FLUVOXAMINE

 Fluvoxamine, Proxalutamide, and Ivermectin: 100% success

Mar 14, 20211 min read

I'm very bullish on two drug combos since it is rare for a single drug to be 100% successful.

For example all of these combos should have near 100% success against hospitalization, death, and long-haul COVID symptoms:

1.     Proxalutamide and fluvoxamine

2.     Proxalutamide and ivermectin

3.     Fluvoxamine and ivermectin

Proxalutamide on its own has had 100% success in both inpatients and outpatients (100% for men, 90% for women).

Fluvoxamine has been 100% successful in two randomized trials. That 100% success rate was replicated in the real-world prescribing experience of Syed Haider who has been prescribing IVM+FLV for over 100 patients now. So 100% three times in a row, all by independent researchers.

Ivermectin alone has also had its share of 100% successes, e.g., in Argentina in the Carvallo study. There was a recent study in JAMA claiming ivermectin doesn't work, but see https://osf.io/u7ewz/ and https://www.youtube.com/watch?v=VwqCuqCE4aU.

 

Steve Kirsch

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New report describes positive results

of generic drug in treating COVID

Medical journal publishes details on fluvoxamine

 

Berkeley, CA (Feb. 1, 2021) – The Covid Early Treatment Fund (CETF) www.treatearly.org announced today that the medical journal Open Forum Infectious Diseases published a report that outlines the success in using a generic drug – fluvoxamine – to prevent complications of COVID-19. 

“This real-world evidence study provides additional independent confirmation that fluvoxamine is highly effective in preventing hospitalization and death from COVID,’’ said Steve Kirsch, a Silicon Valley high-tech entrepreneur and the founder of CETF, a charitable organization that funds outpatient trials of existing drugs. “Repurposed drugs always have had the potential to be the fastest and least expensive way out of this pandemic. Fluvoxamine was again shown to be 100% effective in preventing hospitalization and death, and we are urging the medical community to consider these confirmatory results.”

 

The report by Dr. David Seftel, CEO of Enable Biosciences and a reviewer for the National Institutes of Health, and Dr. David Boulware, a professor and infectious disease physician-scientist at the University of Minnesota’s School of Medicine,  discusses the real-world experience of using fluvoxamine to treat workers after a COVID-19 outbreak in November and December at Golden Gate Fields, a Berkeley, Ca., horse-racing track. 

Dr. Seftel, the track physician, offered fluvoxamine to infected employees after learning about the 100% success rate in avoiding hospitalization in a Phase 2 randomized controlled trial published on November 12, 2020, in the Journal of the American Medical Association.  None of the 77 employees at Golden Gate Fields who opted to take fluvoxamine required hospitalization, compared with a 12.5% hospitalization rate for the 48 employees who declined the drug.  In addition, after 2 weeks, none of the treatment group had any COVID symptoms while 60% of the group who declined the drug had 1 or more COVID symptoms.

“This is one of the most extraordinary therapeutic effects I’ve witnessed in my 25 years of practicing medicine,’’ said Dr. Seftel. “There is no doubt in my mind that fluvoxamine significantly helped the workers at Golden Gates Fields battle this virus. In every case, respiratory decline reversed within about three days after starting the drug.”

The paper states: “Overall, fluvoxamine appears promising as early treatment for COVID-19 to prevent clinical deterioration requiring hospitalization and to prevent possible long-haul symptoms persisting beyond 2 weeks.’’

Dr. Boulware previously led the randomized clinical trial that disproved hydroxychloroquine is an effective treatment for COVID-19.

The Golden Gate Fields experience with fluvoxamine confirmed earlier findings from a 152-patient randomized clinical trial at the Washington University School of Medicine in St. Louis. In that outpatient trial, Dr. Eric Lenze and colleagues found that fluvoxamine was 100% effective in preventing respiratory deterioration that normally would require hospitalization compared with an 8.3% hospitalization rate in the placebo group.

Fluvoxamine, an antidepressant, is in the class of selective serotonin reuptake inhibitors, which work by increasing levels of serotonin within the brain. Lenze said the benefits of taking fluvoxamine appear to greatly outweigh any risks.

“A good way of thinking about SSRI risk is like if you took an aspirin a day for two  weeks,’’ he said. “It is benign, but if you happened to get in a car accident or have a bad fall in those two weeks, you'd be more prone to bleed. But if SSRIs help against COVID, their benefits far outweigh any risks.  No medication is 100% safe, but these are pretty close.’’

