between 68F and 77F (20C to 25C). Keep venlafaxine hydrochloride extended-release capsules in dry place.

SPL UNCLASSIFIED SECTION.

1.1 Major Depressive Disorder. Venlafaxine hydrochloride extended-release capsules are indicated for the treatment of major depressive disorder (MDD). Efficacy was established in three short-term (4, 8, and 12 weeks) and two long-term, maintenance trials.

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. Pregnancy: Based on animal data, may cause fetal harm (8.1).Nursing Mothers: Discontinue drug or nursing, taking into consideration importance of drug to mother (8.3). Pregnancy: Based on animal data, may cause fetal harm (8.1).. Nursing Mothers: Discontinue drug or nursing, taking into consideration importance of drug to mother (8.3). 8.1 Pregnancy. Teratogenic Effects Venlafaxine did not cause malformations in offspring of rats or rabbits given doses up to 2.5 times (rat) or times (rabbit) the maximum recommended human daily dose on mg/m2 basis. However, in rats, there was decrease in pup weight, an increase in stillborn pups, and an increase in pup deaths during the first days of lactation, when dosing began during pregnancy and continued until weaning. The cause of these deaths is not known. These effects occurred at 2.5 times (mg/m2) the maximum human daily dose. The no effect dose for rat pup mortality was 0.25 times the human dose on mg/m2 basis. In reproductive developmental studies in rats and rabbits with O-desmethylvenlafaxine (ODV), the major human metabolite of venlafaxine, evidence of teratogenicity was not observed at exposure margins of 13 in rats and 0.3 in rabbits. There are no adequate and well-controlled studies in pregnant women. Venlafaxine hydrochloride extended-release capsules should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.Non-teratogenic EffectsNeonates exposed to venlafaxine hydrochloride extended-release capsules, other SNRIs, or SSRIs, late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. Such complications can arise immediately upon delivery. Reported clinical findings have included respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying. These features are consistent with either direct toxic effect of SSRIs and SNRIs, or possibly drug discontinuation syndrome. It should be noted, that in some cases the clinical picture is consistent with serotonin syndrome [see Warnings and Precautions (5.2) and Drug Interactions (7.3)]. When treating pregnant woman with venlafaxine hydrochloride extended-release capsules during the third trimester, the physician should carefully consider the potential risks and benefits of treatment.. 8.2 Labor and Delivery. The effect of venlafaxine on labor and delivery in humans is unknown.. 8.3 Nursing Mothers. Venlafaxine and ODV have been reported to be excreted in human milk. Because of the potential for serious adverse reactions in nursing infants from venlafaxine hydrochloride extended-release capsules, decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.. 8.4 Pediatric Use. Two placebo-controlled trials in 766 pediatric patients with MDD and two placebo-controlled trials in 793 pediatric patients with GAD have been conducted with venlafaxine hydrochloride extended-release capsules, and the data were not sufficient to support claim for use in pediatric patients.Anyone considering the use of venlafaxine hydrochloride extended-release capsules in child or adolescent must balance the potential risks with the clinical need [see Boxed Warning, Warnings and Precautions (5.1, 5.10, 5.11) and Adverse Reactions (6.4)].Although no studies have been designed to primarily assess venlafaxine hydrochloride extended-release capsuless impact on the growth, development, and maturation of children and adolescents, the studies that have been done suggest that venlafaxine hydrochloride extended-release capsules may adversely affect weight and height [see Warnings and Precautions (5.10)]. Should the decision be made to treat pediatric patient with venlafaxine hydrochloride extended-release capsules, regular monitoring of weight and height is recommended during treatment, particularly if treatment is to be continued long-term [see Warnings and Precautions (5.10, 5.11)]. The safety of venlafaxine hydrochloride extended-release capsule treatment for pediatric patients has not been systematically assessed for chronic treatment longer than six months in duration. In the studies conducted in pediatric patients (ages to 17), the occurrence of blood pressure and cholesterol increases considered to be clinically relevant in pediatric patients was similar to that observed in adult patients. Consequently, the precautions for adults apply to pediatric patients [see Warnings and Precautions (5.3, 6.3)]. 