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Luvox (Fluvoxamine) - Uses, Dosage, Side effects, Brands

Luvox (Fluvoxamine) is a selective serotonin reuptake inhibitor. It is used to treat the following conditions:

Obsessive-compulsive disorder:
- Treatment of obsessive-compulsive disorder (OCD) in pediatric patients 8 to 17 years of age and adults.
Off Label Use of Fluvoxamine in Adults:
- Bulimia nervosa
- Major depressive disorder
- Panic disorder
- Post-traumatic stress disorder (PTSD)
- Social anxiety disorder (SAD)

Fluvoxamine Dose in Adults

Fluvoxamine Dose in the treatment of Obsessive-compulsive disorder:

Immediate-release:
- 50 mg orally once a day at bedtime.
- The dose may be increased in 50 mg increments at 4 to 7 days intervals, as tolerated.
- The usual dose range: 100 to 300 mg (max dose: 300mg/day).

Note: Recommendations are that daily doses more than 100 mg be given in 2 divided doses, with the larger dose administered at bedtime.

Extended-release:
- 100 mg orally once a day at bedtime.
- The dose may be increased in 50 mg increments for atleast 7 days intervals, as tolerated.
- The usual dose range is 100 to 300 mg (max dose: 300mg/day).

Fluvoxamine Dose in the treatment of Bulimia nervosa as off-label use:

Immediate-release:
- 50 mg orally daily initially.
- Increase the dose based on response and tolerability up to 300 mg/day given in 1 or 2 divided doses.

Fluvoxamine Dose in the treatment of major depressive disorder as off-label use:

Immediate release:
- 50 mg/day orally.
- Increase the dose based on response and tolerability to the usual dosage range of 100 to 200 mg/day.
- Doses as high as 300 mg/day have been studied.

Fluvoxamine dose in the treatment of Panic disorder as off-label use:

Immediate release:
- 25 - 50 mg orally daily.
- Titrate gradually based on response and tolerability.
- The usual dosage range is 100 - 200 mg daily.

Fluvoxamine dose in the treatment of Post-traumatic stress disorder (PTSD) as off-label use:

Immediate-release:
- 75 mg twice orally daily.

Fluvoxamine Dose in the treatment of Social anxiety disorder as off-label use:

Immediate-release:
- 50 mg orally once a day.
- The dose may be increased in 50 mg increments at intervals of at least 1 week to the usual dosage range of 100 - 300 mg daily.

Extended-release:
- 100 mg orally once a day at bedtime.
- The dose may be increased in 50 mg increments at intervals of at least 1 week to the usual dosage range of 100 - 300 mg daily and to a maximum dose of 300 mg/day.

Discontinuation of therapy:
- When discontinuing antidepressant treatment, if used for more than 3 weeks, the dose is gradually decreased (eg, over a period of 2 to 4 weeks) to minimize withdrawal symptoms and detect reemerging symptoms.
- Reasons for a slowly titrating the dose (eg, over 4 weeks) include the use of a drug with a half-life of fewer than 24 hours (eg, paroxetine, venlafaxine), prior history of antidepressant withdrawal symptoms, or patients on high doses of antidepressants.
- In case intolerable withdrawal symptoms occur, take the patient on the previously prescribed dose and/or decrease dose at a more slowly.
- Select patients (eg, those with a history of discontinuation syndrome) on long-term treatment (more than 6 months) may benefit from tapering over >3 months.
MAO inhibitor recommendations:
- Switching from or to an MAO inhibitor to treat psychiatric disorders:
  - There should be 14 days gap between discontinuing an MAO inhibitor intended to treat psychiatric disorders and initiation of fluvoxamine and vice versa.

Fluvoxamine Dose in Children

Fluvoxamine Dose in the treatment of Obsessive-compulsive disorder:

Children and Adolescents 8 - 17 years:
- Immediate release:
  - 25 mg orally once daily at bedtime.
  - Adjust the dose in 25 mg increments at 7 - 14-day intervals as tolerated to the maximum therapeutic benefit.
  - The usual dosage range is 50 - 200 mg/day.
  - If the dose exceeds 50 mg/day, it should be divided into 2 doses.
  - Administer larger portion of the dose at bedtime.
  - The maximum daily dose in children is 8 - 11 years (200 mg in a day) and in adolescents is 300 mg in a day.
  - Lower doses may be effective in female versus male patients.