 

CETF is funding a Phase 3 clinical trial to examine the efficacy of using fluvoxamine for the early treatment of COVID. The trial began in December and is seeking volunteers. Enrollment is free, and you can participate from the comfort of your home. For more information on how to enroll, go to stopcovidtrial.wustl.edu

To learn more about CETF's mission or to donate to expedite the fight against COVID-19, visit www.treatearly.org

 

MEDIA CONTACTS:

David Satterfield

G.F.BUNTING+CO

david@gfbunting.com

 

Russ Stanton

G.F.BUNTING+CO

russ@gfbunting.com

 

Executive Summary

The two clinical trials, one randomized, the other pseudo-randomized

The Lenze fluvoxamine RCT that was published in JAMA that showed a 100% success rate in preventing hospitalization was confirmed a week later at the massive 300 person outbreak at Golden Gate fields.

Dr. David Seftel read about the Lenze trial, and applied the result to a large COVID outbreak at Golden Gate Fields just 3 days after the Lenze trial was published in JAMA. Seftel was able to duplicate the 100% protection from hospitalization and death in the treatment group, vs. a 12.5% hospitalization/death rate for the No treatment group. There were 113 patients in the initial OFID paper submission, but 12 more were added later, N=125.  Latest draft submitted to OFID.

Phase 3 trial

There is a Phase 3 trial of 880 patients that is enrolling now: stopcovidtrial.com.

Effect size

For both trials, the average effect size was 100%. Because Seftel’s study was pseudo-randomized but with the randomization giving the treatment arm arguably higher risk patients, the combined p-value is estimated at .0001.

Fisher exact test on the combined data suggests that there is a 95% chance that the effect size is at least a 72% reduction in hospitalization rate. 

Independently, infectious disease doctors who are familiar with the evidence have speculated that the true effect size (protection from hospitalization vs. placebo) is 75% or more.

Dosing

The Lenze trial used 50mg day 1, then 100mg BID, and increased the dose to 100mg TID as tolerated.

Seftel used a 50mg BID dosing for 14 days. No side effects were reported at that dose for his patients, although some patients will experience mild nausea at that dose. Most people reversed symptoms within 1-3 days of getting the drug in his study. Generally, the greater the symptoms, the longer it took to reverse.

50mg QD dosing was used in one case with mild symptoms, symptoms reversed in just 24 hours and continued to improve. 

Observational studies

There are five independent observational studies (2 in France, 1 in Germany, 2 in the US (TriNetX and Stanford)) all showing statistically significant effect of the SSRI and the differential effect of the sigma1 agonist property of fluvoxamine.

Mechanisms of action

There are at least seven Mechanisms of action. From the French observational data (see the very last page), it appears that the biggest effect is limiting serotonin release (any SSRI will do that). This alone will give a 50% effect size and explains why all of the the SSRIs are effective including those that do not activate the Sigma1 receptor (e.g., Paroxetine).  The next major effect is that fluvoxamine activates the sigma-1 receptor. S1R can essentially turn off IRE1, so IRE1 will not activate XBP1, so that the cytokine production will decrease.  This gives another 50% of benefit (note that the US study in the observational section shows only a 30% additional benefit). 

The virus activates platelets which release serotonin which justifies using SSRIs to vacuum up the serotonin before it can cause havoc. See the directory on serotonin.

Real-world result reporting

There is a fluvoxamine results reporting form where any doctor from anywhere in the world can report their results with fluvoxamine. You can return later and update your statistics. This creates a central world-wide repository of outcomes. But few people know about it so there isn’t any data yet. We know of less than a dozen physicians prescribing fluvoxamine, all without a failure to reverse symptoms, but most haven’t used the form.

Restricted access directory

There is a restricted access directory containing the KOL presentation and Mechanisms of action. Please contact stk@treatearly.org for access. These files have unpublished data or data in which public view rights have not been secured.

 

Anecdotal evidence :

https://docs.google.com/presentation/d/1EjSG3bnUq3c9vAeiXx50F5WvxeIUrQoiZN66HMyTWXM/edit#slide=id.gaeebd14cc9_0_79

Steve Kirsch

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High tech serial entrepreneur and medical philanthropist.

 LOS ALTOS HILLS, CA

 

Fluvoxamine dosing guidelines

 

Summary

We don’t know the right dose. Presumably, the protective effect is proportional to the drug and the amount needed will vary individual by individual and based on disease severity and when you are able to start to give the drug.