8.5 Geriatric Use. The percentage of patients in clinical studies for venlafaxine hydrochloride extended-release capsules for MDD, GAD, SAD, and PD who were 65 years of age or older are shown in Table 15.Table 15: Percentage (and Number of Patients Studied) of Patients 65 Years of Age and Older by Indicationa Indication Venlafaxine Hydrochloride Extended-release Capsules MDD (14/357) GAD (77/1,381) SAD (10/819) PD (16/1,001) In addition, in the premarketing assessment of venlafaxine tablets (immediate release), 12% (357/2,897) of patients were >= 65 years of age. No overall differences in effectiveness or safety were observed between geriatric patients and younger patients, and other reported clinical experience generally has not identified differences in response between the elderly and younger patients. However, greater sensitivity of some older individuals cannot be ruled out. SSRIs and SNRIs, including venlafaxine hydrochloride extended-release capsules, have been associated with cases of clinically significant hyponatremia in elderly patients, who may be at greater risk for this adverse event [see Warnings and Precautions (5.9)].The pharmacokinetics of venlafaxine and ODV are not substantially altered in the elderly [see Clinical Pharmacology (12.3)] (see Figure 3). No dose adjustment is recommended for the elderly on the basis of age alone, although other clinical circumstances, some of which may be more common in the elderly, such as renal or hepatic impairment, may warrant dose reduction [see Dosage and Administration (2.6)]. 8.6 Age and Gender. population pharmacokinetic analysis of 404 venlafaxine-treated patients from two studies involving both twice daily and three times daily regimens showed that dose-normalized trough plasma levels of either venlafaxine or ODV were unaltered by age or gender differences. Dosage adjustment based on the age or gender of patient is generally not necessary [see Dosage and Administration (2.6)] (see Table 15).. 8.7 Use in Patient Subgroups. Figure 3: Pharmacokinetics of venlafaxine and its metabolite O-desmethylvenlafaxine (ODV) in special populations.Abbreviations: ODV, O-desmethylvenlafaxine; AUC, area under the curve; Cmax, peak plasma concentrations;Similar effect is expected with strong CYP2D6 inhibitors. Figure 3.

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. Clinical Worsening/Suicide Risk: Monitor for clinical worsening and suicide risk (5.1).Serotonin Syndrome: Risk increases with concomitant use of other serotonergic drugs. Discontinue venlafaxine hydrochloride extended-release capsules and initiate supportive treatment if serotonin syndrome occurs (4.2, 5.2, 7.3).Elevations in Blood Pressure: Control hypertension before initiating treatment. Monitor blood pressure regularly during treatment (5.3).Abnormal Bleeding: Venlafaxine hydrochloride extended-release capsules may increase risk of bleeding events. Caution patients about the risk of bleeding associated with the concomitant use of venlafaxine hydrochloride extended-release capsules and NSAIDs, aspirin, or other drugs that affect coagulation (5.4).Angle Closure Glaucoma: Angle closure glaucoma has occurred in patients with untreated anatomically narrow angles treated with antidepressants (5.5).Activation of Mania/Hypomania: Use cautiously in patients with bipolar disorder. Caution patients about the risk of activation of mania/hypomania (5.6).Sexual Dysfunction: venlafaxine hydrochloride extended-release capsules may cause symptoms of sexual dysfunction (5.13).. Clinical Worsening/Suicide Risk: Monitor for clinical worsening and suicide risk (5.1).. Serotonin Syndrome: Risk increases with concomitant use of other serotonergic drugs. Discontinue venlafaxine hydrochloride extended-release capsules and initiate supportive treatment if serotonin syndrome occurs (4.2, 5.2, 7.3).. Elevations in Blood Pressure: Control hypertension before initiating treatment. Monitor blood pressure regularly during treatment (5.3).. Abnormal Bleeding: Venlafaxine hydrochloride extended-release capsules may increase risk of bleeding events. Caution patients about the risk of bleeding associated with the concomitant use of venlafaxine hydrochloride extended-release capsules and NSAIDs, aspirin, or other drugs that affect coagulation (5.4).. Angle Closure Glaucoma: Angle closure glaucoma has occurred in patients with untreated anatomically narrow angles treated with antidepressants (5.5).. Activation of Mania/Hypomania: Use cautiously in patients with bipolar disorder. Caution patients about the risk of activation of mania/hypomania (5.6).. Sexual Dysfunction: venlafaxine hydrochloride extended-release capsules may cause symptoms of sexual dysfunction (5.13).. 