Note:

Slower titration of the dose every 2 to 4 weeks may minimize the risk of behavioral activation.
Behavioral activation associated with SSRI use increases the risk of suicidal behavior.
Higher mg/kg doses are needed in children compared to adolescents.
Discontinuation of therapy:
- Upon discontinuation of antidepressant therapy, gradually taper the dose to minimize the incidence of withdrawal symptoms and allow for the detection of re-emerging symptoms.
- Evidence supporting ideal taper rates is limited.
- APA and NICE guidelines suggest tapering therapy over at least several weeks with consideration to the half-life of the antidepressant.
- Antidepressants with a shorter half-life may need to be tapered more conservatively.
- In addition for long-term treated patients, WFSBP guidelines recommend tapering over 4 to 6 months.
- If intolerable withdrawal symptoms occur following a dose reduction, consider resuming the previously prescribed dose and/or decrease dose at a more gradual rate.
Use with other MAO inhibitors (IV methylene blue or linezolid):
- In patients receiving linezolid or intravenous methylene blue, consider other interventions for a psychiatric condition.
- The use of MAOs and Fluvoxamine is not recommended in patients taking the above medications.
- In cases where urgent treatment with linezolid or IV Methylene blue in patients already taking Fluvoxamine, and potential benefits outweigh potential risks, Fluvoxamine can be discontinued abruptly and administer linezolid or IV methylene blue.
- Monitoring for serotonin syndrome is required for 2 weeks or until 24 hours after the last dose of linezolid or IV methylene blue, whichever comes first.
- Fluvoxamine can be restarted 24 Hrs after the last done of linezolid or IV methylene blue.

Pregnancy Risk Factor C

Studies on animal reproduction have shown that there are adverse events.
Fluvoxamine crosses over the placenta, and is found in the amniotic liquid.
However, there are contradicting results for the teratogenic effects.
- Cyanosis
- Apnea
- Seizures
- Neonatal Respiratory distress
- Hypoglycemia and feeding difficulties
- Hypotonia or hypertonia
- Persistent crying, irritability and jitteriness
- Tremors
- Discontinuation syndrome
- The newborn may have persistent pulmonary hypertension.
Women who have stopped taking antidepressant medication during pregnancy or who are at high risk of postpartum depression can resume their medications after delivery.

Use of Luvox (fluvoxamine), during breast-feeding

Breast milk contains fluvoxamine.
Fluvoxamine can be used during pregnancy to treat any complications.

Fluvoxamine Dose in Renal Disease:

Limited data available. The manufacturer has not recommended any dose adjustment in patients with renal disease.

Fluvoxamine Dose in Liver Disease:

Limited data available. Monitor closely.

Frequency varies by dosage form and indication. Adverse reactions reported as a composite of all indications.

Common Side Effects of Luvox (fluvoxamine) Include:

Central Nervous System:
- Headache
- Insomnia
- Drowsiness
- Dizziness
- Nervousness
Gastrointestinal:
- Nausea
- Diarrhea
- Xerostomia
- Anorexia
Genitourinary:
- Ejaculatory Disorder
Neuromuscular & Skeletal:
- Weakness

Less Common Side Effects of Luvox (fluvoxamine) Include:

Cardiovascular:
- Chest Pain
- Palpitations
- Vasodilation
- Hypertension
- Edema
- Hypotension
- Syncope
Central Nervous System:
- Pain
- Anxiety
- Anorgasmia
- Yawning
- Abnormal Dreams
- Abnormality In Thinking
- Paresthesia
- Agitation
- Apathy
- Central Nervous System Stimulation
- Chills
- Depression
- Hypertonia
- Psychoneurosis
- Twitching
- Amnesia
- Manic Reaction
- Myoclonus
- Psychotic Reaction
- Malaise
Dermatologic:
- Diaphoresis
- Ecchymoses
- Acne Vulgaris
Endocrine & Metabolic:
- Decreased Libido
- Hypermenorrhea
- Weight Loss
- Weight Gain
Gastrointestinal:
- Dyspepsia
- Constipation
- Vomiting
- Abdominal Pain
- Flatulence
- Dental Caries
- Tooth Loss
- Toothache
- Dysgeusia
- Dysphagia
- Gingivitis
Genitourinary:
- Urinary Frequency
- Sexual Disorder
- Impotence
- Urinary Tract Infection
- Urinary Retention
Hepatic:
- Abnormal Hepatic Function Tests
Infection:
- Tooth Abscess
- Viral Infection
Neuromuscular & Skeletal:
- Tremor
- Myalgia
- Hyperkinesia
- Hypokinesia
Ophthalmic:
- Amblyopia
Renal:
- Polyuria
Respiratory:
- Upper Respiratory Tract Infection
- Pharyngitis
- Flu-Like Symptoms
- Laryngitis
- Bronchitis
- Dyspnea
- Epistaxis
- Increased Cough
- Sinusitis

Contraindications to Fluvoxamine (Luvox):

Concurrent use

Pimozide or thioridazine;
MAO inhibitors
Fluvoxamine is initiated in patients who have received intravenous methyleneblue or linezolid.

