ADHD Nonstimulants: Viloxazine (SNRIs)

00:01 Viloxazine is marketed as Quelbree.

00:04 Now this is an SNRI, but it increases the norepinephrine and dopamine availability.

00:10 Now it has this additional serotonin receptor modulation.

00:13 It inhibits the five T-2b receptors, but it activates the five T-2c receptors.

00:20 Now it increases serotonin in the prefrontal cortex.

00:23 That's a good thing. And in the amygdala and in the nucleus accumbens, the adverse effects of viloxazine are similar to those that we talked about with atomoxetine.

00:34 You're going to have an increased heart rate and blood pressure.

00:37 And then it can mess with how you feel.

00:39 You can have somnolence where they feel a little sleepy, or they can be really tired and fatigued, but they can also have difficulty sleeping and be stuck with insomnia. When it comes to GI symptoms, they can decrease their appetite.

00:51 They have issues with nausea and vomiting and can also induce mania.

00:56 Now this medication, viloxazine also has a boxed warning regarding the increased risk of suicidal thinking.

01:04 There's two important contraindications you need to keep in mind as a provider if you're considering prescribing viloxazine.

01:11 First of all, a patient who is taking an MAOI, it's a contraindication for them for you to prescribe viloxazine.

01:18 So you want at least a 14 day window that they have not taken any MAOI before they could start taking viloxazine.

01:26 The other issue is you don't want them taking certain cytochrome P450 a1-a2 substrates, things like caffeine or fluoroquinolone antibiotics or macrolide antibiotics.

01:37 Now, I've put examples for you there, like ciprofloxacin and erythromycin just to have that in mind. But keep in the front of your mind.

01:46 You don't want them taking it with an maoi.

01:48 And again, that one's pretty easy to remember because MAOIs don't go well with anything but also certain cytochrome p450s, right? Caffeine. That's a big one.

01:59 Fluoroquinolone antibiotics and macrolide antibiotics.

02:04 Now, the indications for you for you to prescribe this medication are similar to those for atomoxetine.

02:08 It's approved for treatment of ADHD in children who are at least six years of age, adolescents and adults.

02:16 Now, before you're prescribing, make sure you screen for bipolar disease and look for the risk factors for the patient developing a manic episode.

02:23 Make sure you do a thorough cardiovascular assessment.

02:26 Make sure you know the family history.

02:27 Also, look at all of their medications that they're using, prescribed and over-the-counter because there's lots of significant drug interactions with this medication. Consult your drug interactions database for make sure that you have all the most accurate and complete information.

02:43 And keep in mind, this medication could be cost prohibitive for some patients.

02:47 It's really expensive without very specific coverage.

02:52 Viloxazine is an extended release capsule that can be taken once daily.

02:56 Now, when you're thinking about how you're going to prescribe this in initial doses and titrations for children and adolescents, we're going to look at this by age.

03:03 So first of all, let's look at 6 to 11 years.

03:05 The initial dose should be Should be 100mg once daily.

03:09 Now it can be increased by 100mg weekly to the maximum dose of 400mg.

03:14 Now, if your client is 12 to 17 years of age, the initial dose should be 200mg daily.

03:20 Now, this can be increased by 200mg weekly to the maximum dose of 400mg.

03:26 Now, if they're an adult, the initial dose can be 200mg once daily.

03:30 And you can increase that by 200mg weekly to the maximum dose of 600mg.

03:37 Viloxazine can be discontinued abruptly if you need to.

03:41 Your monitoring should include establishing a baseline and then re monitoring after initiation or dose changes, and continue to do that periodically.

03:50 Make sure you know their heart rate, blood pressure, their liver enzymes, and their renal function to keep your patients safe with this treatment.

03:57 Now we've included a chart for you.

03:59 It's a study guide.

04:01 It puts all the information we've talked about right in this slide.

04:04 And this will be available to you in your downloadable materials.