AdultPediatricDosage Forms & Strengths tablet 12.5mg 25mg 50mg 100mg Fibromyalgia 12.5 mg PO once on day 1, then 25 mg/day divided q12hr on days 2-3, then 50 mg/day divided q12hr on days 4-7, then 100 mg/day divided q12hr thereafter; not to exceed 200 mg/day Therapy discontinuation When discontinuing antidepressant therapy that have lasted for more than 3 weeks, taper dose gradually over 2-4 weeks; this will minimize withdrawal symptoms and help detect reemerging symptoms If intolerable withdrawal symptoms occur, resume previously prescribed dose; may also decrease dose at more gradual rate; patients on long-term treatment (>6 weeks) may benefit from tapering over >3 months Switching to or from MAO inhibitors Allow five or more days to elapse between milnacipran discontinuation and initiation of MAO inhibitor Allow 14 days to elapse between MAO inhibitor discontinuation and initiation of milnacipran Severe renal impairment: may increase to 50 mg BID if tolerated Dosing Modifications Renal impairment Mild (CrCl 50-80 mL/min): No dosage adjustment required Moderate (CrCl 30-49 mL/min): Use with caution Severe (CrCl 5-29 mL/min): Reduce maintenance dosage by 50% (ie, to 50 mg/day divided q12hr) End-stage renal disease (ESRD): Use not recommended Hepatic impairment Mild or moderate (Child-Pugh A or B): No dosage adjustment required Severe (Child-Pugh C): Caution advised <17 years: Safety and efficacy not establishedInteraction CheckerEnter a drug name and milnacipranNo Results No Interactions Found Interactions FoundContraindicatedSerious - Use AlternativeSignificant - Monitor CloselyMinorAll Interactions Sort By: SeverityName Contraindicated (7)iobenguane I 123milnacipran decreases effects of iobenguane I 123 by pharmacodynamic antagonism. Contraindicated. If clinically appropriate, discontinue drugs that decrease uptake of NE for at least 5 half-lives; may cause false-negative imaging results.isocarboxazidisocarboxazid and milnacipran both increase serotonin levels. Contraindicated.phenelzinephenelzine and milnacipran both increase serotonin levels. Contraindicated.procarbazineprocarbazine and milnacipran both increase serotonin levels. Contraindicated. Combination is contraindicated within 2 weeks of MAOI use.rasagilinerasagiline and milnacipran both increase serotonin levels. Contraindicated. Concomitant use with MAOIs or within 14 days of discontinuing treatment with an MAOI is contraindicated.safinamidemilnacipran, safinamide. Either increases toxicity of the other by serotonin levels. Contraindicated. Concomitant use could result in life-threatening serotonin syndrome.tranylcyprominetranylcypromine and milnacipran both increase serotonin levels. Contraindicated.Serious - Use Alternative (51)amitriptylinemilnacipran and amitriptyline both increase serotonin levels. Avoid or Use Alternate Drug.amoxapinemilnacipran and amoxapine both increase serotonin levels. Avoid or Use Alternate Drug.apixabanmilnacipran and apixaban both increase anticoagulation. Avoid or Use Alternate Drug.bupropionmilnacipran increases toxicity of bupropion by unspecified interaction mechanism. Avoid or Use Alternate Drug. May lower seizure threshold; keep bupropion dose as low as possible.buspironemilnacipran and buspirone both increase serotonin levels. Avoid or Use Alternate Drug.citalopramcitalopram and milnacipran both increase serotonin levels. Avoid or Use Alternate Drug. Combination may increase risk of serotonin syndrome or neuroleptic malignant syndrome-like reactions.clomipraminemilnacipran and clomipramine both increase serotonin levels. Avoid or Use Alternate Drug.cyclobenzaprinemilnacipran and cyclobenzaprine both increase serotonin levels. Avoid or Use Alternate Drug.desipraminemilnacipran and desipramine both increase serotonin levels. Avoid or Use Alternate Drug.desvenlafaxinemilnacipran and desvenlafaxine both increase serotonin levels. Avoid or Use Alternate Drug.dextromethorphanmilnacipran and dextromethorphan both increase serotonin levels. Avoid or Use Alternate Drug.dolasetrondolasetron, milnacipran. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.dosulepinmilnacipran and dosulepin both increase serotonin levels. Avoid or Use Alternate Drug.doxepinmilnacipran and doxepin both increase serotonin levels. Avoid or Use Alternate Drug.duloxetineduloxetine and milnacipran both increase serotonin levels. Avoid or Use Alternate Drug.epinephrinemilnacipran increases levels of epinephrine by pharmacodynamic synergism. Avoid or Use Alternate Drug. Risk of paroxysmal HTN, arrhythmia.epinephrine racemicmilnacipran increases levels of epinephrine racemic by pharmacodynamic synergism. Avoid or Use Alternate Drug. Risk of paroxysmal HTN, arrhythmia.escitalopramescitalopram and milnacipran both increase serotonin levels. Avoid or Use Alternate Drug.fluoxetinefluoxetine and milnacipran both increase serotonin levels. Avoid or Use Alternate Drug.fluvoxaminefluvoxamine and milnacipran both increase serotonin levels. Avoid or Use Alternate Drug.granisetrongranisetron, milnacipran. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.imipraminemilnacipran and imipramine both increase serotonin levels. Avoid or Use Alternate Drug.iobenguane I 131milnacipran will decrease the level or effect of iobenguane I 131 by Other (see comment). Avoid or Use Alternate Drug. Based on the mechanism of action of iobenguane, drugs that reduce catecholamine uptake or that deplete catecholamine stores may interfere with iobenguane uptake into cells, and thus, reduce iobenguane efficacy. Discontinue interfering drugs for at least 5 half-lives before administration of either the dosimetry or an iobenguane dose. Do not administer these drugs until at least 7 days after each iobenguane dose.levomilnacipranlevomilnacipran and milnacipran both increase serotonin levels. Avoid or Use Alternate Drug.linezolidlinezolid and milnacipran both increase serotonin levels. Avoid or Use Alternate Drug. Linezolid may increase serotonin as a result of MAO-A inhibition. If linezolid must be administered, discontinue serotonergic drug immediately and monitor for CNS toxicity. Serotonergic therapy may be resumed 24 hours after last linezolid dose or after 2 weeks of monitoring, whichever comes first.lofepraminemilnacipran and lofepramine both increase serotonin levels. Avoid or Use Alternate Drug.lorcaserinmilnacipran and lorcaserin both increase serotonin levels. Avoid or Use Alternate Drug.maprotilinemilnacipran and maprotiline both increase serotonin levels. Avoid or Use Alternate Drug.meperidinemilnacipran and meperidine both increase serotonin levels. Avoid or Use Alternate Drug.methylene bluemethylene blue and milnacipran both increase serotonin levels. Avoid or Use Alternate Drug. Methylene blue may increase serotonin as a result of MAO-A inhibition. If methylene blue must be administered, discontinue serotonergic drug immediately and monitor for CNS toxicity. Serotonergic therapy may be resumed 24 hours after last methylene blue dose or after 2 weeks of monitoring, whichever comes first.metoclopramidemetoclopramide and milnacipran both increase serotonin levels. Avoid or Use Alternate Drug. Additive effects; increased risk for serotonin syndrome, neuroleptic malignant syndrome, dystonia, or other extrapyramidal reactionsnefazodonemilnacipran and nefazodone both increase serotonin levels. Avoid or Use Alternate Drug.netupitant/palonosetronnetupitant/palonosetron, milnacipran. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.norepinephrinemilnacipran increases levels of norepinephrine by pharmacodynamic synergism. Avoid or Use Alternate Drug. Risk of paroxysmal HTN, arrhythmia.nortriptylinemilnacipran and nortriptyline both increase serotonin levels. Avoid or Use Alternate Drug.ondansetronondansetron, milnacipran. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.ozanimodozanimod increases toxicity of milnacipran by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Avoid or Use Alternate Drug. Because the active metabolite of ozanimod inhibits MAO-B in vitro, there is a potential for serious adverse reactions, including hypertensive crisis. Therefore, coadministration of ozanimod with drugs that can increase norepinephrine or serotonin is not recommended. Monitor for hypertension with concomitant use.palonosetronpalonosetron, milnacipran. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.paroxetinemilnacipran and paroxetine both increase serotonin levels. Avoid or Use Alternate Drug.phenterminemilnacipran, phentermine. Either increases toxicity of the other by Mechanism: unknown. Avoid or Use Alternate Drug. Risk of serotonin syndrome.protriptylinemilnacipran and protriptyline both increase serotonin levels. Avoid or Use Alternate Drug.pseudoephedrinemilnacipran increases effects of pseudoephedrine by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Avoid or Use Alternate Drug.selegilineselegiline and milnacipran both increase serotonin levels. Avoid or Use Alternate Drug.selegiline transdermalselegiline transdermal and milnacipran both increase serotonin levels. Avoid or Use Alternate Drug.sertralinemilnacipran and sertraline both increase serotonin levels. Avoid or Use Alternate Drug.St John's Wortmilnacipran and St John's Wort both increase serotonin levels. Avoid or Use Alternate Drug.trazodonemilnacipran and trazodone both increase serotonin levels. Avoid or Use Alternate Drug.trimipraminemilnacipran and trimipramine both increase serotonin levels. Avoid or Use Alternate Drug.venlafaxinemilnacipran and venlafaxine both increase serotonin levels. Avoid or Use Alternate Drug.vilazodonemilnacipran, vilazodone. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug. Concomitant therapy should be discontinued immediately if signs or symptoms of serotonin syndrome emerge and supportive symptomatic treatment should be initiated. .vortioxetinemilnacipran, vortioxetine. Either increases effects of the other by serotonin levels. Avoid or Use Alternate Drug.Monitor Closely (109)5-HTPmilnacipran and 5-HTP both increase serotonin levels. Modify Therapy/Monitor Closely.aceclofenacmilnacipran, aceclofenac. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of upper GI bleeding. SSRIs inhib. serotonin uptake by platelets.acemetacinmilnacipran, acemetacin. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of upper GI bleeding. SSRIs inhib. serotonin uptake by platelets.almotriptanalmotriptan and milnacipran both increase serotonin levels. Modify Therapy/Monitor Closely.aripiprazolemilnacipran, aripiprazole. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).asenapinemilnacipran, asenapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).aspirinmilnacipran, aspirin. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of upper GI bleeding. SSRIs inhib. serotonin uptake by platelets.aspirin rectalmilnacipran, aspirin rectal. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of upper GI bleeding. SSRIs inhib. serotonin uptake by platelets.aspirin/citric acid/sodium bicarbonatemilnacipran, aspirin/citric acid/sodium bicarbonate. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of upper GI bleeding. SSRIs inhib. serotonin uptake by platelets.benzhydrocodone/acetaminophenbenzhydrocodone/acetaminophen, milnacipran. Either increases effects of the other by serotonin levels. Use Caution/Monitor. Coadministration of drugs that affect the serotonergic neurotransmitter system may result in serotonin syndrome. If concomitant use is warranted, carefully observe the patient, particularly during treatment initiation and dose adjustment.buprenorphine subdermal implantmilnacipran, buprenorphine subdermal implant. Either increases toxicity of the other by serotonin levels. Use Caution/Monitor. Concomitant use could result in life-threatening serotonin syndrome. If concomitant use is warranted, carefully observe the patient, particularly during treatment initiation, and during dose adjustment of the serotonergic drug. Discontinue buprenorphine if serotonin syndrome is suspected.buprenorphine, long-acting injectionmilnacipran, buprenorphine, long-acting injection. Either increases toxicity of the other by serotonin levels. Use Caution/Monitor. Concomitant use could result in life-threatening serotonin syndrome. If concomitant use is warranted, carefully observe the patient, particularly during treatment initiation, and during dose adjustment of the serotonergic drug. Discontinue buprenorphine if serotonin syndrome is suspected.cariprazinemilnacipran, cariprazine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).celecoxibmilnacipran, celecoxib. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of upper GI bleeding. SSRIs inhib. serotonin uptake by platelets.choline magnesium trisalicylatemilnacipran, choline magnesium trisalicylate. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of upper GI bleeding. SSRIs inhib. serotonin uptake by platelets.clomipraminemilnacipran, clomipramine. Mechanism: unspecified interaction mechanism. Use Caution/Monitor. Risk of euphoria, postural hypot'n when switching from clomipramine to milnacipran.clonidinemilnacipran decreases effects of clonidine by pharmacodynamic antagonism. Use Caution/Monitor.clopidogrelmilnacipran increases effects of clopidogrel by pharmacodynamic synergism. Use Caution/Monitor. SNRIs affect platelet activation; coadministration of SNRIs with clopidogrel may increase the risk of bleeding.clozapinemilnacipran, clozapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).cocaine topicalmilnacipran and cocaine topical both increase serotonin levels. Modify Therapy/Monitor Closely.cyproheptadinecyproheptadine decreases effects of milnacipran by pharmacodynamic antagonism. Use Caution/Monitor. Cyproheptadine may diminish the serotonergic effect of SNRIs.dexfenfluraminemilnacipran and dexfenfluramine both increase serotonin levels. Modify Therapy/Monitor Closely.dextroamphetaminemilnacipran and dextroamphetamine both increase serotonin levels. Modify Therapy/Monitor Closely.dextroamphetamine transdermalmilnacipran, dextroamphetamine transdermal. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor for signs and symptoms of serotonin syndrome, particularly during initiation or dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and concomitant serotonergic drug(s).diazepam intranasaldiazepam intranasal, milnacipran. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Coadministration may potentiate the CNS-depressant effects of each drug.diclofenacmilnacipran, diclofenac. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of upper GI bleeding. SSRIs inhib. serotonin uptake by platelets.diflunisalmilnacipran, diflunisal. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of upper