Warnings and Precautions

Suicidal Behaviors (US Boxed Warnings).
- Fluvoxamine is associated with a higher risk of suicide in children, adolescents and young adults with major depression (18-24 years old).
- Patients should be closely monitored for any changes in behavior or clinical worsening. It is not recommended for children under 12 years old.
Fluvoxamine prevents platelet aggregation.
- Patients with bleeding disorders, serious patients and those on anticoagulants and aspirin should not use it.
QT interval effect:
- Fluvoxamine has been shown to prolong QT in dose-dependent fashion.
- The drug should not be prescribed to patients with heart disease or those suffering from deranged electrolytes such as hypokalemia or hypomagnesemia.
Higher mental functions are affected:
- It can cause impairment of higher mental functions.
- Fluvoxamine should be avoided by drivers and operators of heavy machinery.
Bone fractures
- This increases the risk of getting broken bones.
Eye Effects
- As a result pupillary dilation, fluvoxamine can cause narrow-angle glaucoma.
Serotonin syndrome
- Serotonin syndrome, which is a potentially fatal condition that can be caused by SSRIs, is a serious condition. Patients who show the following symptoms should be concerned:
  - Mental status changes (hallucinations and agitations, delirium, or coma)
  - autonomic instability: sweating, resting bradycardia/ tachycardia and changes in blood pressure
  - Neurological features (rigidity and tremor, seizures and myoclonus).
  - Gastrointestinal symptoms such as nausea, diarrhea, and vomiting can include:
Sexual dysfunction
- It can lead to or exacerbate sexual dysfunction.
Hyponatremia
- Hyponatremia may lead to reversible SIADH. Seizures may result from sodium levels below 120 mEq/l
Bipolar disorder
- Bipolar disorder patients should not be treated with fluvoxamine. Patients with hypomania and mania should avoid fluvoxamine.
Discontinuation syndrome
- After abrupt withdrawal of long-term Luvox, patients may experience a discontinuation syndrome.
- The symptoms of discontinuation syndrome include nausea, vomiting and diarrhea, headaches, nausea, dizziness, headaches, anorexia, tremors.
- Other symptoms include: imbalance, electric shock-like sensations; myalgias; arrhythmias; myalgias; irritability and aggressive behavior; mood instability; confusion; difficulty in concentration.