 

Because we don’t know, from a patient safety perspective, it makes sense to give the highest dose that the patient can tolerate. Because of the short half life, you can always back off the dose.

 

If there are any signs of serotonin syndrome (higher respiratory rate, fatigue, bad diarrhea), then add in the cyproheptadine immediately to the mix.

 

Farid Jalali <f.jalali@me.com> writes:

There are obviously variable degrees of SERT inhibition by different SSRIs, and people also have variable polymorphisms in regards to 5HT transporter, as we very well do know. So the answer is “we don’t know” who responds and by how much given the polymorphisms in receptors and transporters of 5HT in different people. This is probably why someone with severe COVID19 for 3 weeks comes out of ICU unscathed from a pulmonary fibrosis standpoint, and similarly treated patient never reaching ventilator status will end up having severe pulmonary fibrosis after recovery. Serotonin is a highly implicated molecule in pulmonary hypertension and pulmonary fibrosis. It won’t be the only molecule involved, but it’s a very well known driver of pulmonary hypertension and fibrosis.

See this on the polymorphism: https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.158.12.2074

Read this study carefully please (in this landmark study resembling COVID19 IMO the most, Fluoxetine was used for 3 weeks to deplete platelet 5HT - page E1552) https://www.pnas.org/content/pnas/115/7/E1550.full.pdf

Read this on fibrosis and 5HT:
https://pubmed.ncbi.nlm.nih.gov/18321937/
https://www.hindawi.com/journals/mi/2018/7967868/ 

It’s very hard to answer what the dosage should be. But the side effects may pile up at higher dosages with SSRIs (very common) and may limit usage in real-world cases.

50mg BID dosing used by Seftel

David Seftel used 100mg BID for 1 day loading dose, then 50mg BID for his first 35 patients.

 

This led to a significant number of people who complained about nausea. Because Dr. Seftel wanted to ensure compliance, he backed off the loading dose. For all but the first 35 patients, he has used: 

50 mg BID for 14 days

 

This has worked 100% of the time in all 42 patients he used it for including 8 crossover patients from the No Treatment group. In his patients, there were no reported side effects at that dose in the patients treated by Dr. Seftel, but we do know of one individual who complained of mild nausea at that dose for the entire time she was on treatment.

 

Because the drug gets to half of the steady state value in 3 days, the fact that Dr. Seftel uniformly saw patients resolve symptoms in 3 days suggests that an effective steady state dose for COVID could be as low as 50mg QD (and a 50mg BID loading dose for the first day), which is just 1/6 of the dose used for OCD. An even lower dose may be effective. However, this is based on anecdotal data and needs to be proven in larger numbers. But this does suggest that for patients who are leery of using an OCD drug and would refuse even a 50 mg BID, might accept a 50mg QD dosing schedule.

 

50mg QD dosing

I know of one patient, who was diagnosed shortly after getting COVID and had relatively mild symptoms who tried the 50mg QD dose and her symptoms resolved 80% after 24 hours and disappeared after 48 hours. This is a very promising result that deserves further study

 

50mg QD, then 100mg BID dosing used in WashU

In the fluvoxamine RCT, the dosing was based on the FDA dose approved for OCD.

In this study, people started fluvoxamine at 50mg on the first night, then increased to 100mg twice daily.  Later in the 15-day course, some patients increased to 100mg three times daily as tolerated.  This rapid increase can cause side effects such as nausea, dizziness, and changes in sleep like insomnia.  However, these side effects are usually mild and go away.  Almost all patients in the study could take fluvoxamine for at least 5 days (and we don’t know if a 15-day course is needed).

Other than Dr. Seftel, we are aware of only two doctors who have prescribed fluvoxamine off-label for COVID patients:

 

Karl E. Steinberg, MD
3 total, none hospitalized.  All high-risk.  

I used the 50 mg bid dose.  One patient who was also on routine tramadol had some tachycardia and tremors that I thought might be serotonin syndrome.  I asked her what she wanted to do and she decided to cut back on the tramadol while finishing out the fluvoxamine and that worked out for her.  Interestingly, she also developed shingles not long after finishing the course of fluvoxamine.