5.1Suicidal Thoughts and Behaviors in Children, Adolescents, and Young Adults. Patients with major depressive disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. Suicide is known risk of depression and certain other psychiatric disorders, and these disorders themselves are the strongest predictors of suicide. There has been long-standing concern, however, that antidepressants may have role in inducing worsening of depression and the emergence of suicidality in certain patients during the early phases of treatment. Pooled analyses of short-term placebo-controlled studies of antidepressant drugs (SSRIs and others) showed that these drugs increase the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults (ages 18 to 24) with MDD and other psychiatric disorders. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was reduction with antidepressants compared to placebo in adults aged 65 and older.The pooled analyses of placebo-controlled studies in children and adolescents with MDD, Obsessive Compulsive Disorder (OCD), or other psychiatric disorders included total of 24 short-term studies of antidepressant drugs in over 4,400 patients. The pooled analyses of placebo-controlled studies in adults with MDD or other psychiatric disorders included total of 295 short-term studies (median duration of months) of 11 antidepressant drugs in over 77,000 patients. There was considerable variation in risk of suicidality among drugs, but tendency toward an increase in the younger patients for almost all drugs studied. There were differences in absolute risk of suicidality across the different indications, with the highest incidence in MDD. The risk differences (drug versus placebo), however, were relatively stable within age strata and across indications. These risk differences (drug-placebo difference in the number of cases of suicidality per 1,000 patients treated) are provided in Table 1.Table 1: Difference in the Number of Cases of Suicidality per 1,000 Patients Treated versus PlaceboAge RangeIncreases Compared to Placebo< 1814 additional cases18 to 245 additional casesDecreases Compared to Placebo25 to 641 fewer case>= 656 fewer casesNo suicides occurred in any of the pediatric studies. There were suicides in the adult studies, but the number was not sufficient to reach any conclusion about drug effect on suicide.It is unknown whether the suicidality risk extends to longer term use, i.e., beyond several months. However, there is substantial evidence from placebo-controlled maintenance studies in adults with depression that the use of antidepressants can delay the recurrence of depression.All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of course of drug therapy, or at times of dose changes, either increases or decreases.The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for MDD, as well as for other indications, both psychiatric and nonpsychiatric. Although causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality.Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality, especially if these symptoms are severe, abrupt in onset, or were not part of the patients presenting symptoms.If the decision has been made to discontinue treatment, medication should be tapered, as rapidly as is feasible, but with recognition that abrupt discontinuation can be associated with certain symptoms [see Warnings and Precautions (5.7) and Dosage and Administration (2.8)].Families and caregivers of patients being treated with antidepressants for MDD or other indications, both psychiatric and nonpsychiatric, should be alerted about the need to monitor patients for the emergence of agitation, irritability, unusual changes in behavior, and the other symptoms described above, as well as the emergence of suicidality, and to report such symptoms immediately to healthcare providers. Such monitoring should include daily observation by families and caregivers. Prescriptions for venlafaxine hydrochloride extended-release capsules should be written for the smallest quantity of capsules consistent with good patient management, in order to reduce the risk of overdose.Screening Patients for Bipolar DisorderA major depressive episode may be the initial presentation of bipolar disorder. It is generally believed (though not established in controlled studies) that treating such an episode with an antidepressant alone may increase the likelihood of precipitation of mixed/manic episode in patients at risk for bipolar disorder. Whether any of the symptoms described above represent such conversion is unknown. However, prior to initiating treatment with an antidepressant, patients with depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include detailed psychiatric history, including family history of suicide, bipolar disorder, and depression. It should be noted that venlafaxine hydrochloride extended-release capsules are not approved for use in treating bipolar depression.. 