Fluvoxamine: Drug Interaction

Risk Factor C (Monitor therapy)
Agents with Antiplatelet Properties (e.g., P2Y12 inhibitors, NSAIDs, SSRIs, etc.)	May enhance the antiplatelet effect of other Agents with Antiplatelet Properties.
Ajmaline	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
ALPRAZolam	FluvoxaMINE may increase the serum concentration of ALPRAZolam.
Anticoagulants	Agents with Antiplatelet Properties may enhance the anticoagulant effect of Anticoagulants.
Antiemetics (5HT3 Antagonists)	May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome.
Antipsychotic Agents	Serotonin Modulators may enhance the adverse/toxic effect of Antipsychotic Agents. Specifically, serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotic Agents may enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome.
Apixaban	Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Apixaban. Specifically, the risk for bleeding may be increased. Management: Carefully consider risks and benefits of this combination and monitor closely.
ARIPiprazole	CYP3A4 Inhibitors (Weak) may increase the serum concentration of ARIPiprazole. Management: Monitor for increased aripiprazole pharmacologic effects. Aripiprazole dose adjustments may or may not be required based on concomitant therapy and/or indication. Consult full interaction monograph for specific recommendations.
Asenapine	FluvoxaMINE may increase the serum concentration of Asenapine.
Aspirin	Selective Serotonin Reuptake Inhibitors may enhance the antiplatelet effect of Aspirin.
Bendamustine	CYP1A2 Inhibitors (Strong) may increase the serum concentration of Bendamustine. Concentrations of the active metabolites of bendamustine may be decreased.
Blood Glucose Lowering Agents	Selective Serotonin Reuptake Inhibitors may enhance the hypoglycemic effect of Blood Glucose Lowering Agents.
Brexanolone	Selective Serotonin Reuptake Inhibitors may enhance the CNS depressant effect of Brexanolone.
Broccoli:	May decrease the serum concentration of CYP1A2 Substrates (High risk with Inducers).
	May enhance the adverse/toxic effect of FluvoxaMINE. Specifically, the risk for seizures and serotonin syndrome may be increased.
BuPROPion	CYP2C19 Inhibitors (Moderate) may increase the serum concentration of Cannabidiol.
Cannabidiol	May decrease the serum concentration of CYP1A2 Substrates (High risk with Inducers).
Cannabis	FluvoxaMINE may increase the serum concentration of CarBAMazepine.
CarBAMazepine	Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Cephalothin. Specifically, the risk for bleeding may be increased.
Cephalothin	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
CloBAZam	FluvoxaMINE may enhance the adverse/toxic effect of Clopidogrel. Specifically, the risk for bleeding may be increased. FluvoxaMINE may decrease serum concentrations of the active metabolite(s) of Clopidogrel.
Clopidogrel	May enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Specifically, the risk of psychomotor impairment may be enhanced.
CNS Depressants	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Cobicistat	Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Collagenase (Systemic). Specifically, the risk of injection site bruising and/or bleeding may be increased.
Collagenase (Systemic)	May decrease the serum concentration of CYP1A2 Substrates (High risk with Inducers).
CYP1A2 Inducers (Moderate)	May decrease the metabolism of CYP1A2 Substrates (High risk with Inhibitors).
CYP1A2 Inhibitors (Moderate)	CYP2C19 Inhibitors (Moderate) may decrease the metabolism of CYP2C19 Substrates (High risk with Inhibitors).
CYP2C19 Substrates (High risk with Inhibitors)	May decrease the metabolism of CYP2D6 Substrates (High risk with Inhibitors).
CYP2D6 Inhibitors (Moderate)	May diminish the therapeutic effect of Selective Serotonin Reuptake Inhibitors.
Cyproheptadine	May decrease the serum concentration of CYP1A2 Substrates (High risk with Inducers).
Cyproterone	Agents with Antiplatelet Properties may enhance the anticoagulant effect of Dabigatran Etexilate. Agents with Antiplatelet Properties may increase the serum concentration of Dabigatran Etexilate. This mechanism applies specifically to clopidogrel. Management: Carefully consider risks and benefits of this combination and monitor closely; Canadian labeling recommends avoiding prasugrel or ticagrelor.
Dabigatran Etexilate	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Darunavir	May enhance the anticoagulant effect of Agents with Antiplatelet Properties. Management: Drugs listed as exceptions to this monograph are discussed in further detail in separate drug interaction monographs.
Dasatinib	May increase the serum concentration of CYP1A2 Substrates (High risk with Inhibitors).
Deferasirox	Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Deoxycholic Acid. Specifically, the risk for bleeding or bruising in the treatment area may be increased.
Deoxycholic Acid	Selective Serotonin Reuptake Inhibitors may enhance the adverse/toxic effect of Desmopressin.
Desmopressin	CYP3A4 Inhibitors (Weak) may increase the serum concentration of Dofetilide.
Dofetilide	Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Edoxaban. Specifically, the risk of bleeding may be increased.
Edoxaban	May enhance the adverse/toxic effect of Agents with Antiplatelet Properties.
Fat Emulsion (Fish Oil Based)	CYP3A4 Inhibitors (Weak) may increase the serum concentration of Flibanserin.
Flibanserin	CYP2C19 Inhibitors (Moderate) may increase the serum concentration of Flibanserin.
Flibanserin	FluvoxaMINE may increase the serum concentration of Fosphenytoin.
Fosphenytoin	May enhance the antiplatelet effect of Agents with Antiplatelet Properties.
Glucosamine	May increase the serum concentration of FluvoxaMINE.