 

ALEX NATIVIDAD MD 

1. High flow oxygen patient recovered and will be going home soon
2. The other 2 outpatients on flu day 2-3 recovered 100%

Steve Kirsch arranged for 3 people to get fluvoxamine prescriptions

1. Barbara L. (Wife’s friend): 50mg BID for 7 days: never developed any symptoms
2. Chris E. (Decorator’s husband): 50mg BID. Sick in bed for a week. O2sat =92. Four days after 50mg BID treatment he wanted to run on the treadmill. He’s fully recovered. Never needed to be hospitalized.
3. Micaela M. (Housekeeper): 50mg QD. Wrote: “Yesterday I felt back pain headache sore throat muscle pain and my right ear swollen.  Today, one day after starting the medication, I feel much better. Pain significantly reduced.

Please see the Fluvoxamine reporting form to report your results.

 

Fluvoxamine prescribing information

 Editorial note

There is a consumer and doctor aversion to taking any psychotropic drug.

Dosing

See Fluvoxamine Dosing Guidelines

Caffeine interaction

Warn patients about using caffeine while on the drug! This is not in the FDA guidelines. The WashU trial warns patients about this.

From  https://www.crazyboards.org/topic/14354-luvox/:

"Your one cup of joe will suddenly become like five cups, and the effects will last six times as long. These effects have been confirmed by subsequent studies, including one that shows these effects with just 10mg of fluvoxamine. Don't mix coffee and fluvoxamine!”

Studies: one study. another and another.:

The half-life of caffeine is increased from 5 to 31 hours.

Standard cautions

Adverse Effects:

▪ Restlessness, agitation, insomnia, nausea,

diarrhea, headache, dizziness, fatigue,

sexual dysfunction, hyponatremia

▪ SSRIs can increase the risk of bleeding by

inhibiting serotonin uptake by platelets

▪ QT interval prolongation has been

reported with all SSRIs; the risk appears to

be greatest with citalopram and

escitalopram

 

Drug Interactions:

▪ Increased risk of serotonin syndrome

when used with other serotonergic drugs

▪ Use of SSRIs and monoamine oxidase

inhibitors (MAOIs) concurrently or within

2 weeks of each other is contraindicated

▪ Use with antiplatelet or anticoagulant

drugs may increase the risk of bleeding

▪ Use with other QT-interval prolonging

drugs could result in additive effects and

an increased risk of torsades de pointes

▪ Fluvoxamine is a strong inhibitor of

CYP1A2 and moderate inhibitor of

CYP2C19 and can increase serum

concentrations of drugs metabolized by

these pathways

▪ SSRI often used for treatment of OCD

▪ Effects on the sigma-1 receptor may

down-regulate cytokine release

 

Pregnancy:

▪ Limited data are available on use of

fluvoxamine in pregnancy compared to

other SSRIs

▪ Risk of congenital malformations after

taking an SSRI during pregnancy appears

to be very low, and no increase in

perinatal mortality has been

demonstrated

▪ Increased risk of cardiovascular and other

malformations has been reported in

infants born to mothers who took

paroxetine in the first trimester

1. EJ

 

WashU dispensing guidelines

See https://healthymind.wustl.edu/ 

Three safety issues are important:

• First, fluvoxamine affects the metabolism of some drugs.  In particular, people taking theophylline, clozapine, olanzapine, or tizanidine should either avoid fluvoxamine or talk to their doctor about how to avoid a dangerous drug interaction.  Also, people using caffeine (like in coffee or tea) should greatly cut down on it.
• Second, fluvoxamine has psychiatric effects.  We did not see any untoward effects from it (such as anxiety or loss of concentration), but people with psychiatric conditions such as bipolar disorder or who already take psychiatric medications such as antidepressants or mood stabilizers, should talk carefully with their doctor before adding fluvoxamine.
• Third, patients taking drugs that promote bleeding such as coumadin may be at higher risk because fluvoxamine can also increase bleeding risk.  We don’t know how important this effect is, given how short is the course of fluvoxamine.

FDA dispensing guidelines for use in OCD

Note the warnings:

1.   Coadministration of tizanidine, thioridazine, alosetron, pimozide

2.    Use of MAOI’s concomitantly with or within 14 days of treatment with Luvox Tablets (4)

 

 

Fluvoxamine for COVID 8 mechanisms of action

There is a restricted access directory with information on the mechanisms of action that we don't have the rights to publicly disclose thas significant data on mechanisms of action. There are two presentations (one by Angela Reiersen and the other is the prezo given to the KOL meeting attendees on Jan 22). In particular, if you don’t watch Farid Jalali’s 1.5 hour video on SSRIs, serotonin, platelets, and the virus, you are missing out on a huge part of how and why SSRIs are so effective. 