5.2 Serotonin Syndrome. The development of potentially life-threatening serotonin syndrome has been reported with Serotonin-norepinephrine reuptake inhibitors (SNRIs) and SSRIs, including venlafaxine hydrochloride extended-release capsules alone, but particularly with concomitant use of other serotonergic drugs (including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. Johns wort) and with drugs that impair metabolism of serotonin in particular, MAOIs, both those intended to treat psychiatric disorders and others, such as linezolid or intravenous methylene blue).Serotonin syndrome symptoms may include mental status changes (e.g., agitation, hallucinations, delirium, coma) autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia, diaphoresis, flushing, and dizziness), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination); seizures and gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Patients should be monitored for the emergence of serotonin syndrome.The concomitant use of venlafaxine hydrochloride extended-release capsules with MAOIs (intended to treat psychiatric disorders) is contraindicated. Venlafaxine hydrochloride extended-release capsules should also not be started in patient who is being treated with MAOIs such as linezolid or intravenous methylene blue. All reports with methylene blue that provided information on the route of administration involved intravenous administration in the dose range of mg/kg to mg/kg. No reports involved the administration of methylene blue by other routes (such as oral tablets or local tissue injection) or at lower doses. There may be circumstances when it is necessary to initiate treatment with MAOI such as linezolid or intravenous methylene blue in patient taking venlafaxine hydrochloride extended-release capsules. Venlafaxine hydrochloride extended-release capsules should be discontinued before initiating treatment with the MAOI [see Contraindications (4.2), Dosage and Administration (2.6), and Drug Interactions (7.3)]. If concomitant use of venlafaxine hydrochloride extended-release capsules with other serotonergic drugs (e.g., triptans, tricyclic antidepressants, mirtazapine, fentanyl, lithium, tramadol, buspirone, amphetamines, tryptophan, or St. Johns wort) is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases [see Drug Interactions (7.3)]. Patients should be made aware of the potential risk of serotonin syndrome. Treatment with venlafaxine hydrochloride extended-release capsules and any concomitant serotonergic agents should be discontinued immediately if the above events occur, and supportive symptomatic treatment should be initiated.. 5.3 Elevations in Blood Pressure. In controlled trials, there were dose-related increases in systolic and diastolic blood pressure, as well as cases of sustained hypertension [see Adverse Reactions (6.2)].Monitor blood pressure before initiating treatment with venlafaxine hydrochloride extended-release capsules and regularly during treatment. Control preexisting hypertension before initiating treatment with venlafaxine hydrochloride extended-release capsules. Use caution in treating patients with preexisting hypertension or cardiovascular or cerebrovascular conditions that might be compromised by increases in blood pressure. Sustained blood pressure elevation can lead to adverse outcomes. Cases of elevated blood pressure requiring immediate treatment have been reported with venlafaxine hydrochloride extended-release capsules. Consider dose reduction or discontinuation of treatment for patients who experience sustained increase in blood pressure.Across all clinical studies with venlafaxine tablets, 1.4% of patients in the venlafaxine hydrochloride extended-release capsule treated groups experienced >= 15 mm Hg increase in supine diastolic blood pressure (SDBP) >= 105 mm Hg, compared to 0.9% of patients in the placebo groups. Similarly, 1% of patients in the venlafaxine hydrochloride extended-release capsule treated groups experienced >= 20 mm Hg increase in supine systolic blood pressure (SSBP) with blood pressure >= 180 mm Hg, compared to 0.3% of patients in the placebo groups [see Table 10 in Adverse Reactions (6.2)]. Venlafaxine hydrochloride extended-release capsule treatment was associated with sustained hypertension (defined as treatment-emergent SDBP >= 90 mm Hg and >= 10 mm Hg above baseline for three consecutive on-therapy visits [see Table 11 in Adverse Reactions (6.2)]. An insufficient number of patients received mean doses of venlafaxine hydrochloride extended-release capsules over 300 mg per day in clinical studies to fully evaluate the incidence of sustained increases in blood pressure at these higher doses.. 5.4 Abnormal Bleeding. SSRIs and SNRIs, including venlafaxine hydrochloride extended-release capsules, may increase the risk of bleeding events, ranging from ecchymoses, hematomas, epistaxis, petechiae, and gastrointestinal hemorrhage to life-threatening hemorrhage. Concomitant use of aspirin, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), warfarin, and other anti-coagulants or other drugs known to affect platelet function may add to this risk. Case reports and epidemiological studies (case-control and cohort design) have demonstrated an association between use of drugs that interfere with serotonin reuptake and the occurrence of gastrointestinal bleeding. Caution patients about the risk of bleeding associated with the concomitant use of venlafaxine hydrochloride extended-release capsules and NSAIDs, aspirin, or other drugs that affect coagulation. 