Grapefruit Juice	FluvoxaMINE may increase the serum concentration of Haloperidol. Management: Monitor for increased haloperidol concentrations/effects when patients are receiving fluvoxamine, particularly when fluvoxamine dose is 150 mg/day or greater.
Haloperidol	Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Ibritumomab Tiuxetan. Both agents may contribute to impaired platelet function and an increased risk of bleeding.
Ibritumomab Tiuxetan	May enhance the adverse/toxic effect of Agents with Antiplatelet Properties.
Ibrutinib	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Imatinib	May enhance the antiplatelet effect of Agents with Antiplatelet Properties.
Inotersen	Selective Serotonin Reuptake Inhibitors may diminish the diagnostic effect of Ioflupane I 123.
Ioflupane I 123	May enhance the serotonergic effect of FluvoxaMINE. This could result in serotonin syndrome. FluvoxaMINE may increase the serum concentration of Levomethadone.
Levomethadone	May enhance the antiplatelet effect of Agents with Antiplatelet Properties.
Limaprost	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Lumefantrine	May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome.
Metaxalone	May enhance the serotonergic effect of FluvoxaMINE. This could result in serotonin syndrome. FluvoxaMINE may increase the serum concentration of Methadone.
Methadone	May enhance the adverse/toxic effect of Serotonin Modulators. Specifically, the risk of serotonin syndrome or serotonin toxicity may be increased.
Methylphenidate	May enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors.
MetyroSINE	FluvoxaMINE may increase the serum concentration of Mexiletine.
Mexiletine	May enhance the antiplatelet effect of Agents with Antiplatelet Properties.
Multivitamins/Fluoride (with ADE)	May enhance the antiplatelet effect of Agents with Antiplatelet Properties.
Multivitamins/Minerals (with ADEK, Folate, Iron)	May enhance the antiplatelet effect of Agents with Antiplatelet Properties.
Multivitamins/Minerals (with AE, No Iron)	Selective Serotonin Reuptake Inhibitors may enhance the antiplatelet effect of Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective). Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective) may diminish the therapeutic effect of Selective Serotonin Reuptake Inhibitors.
Nonsteroidal Anti-Inflammatory Agents (COX-2 Selective)	May increase the serum concentration of CYP1A2 Substrates (High risk with Inhibitors).
NiMODipine	CYP3A4 Inhibitors (Weak) may increase the serum concentration of NiMODipine.
Obeticholic Acid	Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Obinutuzumab. Specifically, the risk of serious bleeding-related events may be increased.
Obinutuzumab	FluvoxaMINE may increase the serum concentration of OLANZapine.
OLANZapine	May enhance the antiplatelet effect of Agents with Antiplatelet Properties.
Omega-3 Fatty Acids	May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome.
Opioid Agonists	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Panobinostat	May decrease the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Peginterferon Alfa-2b may increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Peginterferon Alfa-2b	May increase the serum concentration of CYP1A2 Substrates (High risk with Inhibitors).
Peginterferon Alfa-2b	May enhance the adverse/toxic effect of Agents with Antiplatelet Properties. Specifically, the risk of bleeding may be increased by concurrent use of these agents.
Pentosan Polysulfate Sodium	May enhance the antiplatelet effect of Agents with Antiplatelet Properties.
Pentoxifylline	CYP1A2 Inhibitors (Strong) may increase the serum concentration of Pentoxifylline.
Pentoxifylline	CYP2D6 Substrates (High risk with Inhibitors) may increase the serum concentration of Perhexiline. Perhexiline may increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Perhexiline	FluvoxaMINE may increase the serum concentration of Phenytoin.
Phenytoin	FluvoxaMINE may increase the serum concentration of Propafenone.
Propafenone	Prostacyclin Analogues: May enhance the antiplatelet effect of Agents with Antiplatelet Properties.
QuiNIDine	FluvoxaMINE may increase the serum concentration of QuiNIDine. QuiNIDine may increase the serum concentration of FluvoxaMINE.
QuiNINE	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Ramosetron	FluvoxaMINE may increase the serum concentration of Ramosetron.
Rivaroxaban	Agents with Antiplatelet Properties may enhance the anticoagulant effect of Rivaroxaban. Management: Carefully consider risks and benefits of this combination and monitor closely; Canadian labeling recommends avoiding prasugrel or ticagrelor.
Roflumilast	FluvoxaMINE may increase serum concentrations of the active metabolite(s) of Roflumilast. FluvoxaMINE may increase the serum concentration of Roflumilast.
Ropivacaine	FluvoxaMINE may increase the serum concentration of Ropivacaine.
Salicylates	Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Salicylates. Increased risk of bleeding may result.
Serotonin Modulators	May enhance the adverse/toxic effect of other Serotonin Modulators. The development of serotonin syndrome may occur. Exceptions: Nicergoline; Tedizolid.
Tedizolid	May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome.
Teriflunomide	May decrease the serum concentration of CYP1A2 Substrates (High risk with Inducers).
Thiazide and Thiazide-Like Diuretics	Selective Serotonin Reuptake Inhibitors may enhance the hyponatremic effect of Thiazide and Thiazide-Like Diuretics.
Thrombolytic Agents	Agents with Antiplatelet Properties may enhance the anticoagulant effect of Thrombolytic Agents.
Thyroid Products	Selective Serotonin Reuptake Inhibitors may diminish the therapeutic effect of Thyroid Products. Thyroid product dose requirements may be increased.
Tobacco (Smoked)	May decrease the serum concentration of FluvoxaMINE.