My personal guess is that 50% of the effect is explained in Farid’s prezo since all SSRIs have this level of effect or more. Also, smokers don’t get COVID symptoms. Again, this points to platelets and serotonin. And depression is the only comorbidity that is protective.

The other 50% is due to sigma1 activation, this is why some SSRIs are more effective than others. They line up perfectly based on their sigma1 activation. 

Other mechanisms like the FIASMA antiviral effect are present as well, but likely not as significant. So serotonin vacuuming and the sigma1 activation are really the big 2.

Contact stk@treatearly.org for access permission.

The “serotonin related” directory has data regarding platelets and serotonin, the use of cyproheptadine for COVID patients, and why amitriptyline might be very useful for long haul patients (and SSRIs may make things worse for those patients).

Sigma1 activation

Is sigma1 basically in the mitochondria of every cell? do we understand how it works to regulate the inflammatory storm?

A: S1R is NOT in the mitochondria. It is located at the membrane of the endoplasmic reticulum (ER), and especially at the portions of the ER membrane that are NEAR mitochondria. S1R regulates activity of another ER protein called IRE1 (see additional information about IRE1 below). S1R also regulates some other ER proteins. 

 

For example, is it mast cells that would be the most important that would be regulated here or are all cells involved?

A: S1R is in many types of cells. 

I think SSRIs in general inhibit mast cell activity (not sure how relevant S1R is to effects on the mast cells). 

 

The article says the receptor acts as a “chaperone”…. so activating it is “enabling” some sort of activity here that is helpful. what is a good way to describe to a lay person what is going on? it’s not really like a fire sprinkler turning on, is it?

A: The endoplasmic reticulum is somewhat like a factory for building proteins into their final form. In general, chaperone proteins can assist in proper folding and maturation of other proteins that are being produced in the endoplasmic reticulum. one S1R  function is to act as a chaperone to facilitate the maturation of certain proteins. But it also has other functions, such as regulating the actions of other ER proteins (including a protein called IREI that that is involved with the ER stress response and inflammatory responses). IRE1 is a protein that can activate another protein called XBP1 which can then promote the production of cytokines. In the presence of a S1R agonist, S1R can essentially turn off IRE1, so IRE1 will not activate XBP1, so that the cytokine production will decrease.  

 

Summary of mechanisms

Dr. Angela Reiersen who led the Wash U study writes the following:

I have counted about 7-8 plausible mechanisms. I think at least 2 of them are likely to have very substantial effects. In approximate order of my current guess on which are most important:

1. Anti-inflammatory effect SIR-IRE1 pathway (reduction of the amount of cytokines produced in response to the infection).
2. Inhibition of platelet activation.
3. Inhibition of mast cell activation.
4. Functional inhibition of acid sphingomyelinase activity(FIASMA).
5. Lysosomotropism, which is characteristic of cationic amphiphilic drugs (CAD) in general. This is also related to #4. 
6. Direct interaction of S1R with viral proteins (which could be modified by various S1R ligands).
7. Inhibition of melatonin metabolism, which leads to increased melatonin levels (melatonin had its own anti-inflammatory effects).
8. Reduction of G9a histone methyltransferase (this is an interesting mechanism which seems to be affected by some antidepressants, but I don’t know yet whether fluvoxamine acts on this pathway). 

I could certainly be wrong about the order of importance. All the potential mechanisms need further study. 

1 applies to SSRIs (and other drugs) only if they are S1R agonists (as far as SSRIS, probably applies at least to fluvoxamine and fluoxetine, maybe to escitalopram and citalopram also).

2&3 probably apply to all SSRIs.

4&5 probably apply to most or all SSRIs (and probably quite a few other drugs).

6 might apply to SSRIs (and other drugs) if they are S1R ligands (might include agonists & antagonists), but each would need to be tested individually to confirm.

7 applies only to fluvoxamine.

8 may apply to some antidepressants and some other drugs, but each would need to be tested individually to determine this. I have read that this applies to amitriptyline, imipramine and paroxetine, but not venlafaxine, carbamazepine, or valproic acid. The only SSRI on this list is paroxetine, but I don’t know if other SSRIs have been tested.

Articles on antidepressants that inhibit G9a:

https://pubmed.ncbi.nlm.nih.gov/29417943/

https://pubmed.ncbi.nlm.nih.gov/22880885/

 

IL-6 and IL-10 ratio

FLV is known to reduce IL-6 and increase IL-10. 

IL-6:IL-10 ratio is highly correlated with clinical outcome of Covid patients, higher IL-6:IL-10 means worst outcome.