5.5 Angle-Closure Glaucoma. The pupillary dilation that occurs following use of many antidepressant drugs including venlafaxine hydrochloride extended-release capsules may trigger an angle closure attack in patient with anatomically narrow angles who does not have patent iridectomy. 5.6 Activation ofMania/Hypomania. Mania or hypomania was reported in venlafaxine hydrochloride extended-release capsule treated patients in the premarketing studies in MDD, SAD, and PD (see Table 2). Mania/hypomania has also been reported in small proportion of patients with mood disorders who were treated with other marketed drugs to treat MDD. Venlafaxine hydrochloride extended-release capsules should be used cautiously in patients with history of mania or hypomania.Table 2: Incidence (%) of Mania or Hypomania Reported in Venlafaxine Hydrochloride Extended-release Capsule Treated Patients in the Premarketing StudiesIndication Venlafaxine Hydrochloride Extended-release CapsulesPlaceboMDD0.30.0GAD0.00.2SAD0.20.0PD0.10.0. 5.7 Discontinuation Syndrome. Discontinuation symptoms have been systematically evaluated in patients taking venlafaxine, including prospective analyses of clinical studies in GAD and retrospective surveys of studies in MDD and SAD. Abrupt discontinuation or dose reduction of venlafaxine at various doses has been found to be associated with the appearance of new symptoms, the frequency of which increased with increased dose level and with longer duration of treatment. Reported symptoms include agitation, anorexia, anxiety, confusion, impaired coordination and balance, diarrhea, dizziness, dry mouth, dysphoric mood, fasciculation, fatigue, flu-like symptoms, headaches, hypomania, insomnia, nausea, nervousness, nightmares, sensory disturbances (including shock-like electrical sensations), somnolence, sweating, tremor, vertigo, and vomiting.There have been postmarketing reports of serious discontinuation symptoms which can be protracted and severe. Completed suicide, suicidal thoughts, aggression and violent behavior have been observed in patients during reduction in venlafaxine hydrochloride extended-release capsules dosage, including during discontinuation. Other postmarketing reports describe visual changes (such as blurred vision or trouble focusing) and increased blood pressure after stopping or reducing the dose of venlafaxine hydrochloride extended-release capsules.During marketing of venlafaxine hydrochloride extended-release capsules, other SNRIs, and SSRIs, there have been spontaneous reports of other adverse events occurring upon discontinuation of these drugs, particularly when abrupt, including the following: irritability, lethargy, emotional lability, tinnitus, and seizures.Patients should be monitored for these symptoms when discontinuing treatment with venlafaxine hydrochloride extended-release capsules. gradual reduction in the dose, rather than abrupt cessation, is recommended. If intolerable symptoms occur following decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the healthcare provider may continue decreasing the dose, but at more gradual rate. In some patients, discontinuation may need to occur over period of several months [see Dosage and Administration (2.8)].. 5.8 Seizures. Seizures have occurred with venlafaxine therapy. Venlafaxine hydrochloride extended-release capsules, like many antidepressants, should be used cautiously in patients with history of seizures and should be discontinued in any patient who develops seizures. [Must mitigate the risk: Risk factors, concomitant meds that lower the seizure threshold.] 5.9 Hyponatremia. Hyponatremia can occur as result of treatment with SSRIs and SNRIs, including venlafaxine hydrochloride extended-release capsules. In many cases, the hyponatremia appears to be the result of the Syndrome of Inappropriate Antidiuretic Hormone (SIADH) secretion. Cases with serum sodium lower than 110 mmol/L have been reported. Elderly patients may be at greater risk of developing hyponatremia with SSRIs and SNRIs [see Use in Specific Populations (8.5)]. Also, patients taking diuretics, or those who are otherwise volume-depleted, may be at greater risk. Consider discontinuation of venlafaxine hydrochloride extended-release capsules in patients with symptomatic hyponatremia, and institute appropriate medical intervention.Signs and symptoms of hyponatremia include headache, difficulty concentrating, memory impairment, confusion, weakness, and unsteadiness, which may lead to falls. Signs and symptoms associated with more severe and/or acute cases have included hallucination, syncope, seizure, coma, respiratory arrest, and death.. 