TraMADol	Serotonin Modulators may enhance the adverse/toxic effect of TraMADol. The risk of seizures may be increased. TraMADol may enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome.
Vitamin E (Systemic)	May enhance the antiplatelet effect of Agents with Antiplatelet Properties.
Vitamin K Antagonists (eg, warfarin)	Selective Serotonin Reuptake Inhibitors may enhance the anticoagulant effect of Vitamin K Antagonists.
Zolpidem	FluvoxaMINE may enhance the CNS depressant effect of Zolpidem. FluvoxaMINE may increase the serum concentration of Zolpidem.
Risk Factor D (Consider therapy modification)
Abiraterone Acetate	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Management: Avoid concurrent use of abiraterone with CYP2D6 substrates that have a narrow therapeutic index whenever possible. When concurrent use is not avoidable, monitor patients closely for signs/symptoms of toxicity.
Alcohol (Ethyl)	May enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Specifically, the risk of psychomotor impairment may be enhanced. Management: Patients receiving selective serotonin reuptake inhibitors should be advised to avoid alcohol. Monitor for increased psychomotor impairment in patients who consume alcohol during treatment with selective serotonin reuptake inhibitors.
Asunaprevir	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors).
Bromazepam	FluvoxaMINE may increase the serum concentration of Bromazepam. Management: With concomitant fluvoxamine, consider use of a benzodiazepine that does not undergo oxidative metabolism (e.g., lorazepam). If bromazepam is initiated in patients receiving fluvoxamine, monitor closely for increased bromazepam levels/adverse effects.
BusPIRone	May enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This may cause serotonin syndrome. Selective Serotonin Reuptake Inhibitors may decrease the metabolism of BusPIRone. Management: The combination of a selective serotonin reuptake inhibitor and buspirone should be undertaken with great caution. When combined treatment is clinically indicated, monitor closely for signs of serotonin toxicity/serotonin syndrome.
Cilostazol	CYP2C19 Inhibitors may increase the serum concentration of Cilostazol. Management: Consider reducing the cilostazol dose to 50 mg twice daily in patients who are also receiving inhibitors of CYP2C19.
Citalopram	CYP2C19 Inhibitors (Moderate) may increase the serum concentration of Citalopram. Management: Limit citalopram dose to a maximum of 20 mg/day if used with a moderate CYP2C19 inhibitor. Patients using this combination should be monitored closely for evidence of citalopram toxicity (e.g., serotonin syndrome, QT prolongation, etc.).
CloZAPine	CYP1A2 Inhibitors (Strong) may increase the serum concentration of CloZAPine. Management: Reduce the dose of clozapine to one-third of the original dose when adding a strong CYP1A2 inhibitor, and monitor patient response closely. Return to the original clozapine dose when the strong CYP1A2 inhibitor is removed.
CYP1A2 Substrates (High risk with Inhibitors)	CYP1A2 Inhibitors (Strong) may decrease the metabolism of CYP1A2 Substrates (High risk with Inhibitors).
CYP2D6 Inhibitors (Strong)	May decrease the metabolism of CYP2D6 Substrates (High risk with Inhibitors).
Dacomitinib	May increase the serum concentration of CYP2D6 Substrates (High risk with Inhibitors). Management: Avoid concurrent use of dacomitinib with CYP2D6 subtrates that have a narrow therapeutic index.
Erlotinib	FluvoxaMINE may increase the serum concentration of Erlotinib. Management: Avoid use of this combination when possible. When the combination must be used, monitor the patient closely for the development of severe adverse reactions, and if such severe reactions occur, reduce the erlotinib dose (in 50 mg decrements).
Etizolam	FluvoxaMINE may increase the serum concentration of Etizolam. Management: Use lower etizolam doses when using this combination.
Gilteritinib	May diminish the therapeutic effect of Selective Serotonin Reuptake Inhibitors. Management: Avoid use of this combination if possible. If the combination cannot be avoided, monitor closely for evidence of reduced response to the selective serotonin reuptake inhibitor.
Herbs (Anticoagulant/Antiplatelet Properties) (eg, Alfalfa, Anise, Bilberry)	May enhance the adverse/toxic effect of Agents with Antiplatelet Properties. Bleeding may occur. Management: Avoid combination when possible. If used, monitor more closely for evidence of bleeding. Discontinue herbal products with anticoagulant or antiplatelet actions 2 weeks prior to surgical, dental, or invasive procedures.
Linezolid	May enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This could result in serotonin syndrome. Management: Consider alternatives to this combination whenever possible. If clinically acceptable, wait at least 2 weeks (5 weeks for fluoxetine) after SSRI discontinuation to initiate linezolid.
Linezolid	May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Management: Due to a risk of serotonin syndrome/serotonin toxicity, discontinue serotonin modulators 2 weeks prior to the administration of linezolid. If urgent initiation of linezolid is needed, discontinue serotonin modulators immediately and monitor closely.
Lithium	May enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This could increase the risk of serotonin toxicity/serotonin syndrome. Management: This combination should be undertaken with great caution. When combined treatment is clinically indicated, monitor closely for signs of serotonin toxicity/serotonin syndrome.
Lomitapide	CYP3A4 Inhibitors (Weak) may increase the serum concentration of Lomitapide. Management: Patients on lomitapide 5 mg/day may continue that dose. Patients taking lomitapide 10 mg/day or more should decrease the lomitapide dose by half. The lomitapide dose may then be titrated up to a max adult dose of 30 mg/day.
