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INTRODUCTION

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milnacipran (mil-na-sip-ran)

Savella

Classification

Therapeutic: antifibromyalgia agents

Pharmacologic: selective norepinephrine reuptake inhibitors

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Indications
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Management of fibromyalgia.

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Action
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Inhibits neuronal reuptake of norepinephrine and serotonin. Therapeutic Effects: Decreased pain associated with fibromyalgia.

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Adverse Reactions/Side Effects
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CNS: dizziness, headache, insomnia. CV: hypertension, tachycardia. GI: constipation, dry mouth, liver function abnormalities, nausea, vomiting. Derm: hot flushes, hyperhydrosis.

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PHYSICAL THERAPY IMPLICATIONS

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Examination and Evaluation
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  • Assess pain using visual analogue scales and other appropriate pain scales. Document any changes in pain to help determine the effects of drug therapy in treating fibromyalgia.

  • Assess dizziness that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician, and caution the patient and family/caregivers to guard against falls and trauma.

  • Assess blood pressure (BP) and compare to normal values (See Appendix F). Report a sustained increase in BP (hypertension).

  • Assess heart rate, ECG, and heart sounds, especially during exercise (See Appendices G, H). Report a rapid heart rate (tachycardia) or symptoms of other arrhythmias, including palpitations, chest discomfort, shortness of breath, fainting, and fatigue/weakness.

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Interventions
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  • Implement appropriate interventions (physical agents, manual techniques, therapeutic exercise) to help manage pain and reduce the need for drug therapy.

  • Because of the risk of hypertension and tachycardia, use caution during aerobic exercise and other forms of therapeutic exercise. Assess exercise tolerance frequently (BP, heart rate, fatigue levels), and terminate exercise immediately if any untoward responses occur (See Appendix L).

  • Help patient explore other nonpharmacologic methods to reduce chronic pain such as relaxation techniques, imagery, counseling, and so forth.

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Patient/Client-Related Instruction
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  • Instruct patient to report other troublesome side effects such as severe or prolonged headache, sleep loss, excessive sweating, hot flashes, or GI problems (nauseas, vomiting, constipation, dry mouth).

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Pharmacokinetics
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Absorption: 85–90% absorbed following oral administration.

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Distribution: Unknown.

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Metabolism and Excretion: Mostly excreted urine as unchanged drug (55%) and inactive metabolites.

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Half-life: D-isomer 8–10 hr; L-isomer 4–6 hr.

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TIME/ACTION PROFILE (decrease in pain)

ROUTE ONSET PEAK DURATION
PO 1 wk unknown unknown

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Contraindications/Precautions
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Contraindicated in: Uncontrolled narrow-angle glaucoma; Concurrent use of or in close temporal proximity to MAO inhibitors; End-stage renal disease; Significant history of alcohol use/abuse; Chronic liver disease.

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Use Cautiously in: History of suicide risk or attempt; History of seizures; Moderate-to-severe renal impairment; for CCr <30 mL/min reduced dose is required; Severe hepatic impairment; Obstructive uropathy (↑ risk of adverse genitourinary effects); Geri: Consider age-related decrease in renal function, chronic disease state, and concurrent drug therapy; OB: Use only if clearly required during pregnancy, ...

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