 

Adverse reactions

This is from FDA and applies to use in treating OCD. See Full Prescribing Information. 

Because the dosing required for COVID is modest and the treatment is only for 14 days, the side effects we’ve seen dosing at 50mg BID for 14 days produced mild nausea in one patient.

Patients should avoid caffeine while on the drug.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Frequency varies by dosage form and indication. Adverse reactions reported as a composite of all indications.

>10%:

Central nervous system: Headache (22% to 35%), insomnia (21% to 35%), drowsiness (22% to 27%), dizziness (11% to 15%), nervousness (10% to 12%)

Gastrointestinal: Nausea (34% to 40%), diarrhea (11% to 18%), xerostomia (10% to 14%), anorexia (6% to 14%)

Genitourinary: Ejaculatory disorder (8% to 11%)

Neuromuscular & skeletal: Weakness (14% to 26%)

1% to 10%:

Cardiovascular: Chest pain (3%), palpitations (3%), vasodilation (2% to 3%), hypertension (1% to 2%), edema (≥1%), hypotension (≥1%), syncope (≥1%)

Central nervous system: Pain (10%), anxiety (5% to 8%), anorgasmia (2% to 5%), yawning (2% to 5%), abnormal dreams (3%), abnormality in thinking (3%), paresthesia (3%), agitation (2% to 3%), apathy (≥1% to 3%), central nervous system stimulation (2%), chills (2%), depression (2%), hypertonia (2%), psychoneurosis (2%), twitching (2%), amnesia (≥1%), manic reaction (≥1%), myoclonus (≥1%), psychotic reaction (≥1%), malaise (≤1%)

Dermatologic: Diaphoresis (6% to 7%), ecchymoses (4%), acne vulgaris (2%)

Endocrine & metabolic: Decreased libido (2% to 10%; incidence higher in males), hypermenorrhea (3%), weight loss (≥1% to 2%), weight gain (≥1%)

Gastrointestinal: Dyspepsia (8% to 10%), constipation (4% to 10%), vomiting (5% to 6%), abdominal pain (5%), flatulence (4%), dental caries (≤3%), tooth loss (≤3%), toothache (≤3%), dysgeusia (2% to 3%), dysphagia (2%), gingivitis (2%)

Genitourinary: Urinary frequency (3%), sexual disorder (2% to 3%), impotence (2%), urinary tract infection (2%), urinary retention (1%)

Hepatic: Abnormal hepatic function tests (2%)

Infection: Tooth abscess (≤3%), viral infection (2%)

Neuromuscular & skeletal: Tremor (5% to 8%), myalgia (5%), hyperkinesia (≥1%), hypokinesia (≥1%)

Ophthalmic: Amblyopia (2% to 3%)

Renal: Polyuria (2%)

Respiratory: Upper respiratory tract infection (9%), pharyngitis (6%), flu-like symptoms (3%), laryngitis (3%), bronchitis (2%), dyspnea (2%), epistaxis (2%), increased cough (≥1%), sinusitis (≥1%)

<1%, postmarketing, and/or case reports: Abnormal gait, activation syndrome, acute renal failure, aggressive behavior, agranulocytosis, akinesia, amenorrhea, anaphylaxis, anemia, angina pectoris, angioedema, angle-closure glaucoma, anuria, aplastic anemia, apnea, asthma, ataxia, blurred vision, bradycardia, bruxism, bullous skin disease, cardiac conduction delay, cardiomyopathy, cardiorespiratory arrest, cerebrovascular accident, cholecystitis, cholelithiasis, colitis, crying, decreased white blood cell count, delirium, diplopia, drowsiness (neonatal), dysarthria, dyskinesia, dystonia, extrapyramidal reaction, fatigue, fever, first degree atrioventricular block, gastroesophageal reflux disease, gastrointestinal hemorrhage, glossalgia, goiter, hallucination, hematemesis, hematuria, hemoptysis, hepatitis, homicidal ideation, hypercholesterolemia, hyperglycemia, hypersensitivity reaction, hypoglycemia, hypokalemia, hyponatremia, hypothyroidism, IgA vasculitis, impulsivity, interstitial pulmonary disease, intestinal obstruction, intoxicated feeling, irritability, jaundice, jitteriness, laryngismus, lethargy, leukocytosis, leukopenia, loss of consciousness, lymphadenopathy, melena, myasthenia, myocardial infarction, myopathy, neuroleptic malignant syndrome (Stevens 2008), outbursts of anger, pancreatitis, paralysis, Parkinsonian-like syndrome, pericarditis, porphyria, priapism, prolonged QT interval on ECG, purpura, Raynaud's phenomenon (Khouri 2016; Peiró 2007), renal insufficiency, rhabdomyolysis, seizure, serotonin syndrome, shock, SIADH, ST segment changes on ECG, Stevens-Johnson syndrome, suicidal tendencies, supraventricular extrasystole, tachycardia, tardive dyskinesia, thrombocytopenia, thromboembolism, toxic epidermal necrolysis, vasculitis, ventricular arrhythmia, ventricular tachycardia (including torsades de pointes)