Melatonin	FluvoxaMINE may increase the serum concentration of Melatonin. Management: Consider the use of alternative agents in order to avoid this combination. If combined, monitor for increased melatonin effects (eg, sedation, somnolence) if combined with fluvoxamine.
Metoclopramide	May enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors. Management: Seek alternatives to this combination when possible. Monitor patients receiving metoclopramide with selective serotonin reuptake inhibitors for signs of extrapyramidal symptoms, neuroleptic malignant syndrome, and serotonin syndrome.
Mirtazapine	May enhance the serotonergic effect of FluvoxaMINE. This could result in serotonin syndrome. FluvoxaMINE may increase the serum concentration of Mirtazapine. Management: Consider alternatives to this combination when possible. If combined, monitor for increased mirtazapine effects/toxicities and for signs and symptoms of serotonin syndrome.
Neratinib	FluvoxaMINE may increase the serum concentration of Neratinib. Management: Avoid concomitant use of neratinib and fluvoxamine if possible. If combined, monitor for increased neratinib effects/toxicities.
Nonsteroidal Anti-Inflammatory Agents (Nonselective)	Selective Serotonin Reuptake Inhibitors may enhance the antiplatelet effect of Nonsteroidal Anti-Inflammatory Agents (Nonselective). Nonsteroidal Anti-Inflammatory Agents (Nonselective) may diminish the therapeutic effect of Selective Serotonin Reuptake Inhibitors. Management: Consider using alternative analgesics, when appropriate, and/or addition of a gastroprotective agent. Monitor patients closely for signs/symptoms of bleeding, and for evidence of diminished SSRI effectiveness with concurrent use.
Pirfenidone	CYP1A2 Inhibitors (Strong) may increase the serum concentration of Pirfenidone. Management: See full monograph for specific recommendations. Canadian product labeling specifically lists the use of pirfenidone with fluvoxamine as contraindicated.
Pomalidomide	CYP1A2 Inhibitors (Strong) may increase the serum concentration of Pomalidomide. Management: Avoid when possible. If coadministration is necessary, reduce the pomalidomide dose 50% and monitor for increased pomalidomide effects/toxicities.
Propranolol	FluvoxaMINE may increase the serum concentration of Propranolol. Management: Use a lower initial propranolol dose and be cautious with propranolol dose titration.
Serotonin Reuptake Inhibitor/Antagonists	Selective Serotonin Reuptake Inhibitors may enhance the serotonergic effect of Serotonin Reuptake Inhibitor/Antagonists. This may cause serotonin syndrome. Management: Consider alternatives, and use conservative initial dosing. Monitor patients receiving these combinations for signs/symptoms of serotonin toxicity.
Theophylline Derivatives	FluvoxaMINE may decrease the metabolism of Theophylline Derivatives. Exceptions: Dyphylline.
Tricyclic Antidepressants	FluvoxaMINE may enhance the adverse/toxic effect of Tricyclic Antidepressants. FluvoxaMINE may increase the serum concentration of Tricyclic Antidepressants. Management: Consider alternatives to this combination when possible. Monitor for adverse effects of tricyclic antidepressants (TCAs), including serotonin syndrome and QTinterval prolongation, when a TCA is being used in combination with fluvoxamine.
Vemurafenib	May increase the serum concentration of CYP1A2 Substrates (High risk with Inhibitors). Management: Consider alternatives to such combinations whenever possible, particularly if the CYP1A2 substrate has a relatively narrow therapeutic index. Drugs listed as exceptions to this monograph are discussed in separate drug interaction monographs.
Risk Factor X (Avoid combination)
Agomelatine	CYP1A2 Inhibitors (Strong) may increase the serum concentration of Agomelatine.
Alosetron	FluvoxaMINE may decrease the metabolism of Alosetron.
Bromopride	May enhance the adverse/toxic effect of Selective Serotonin Reuptake Inhibitors.
Dapoxetine	May enhance the adverse/toxic effect of Serotonin Modulators.
Dosulepin	Selective Serotonin Reuptake Inhibitors may increase the serum concentration of Dosulepin.
DULoxetine	CYP1A2 Inhibitors (Strong) may increase the serum concentration of DULoxetine.
Methylene Blue	Selective Serotonin Reuptake Inhibitors may enhance the serotonergic effect of Methylene Blue. This could result in serotonin syndrome.
Methylene Blue	May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome.
Monoamine Oxidase Inhibitors	May enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This may cause serotonin syndrome. While methylene blue and linezolid are expected to interact via this mechanism, management recommendations differ from other monoamine oxidase inhibitors. Refer to monographs specific to those agents for details. Exceptions: Linezolid; Methylene Blue; Tedizolid.
Pimozide	Selective Serotonin Reuptake Inhibitors may enhance the adverse/toxic effect of Pimozide. Management: Drugs listed as exceptions to this monograph are discussed in further detail in separate drug interaction monographs.
Pimozide	CYP3A4 Inhibitors (Weak) may increase the serum concentration of Pimozide.
Ramelteon	FluvoxaMINE may increase the serum concentration of Ramelteon.
Tasimelteon	CYP1A2 Inhibitors (Strong) may increase the serum concentration of Tasimelteon.
Thioridazine	FluvoxaMINE may increase the serum concentration of Thioridazine.
TiZANidine	CYP1A2 Inhibitors (Strong) may increase the serum concentration of TiZANidine.
Tryptophan	May enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This may cause serotonin syndrome.
Urokinase	Agents with Antiplatelet Properties may enhance the anticoagulant effect of Urokinase.