5.10 Weight and HeightChanges in Pediatric Patients. Weight ChangesThe average change in body weight and incidence of weight loss (percentage of patients who lost 3.5% or more) in the placebo-controlled pediatric studies in MDD, GAD, and SAD are shown in Tables and 4.Table 3: Average Change in Body Weight (kg) From Beginning of Treatment in Pediatric Patients in Double-blind, Placebo-controlled Studies of Venlafaxine Hydrochloride Extended-release CapsulesIndication (Duration)Venlafaxine Hydrochloride Extended-release CapsulesPlaceboMDD and GAD(4 pooled studies, weeks)-0.45 (n 333)+0.77 (n 333)SAD(16 weeks)-0.75 (n 137)+0.76 (n 148)Table 4: Incidence (%) of Pediatric Patients Experiencing Weight Loss (3.5% or more) in Double-blind, Placebo-controlled Studies of Venlafaxine Hydrochloride Extended-release CapsulesIndication (Duration)Venlafaxine Hydrochloride Extended-release CapsulesPlaceboMDD and GAD(4 pooled studies, weeks)18a (n 333)3.6 (n 333)SAD(16 weeks)47a (n 137)14 (n 148)a < 0.001 versus placeboWeight loss was not limited to patients with treatment-emergent anorexia [see Warnings and Precautions (5.11)].The risks associated with longer term venlafaxine hydrochloride extended-release capsules use were assessed in an open-label MDD study of children and adolescents who received venlafaxine hydrochloride extended-release capsules for up to six months. The children and adolescents in the study had increases in weight that were less than expected, based on data from age- and sex-matched peers. The difference between observed weight gain and expected weight gain was larger for children (< 12 years old) than for adolescents (>= 12 years old).Height ChangesTable shows the average height increase in pediatric patients in the short-term, placebo-controlled MDD, GAD, and SAD studies. The differences in height increases in GAD and MDD studies were most notable in patients younger than twelve.Table 5: Average Height Increases (cm) in Pediatric Patients in Placebo-controlled Studies of Venlafaxine Hydrochloride Extended-release CapsulesIndication (Duration)Venlafaxine Hydrochloride Extended-release CapsulesPlaceboMDD(8 weeks)0.8 (n 146)0.7 (n 147)GAD(8 weeks)0.3a (n 122)1.0 (n 132)SAD(16 weeks)1.0 (n 109)1.0 (n 112)a = 0.041In the six-month, open-label MDD study, children and adolescents had height increases that were less than expected, based on data from age- and sex-matched peers. The difference between observed and expected growth rates was larger for children (< 12 years old) than for adolescents (>= 12 years old).. 5.11Appetite Changes in Pediatric Patients. Decreased appetite (reported as treatment-emergent anorexia) was more commonly observed in venlafaxine hydrochloride extended-release capsule treated patients versus placebo-treated patients in the premarketing evaluation of venlafaxine hydrochloride extended-release capsules for MDD, GAD, and SAD (see Table 6).Table 6: Incidence (%) of Decreased Appetite and Associated Discontinuation Ratesa (%) in Pediatric Patients in Placebo-controlled Studies of Venlafaxine Hydrochloride Extended-release CapsulesIndication (Duration)Venlafaxine Hydrochloride Extended-release Capsules IncidenceDiscontinuationPlacebo IncidenceDiscontinuationMDD and GAD(pooled, weeks)100.03-SAD(16 weeks)220.730.0a The discontinuation rates for weight loss were 0.7% for patients receiving either venlafaxine hydrochloride extended-release capsules or placebo.. 5.12 Interstitial Lung Disease and Eosinophilic Pneumonia. Interstitial lung disease and eosinophilic pneumonia associated with venlafaxine therapy have been rarely reported. The possibility of these adverse events should be considered in venlafaxine-treated patients who present with progressive dyspnea, cough or chest discomfort. Such patients should undergo prompt medical evaluation, and discontinuation of venlafaxine therapy should be considered. 5.13Sexual Dysfunction. Use of SNRIs, including venlafaxine hydrochloride extended-release capsules, may cause symptoms of sexual dysfunction [see Adverse Reactions (6.1)]. In male patients, SNRI use may result in ejaculatory delay or failure, decreased libido, and erectile dysfunction. In female patients, SNRI use may result in decreased libido and delayed or absent orgasm. It is important for prescribers to inquire about sexual function prior to initiation of venlafaxine hydrochloride extended-release capsules and to inquire specifically about changes in sexual function during treatment, because sexual function may not be spontaneously reported. When evaluating changes in sexual function, obtaining detailed history (including timing of symptom onset) is important because sexual symptoms may have other causes, including the underlying psychiatric disorder. Discuss potential management strategies to support patients in making informed decisions about treatment.