Contraindications

Concurrent use with alosetron, pimozide, thioridazine, or tizanidine; use of MAO inhibitors intended to treat psychiatric disorders (concurrently or within 14 days of discontinuing either fluvoxamine or the MAO inhibitor); initiation of fluvoxamine in a patient receiving linezolid or intravenous methylene blue.

Canadian labeling: Additional contraindications (not in US labeling): Hypersensitivity to fluvoxamine or any component of the formulation; concurrent use with astemizole, cisapride, mesoridazine, ramelteon, or terfenadine.

Warnings/Precautions

Major psychiatric warnings:

• Suicidal thinking/behavior: [US Boxed Warning]: Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18 to 24 years of age) with major depressive disorder (MDD) and other psychiatric disorders; consider risk prior to prescribing. Short-term studies did not show an increased risk in patients >24 years of age and showed a decreased risk in patients ≥65 years. Closely monitor patients for clinical worsening, suicidality, or unusual changes in behavior, particularly during the initial 1 to 2 months of therapy or during periods of dosage adjustments (increases or decreases); the patient's family or caregiver should be instructed to closely observe the patient and communicate condition with healthcare provider. A medication guide concerning the use of antidepressants should be dispensed with each prescription. Fluvoxamine is FDA approved for the treatment of OCD in children ≥8 years of age.

- The possibility of a suicide attempt is inherent in major depression and may persist until remission occurs. Worsening depression and severe abrupt suicidality that are not part of the presenting symptoms may require discontinuation or modification of drug therapy. Use caution in high-risk patients during initiation of therapy.

- Prescriptions should be written for the smallest quantity consistent with good patient care. The patient's family or caregiver should be alerted to monitor patients for the emergence of suicidality and associated behaviors such as anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia, hypomania, and mania; patients should be instructed to notify their health care provider if any of these symptoms or worsening depression occur.

Concerns related to adverse effects:

• Bleeding risk: May impair platelet aggregation resulting in increased risk of bleeding events, particularly if used concomitantly with aspirin, NSAIDs, warfarin or other anticoagulants. Bleeding related to SSRI use has been reported to range from relatively minor bruising and epistaxis to life-threatening hemorrhage.

• CNS depression: Has a low potential to impair cognitive or motor performance; caution operating hazardous machinery or driving.

• Fractures: Bone fractures have been associated with antidepressant treatment. Consider the possibility of a fragility fracture if an antidepressant-treated patient presents with unexplained bone pain, point tenderness, swelling, or bruising (Rabenda 2013; Rizzoli 2012).

• Impaired glucose control: Impaired glucose control (eg, hyperglycemia, hypoglycemia) has been reported; monitor for signs/symptoms of loss of glucose control particularly in diabetic patients.

• Ocular effects: May cause mild pupillary dilation which in susceptible individuals can lead to an episode of narrow-angle glaucoma. Consider evaluating patients who have not had an iridectomy for narrow-angle glaucoma risk factors.

• Serotonin syndrome: Potentially life-threatening serotonin syndrome (SS) has occurred with serotonergic agents (eg, SSRIs, SNRIs), particularly when used in combination with other serotonergic agents (eg, triptans, TCAs, fentanyl, lithium, tramadol, buspirone, St John's wort, tryptophan) or agents that impair metabolism of serotonin (eg, MAO inhibitors intended to treat psychiatric disorders, other MAO inhibitors [ie, linezolid and intravenous methylene blue]). Monitor patients closely for signs of SS such as mental status changes (eg, agitation, hallucinations, delirium, coma); autonomic instability (eg, tachycardia, labile blood pressure, diaphoresis); neuromuscular changes (eg, tremor, rigidity, myoclonus); GI symptoms (eg, nausea, vomiting, diarrhea); and/or seizures. Discontinue treatment (and any concomitant serotonergic agent) immediately if signs/symptoms arise.