Monitoring Parameters:

Assess your mental health
Suicide ideation, especially at the beginning of therapy and when dosages are increased/ decreased
Anxiety
Social functioning
Mania
Panic attacks and other unusual behavior changes
Signs & symptoms of serotonin Syndrome
Akathisia
BMI and weight
Hepatic function (baseline, and as clinically indicated).

How to take Luvox (fluvoxamine)?

Administer fluvoxamine in the morning or evening with or without food.

Mechanism of action of Luvox (Fluvoxamine):

Luvox (fluvoxamine), selectively inhibits serotonin reuptake It does not affect the dopamine or Norepinephrine receptors.
It has a very limited effect on beta-adrenergic receptors, D 1-5 to 5, H 1-3 to 4, M 1-5 and 5HT 1-7.
Fluvoxamine doesn't bind to sodium, potassium, chloride, or calcium ion channel channels.

The Beginning of ActionIt takes approximately one week for the effect to take place. You may see the maximum response in between 8 and 12 weeks. Protein bindingApproximately 80% of the protein is bound to proteins, most notably to albumin.

Metabolism: Hepatic. Immediate Release: 53%bioavailableExtended-release is 74%bioavailable Eliminating half-lifeApproximately 14-16 hours; Around 17-26 hours for the elderly When plasma concentration reaches its peak is3-8 hours

Excretion is85% via urine

International Brands of Fluvoxamine:

ACT Fluvoxamine
APO-Fluvoxamine
DOM-Fluvoxamine
Luvox
NOVO-Fluvoxamine
PHL-Fluvoxamine
PMS-Fluvoxamine
RATIO-Fluvoxamine
RIVA-Fluvox
SANDOZ Fluvoxamine
Anwu
Avoxin
Depromel
Dumirox
Dumyrox
Ervosal
Faverin
Favoxil
Fevalax
Fevarin
Fluvohexal
Fluvoxim
Fluvoxin
Fluxamine
Lote
Luvox
Movox
Relafin
Voxam
Voxamin
Voxamine
Vuminix

Fluvoxamine brands in Pakistan:

Fluvoxamine (Maleate) [Tabs 25 Mg]
Mild	Xenon Pharmaceuticals (Pvt) Ltd.

Fluvoxamine (Maleate) [Tabs 50 Mg]
B-Vert	Focous & Rulz Pharmaceuticals
Faverin	Abbott Laboratories (Pakistan) Limited.
Flomin	Global Pharmaceuticals
Meduxa	Mediate Pharmaceuticals (Pvt) Ltd
Voxamine	Pharmevo (Pvt) Ltd.

Fluvoxamine (Maleate) [Tabs 75 Mg]
Mild	Xenon Pharmaceuticals (Pvt) Ltd.

Fluvoxamine (Maleate) [Tabs 100 Mg]
B-Vert	Focous & Rulz Pharmaceuticals
Faverin	Abbott Laboratories (Pakistan) Limited.
Flomin	Global Pharmaceuticals
Hexal	Everest Pharmaceuticals
Meduxa	Mediate Pharmaceuticals (Pvt) Ltd
Voxamine	Pharmevo (Pvt) Ltd.