Venlafaxine – Effexor (Selective Serotonin-Norepinephrine Reuptake Inhibitor /SNRI)

Venlafaxine is a selective serotonin-norepinephrine reuptake inhibitor (SNRI) used in the palliative care setting for concurrent treatment of depressive disorders and neuropathic pain. (Neuropathic chronic pain is often resistance to standard opioid therapy and is best treated with a secondary amine tricyclic antidepressant (nortriptyline, desipramine), a selective serotonin or norepinephrine reuptake inhibitor (SSNRI) (venlafaxine, duloxetine), or a calcium channel alpha2 delta lignd (anticonvulsants) (gabapentin or pregabalin).

In the United States there are three SNRIs that have been approved by the FDA: venlafaxine (Effexor and Effexor XR), desvenlafaxine (Pristiq), and duloxetine (Symbalta). Venlafaxine and duloxetine both block the serotonin and norepinephrine transporters, thereby inhibiting and availability to bind with the postsynaptic receptors. At lower doses, venlafazine predominantly affects serotonin reuptak, contributing to greater anxiety reduction more so than depressive symptom reduction. Duloxetine, however, appears to be a more potent and equal serotonin and norepinephrine reuptake inhibitor than venlafaxine is. These drugs are rapidly absorbed after oral intake and metabolized extensively in the liver. Time needed to reach maximum plasma concentration is 2 hours for both venlafaxine and duloxetine. Venlafaxine has a half-life of 5 hours and the active metabolite is 11 hours. Steady state is achieve in 3 to 4 days. Duloxetine has a half-life of 12 hours, reaching steady state in 3 days. Both drugs are excreted mostly in urine.

The most common side effects with both venlafaxine and duloxetine include headache, somnolence, dizziness, insomnia, nervousness, nausea, dry mouth, constipation, and abnormal ejaculation. Appetite and weight decreases may occur. At higher doses, both drugs may contribute to elevated blood pressure. No specific serum level monitoring is available for either of these drugs. With duloxetine, liver function should be monitoered once weekly, once monthly, biannually, and finally annually. All patients taking antidepressants need to be carefully monitored for suicidal risk as well as activation of hypomanic or manic symptoms.

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Predicting Prognosis: Activities of Daily Living (Reading & Sharing)

The most common method of assessing the functional status of patients with diagnoses other than cancer is by the evaluation of the activities of daily living (ADLs).

The original six activities, defined by Katz in the 1960s were bathing, dressing, toileting, transfer, continence, and feeding.

A patient’s ability to perform each of these activities, the evaluation of ADLs on a serial basis has been found to be an important indicator of patient prognosis.

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What is PPS: Palliative Performance Scale

The Palliative Performance Scale (PPS) is a modification of the KPS and aims to help overcome the limitation of the KPS. In addition to the activities already measured in the KPS, the PPS assesses the patient characteristics of food/fluid intake and level of consciousness. PPS ratings directly correlated with short-term prognosis for terminally ill patients with or without cancer. It is generally accepted that a KPS or PPS score of 50 or less is predictive that the patient may have a prognosis of 6 months or less.

The PPS assessing ambulation, self care ability, intake, level of consciousness, activity level, and evidence of disease, is described as follows:

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What is KPS: Karnofsky Performance Status

The Karnofsky Performance Status (KPS) index designed in the late 1940s as an adjunctive tool to evaluate the activity levels of patients with cancer who were participating in cancer chemotherapy trials.

The KPS assessing ambulation, self care ability, activity level, and evidence of disease, is described as follows: (Measures of performance status for patients with malignant disease)

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