• Sexual dysfunction: May cause or exacerbate sexual dysfunction.

• SIADH and hyponatremia: SSRIs and SNRIs have been associated with the development of SIADH; hyponatremia has been reported rarely (including severe cases with serum sodium <110 mmol/L), predominately in the elderly. Volume depletion and/or concurrent use of diuretics likely increases risk. Consider discontinuation if symptomatic hyponatremia occurs.

Disease-related concerns:

• Cardiovascular disease: Use with caution in patients with cardiovascular disease; fluvoxamine has not been systemically evaluated in patients with a recent history of MI or unstable heart disease.

• Hepatic impairment: Use with caution in patients with hepatic impairment; clearance is decreased and half-life and plasma concentrations are increased; a lower dosage may be needed. However, selective serotonin reuptake inhibitors such as fluvoxamine are considered the safest antidepressants to use in chronic liver disease because of their relative lack of side effects and high therapeutic index (Mullish 2014).

• May precipitate a shift to mania or hypomania in patients with bipolar disorder. Monotherapy in patients with bipolar disorder should be avoided. Combination therapy with an antidepressant and a mood stabilizer may be effective for acute treatment of bipolar major depressive episodes, but should be avoided in acute mania or mixed episodes, as well as maintenance treatment in bipolar disorder due to the mood-destabilizing effects of antidepressants (CANMAT [Yatham 2018]; WFSBP [Grunze 2018]). Patients presenting with depressive symptoms should be screened for bipolar disorder. Fluvoxamine is not FDA approved for the treatment of bipolar depression.

• Seizure disorder: Use with caution in patients with a previous seizure disorder and avoid use with unstable seizure disorder. Discontinue use if seizures occur or if seizure frequency increases.

Concurrent drug therapy issues:

• Smokers: Fluvoxamine levels may be lower in patients who smoke.

Other warnings/precautions:

• Discontinuation syndrome: Abrupt discontinuation or interruption of antidepressant therapy has been associated with a discontinuation syndrome. Symptoms arising may vary with antidepressant however commonly include nausea, vomiting, diarrhea, headaches, light-headedness, dizziness, diminished appetite, sweating, chills, tremors, paresthesias, fatigue, somnolence, and sleep disturbances (eg, vivid dreams, insomnia). Less common symptoms include electric shock-like sensations, cardiac arrhythmias (more common with tricyclic antidepressants), myalgias, parkinsonism, arthralgias, and balance difficulties. Psychological symptoms may also emerge such as agitation, anxiety, akathisia, panic attacks, irritability, aggressiveness, worsening of mood, dysphoria, mood lability, hyperactivity, mania/hypomania, depersonalization, decreased concentration, slowed thinking, confusion, and memory or concentration difficulties. Greater risks for developing a discontinuation syndrome have been associated with antidepressants with shorter half-lives, longer durations of treatment, and abrupt discontinuation. For antidepressants of short or intermediate half-lives, symptoms may emerge within 2 to 5 days after treatment discontinuation and last 7 to 14 days (APA 2010; Fava 2006; Haddad 2001; Shelton 2001; Warner 2006).

• Electroconvulsive therapy: Risk:benefits of combined therapy with electroconvulsive therapy have not been established.

Warnings: Additional Pediatric Considerations

SSRI-associated behavioral activation (ie, restlessness, hyperkinesis, hyperactivity, agitation) is two- to threefold more prevalent in children compared to adolescents; it is more prevalent in adolescents compared to adults. Somnolence (including sedation and drowsiness) is more common in adults compared to children and adolescents (Safer 2006). May impair cognitive or motor performance. SSRI-associated vomiting is two- to threefold more prevalent in children compared to adolescents and is more prevalent in adolescents compared to adults (Safer 2006). A recent report (Lake 2000) describes five children (age 8 to 15 years) who developed epistaxis (n=4) or bruising (n=1) while receiving sertraline therapy. Another recent report describes the SSRI discontinuation syndrome in six children; the syndrome was similar to that reported in adults (Diler 2002). Due to limited long-term studies, the clinical usefulness of fluvoxamine should be periodically reevaluated in patients receiving the drug for extended intervals; effects of long-term use of fluvoxamine on pediatric growth, development, and maturation have not been directly assessed. Note: Case reports of decreased growth in children receiving fluoxetine or fluvoxamine (n=4; age: 11.6 to 13.7 years) for 6 months to 5 years suggest a suppression of growth hormone secretion during SSRI therapy (Weintrob 2002).

 

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