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Vilazodone 

Viibryd

Viibryd (vilazodone) is a prescription medication primarily used to treat major depressive disorder (MDD) in adults. It works as a selective serotonin reuptake inhibitor (SSRI) and uniquely binds to serotonin receptors, enhancing its mood-regulating effects. It is available in different strengths and may be used long-term under medical supervision. Viibryd can interact with several medications and supplements, possibly affecting its effectiveness or causing side effects like serotonin syndrome. It should not be used by children and requires caution in individuals with certain medical conditions or who are taking specific medications.

Viibryd Overview

Viibryd (vilazodone) is an antidepressant that is commonly prescribed for the treatment of major depressive disorder (MDD) in adults. It belongs to a class of medications known as selective serotonin reuptake inhibitors (SSRIs) but stands out due to its additional ability to act directly on serotonin receptors. This dual-action not only helps in preventing the reabsorption of serotonin but also mimics the effects of serotonin, leading to improved mood regulation. 

The medication is taken orally, typically once a day, and is available in tablet form in strengths of 10 mg, 20 mg, and 40 mg. For those beginning treatment, Viibryd is usually started at a lower dose to minimize side effects, with the possibility of increasing the dosage based on individual response and tolerance. The maximum recommended dosage under special circumstances can go up to 60 mg or 80 mg daily, though this is less common. Viibryd has been associated with both common and serious side effects. Common side effects may include gastrointestinal disturbances, sexual dysfunction, sleep disturbances, and emotional changes, whereas more severe risks include serotonin syndrome, mania, and an increased risk of bleeding. 

Due to its interactions with other drugs, particularly those affecting serotonin levels and those metabolized by the CYP3A4 enzyme, it is important to manage Viibryd under close medical supervision. Before starting Viibryd, it is crucial for patients to discuss their full medical history with their healthcare provider, especially if they have bipolar disorder, are pregnant, breastfeeding, or have conditions like glaucoma or a history of seizures. Adjustments in dosage or close monitoring may be necessary to ensure safety and effectiveness. Moreover, patients should avoid abrupt discontinuation to prevent withdrawal symptoms and consult with a healthcare provider for any concerns about side effects or interactions.

Uses of Viibryd

Viibryd (vilazodone) is a prescription medication available under a brand name. It is prescribed for adults to manage:

  • Major depressive disorder (MDD), a type of depression.
  • Anxiety (this is an off-label use, meaning it’s not officially approved for this purpose).
  • Post-traumatic stress disorder (PTSD), which is also not a recommended use. 
  • OCD (obsessive-compulsive disorder), but it is not considered suitable for this condition.

[Important Warning: Viibryd is not suitable for children and should not be used by them.]

Viibryd Dosage

  • It is available as a tablet and can be taken orally once daily. It comes in three different strengths:
    • Viibryd 10 mg tablets
    • Viibryd 20 mg tablets
    • Viibryd 40 mg tablets
  • For the first 30 days of treatment, Viibryd offers two types of starter packs:
    • Starter pack option 1 includes seven 10-mg tablets, seven 20-mg tablets, and sixteen 40-mg tablets.
    • Starter pack option 2 includes seven 10-mg tablets and twenty-three 20-mg tablets.

Recommended Viibryd Dosage for Different Patients

Dosage for Major Depressive Disorder

  • Starting Dosage: Typically, your doctor will start you on a lower dose of Viibryd. You might begin with 10 mg per day for the first week.
  • Adjusting Dosage: Depending on how you respond to the initial dosage, your doctor may then increase your dose to 20 mg per day after the first week.
  • Evaluating and Modifying Dosage: After taking 20 mg per day for at least one week, your doctor will assess how well your symptoms are managed. Based on your response, they might decide to keep you on 20 mg or increase the dose to 40 mg per day.

Maximum Dosage for Viibryd

  • Standard Limit: The typical maximum dosage of Viibryd is 40 mg per day.
  • Potential Exceptions: In certain cases, based on individual needs and how well the treatment is tolerated, doctors may prescribe higher doses, such as 60 mg or even 80 mg per day.

[Note: Remember these recommendations may vary depending on person to person. Discuss it with your doctor, and they’ll customize your dosage accordingly.]

How to Take Viibryd?

  • Viibryd is typically prescribed as a long-term treatment for Major Depressive Disorder (MDD), which often requires ongoing management even during periods when symptoms may lessen.
  • If deemed safe and effective for you, expect to continue taking Viibryd for an extended period as directed by your doctor.
  • Take Viibryd once daily, ideally at the same time each day, to maintain a consistent level of medication in your body.
  • Always take Viibryd with food to improve absorption and reduce potential gastrointestinal side effects such as nausea and vomiting.
  • Viibryd tablets can be crushed, split, or chewed if needed. Discuss these options with your healthcare provider to determine the best method for you.
  • If splitting the tablet is necessary, using a pill cutter can help achieve an even dose.
  • Set reminders on your phone or use a medication timer to help you remember to take your dose every day without fail.
  • Consult with your pharmacist for further advice on taking Viibryd effectively.
  • Always follow your healthcare provider’s instructions closely regarding how to take your medication.

[Note: Your doctor will decide the right amount for you based on your condition, following guidelines and studies on the drug. They’ll adjust it as needed over time.]

How Does Viibryd Work?

Viibryd is a medication used to manage major depressive disorder (MDD), a specific type of mood disorder that significantly impacts a person’s emotions, disrupting their ability to perform daily tasks like working, eating, and sleeping. MDD is often linked to an imbalance of neurotransmitters, such as serotonin, in the brain. These chemical messengers play a crucial role in regulating mood. The exact cause of this neurotransmitter imbalance can vary, involving genetic factors, other medications, and environmental influences. Viibryd works by helping to restore a more balanced state of these chemicals.

While the precise mechanism of Viibryd isn’t fully understood, it is known to function as a selective serotonin reuptake inhibitor (SSRI). This means it helps increase the level of serotonin in the brain by preventing its reabsorption into neurons, allowing more serotonin to be available. Additionally, Viibryd uniquely interacts directly with serotonin receptors, mimicking the action of serotonin itself. These receptors are proteins located on the surface of cells, where they receive chemical signals.

Due to its dual mechanism—both inhibiting the reuptake of serotonin and binding to its receptors—Viibryd is often categorized differently from typical SSRIs and is considered a miscellaneous antidepressant. This combination of actions is thought to contribute effectively to balancing serotonin levels in the brain, thereby helping alleviate symptoms of depression.

Viibryd Side Effects

Common side effects of Viibryd may include:

  • Sexual problems, such as:
    • Erectile dysfunction
    • Decrease in sex drive
  • Digestive system problems, such as 
    • Abdominal pain
    • Diarrhea
    • Vomiting
    • Nausea
  • Joint pain
  • Insomnia (not being able to sleep)
  • Dizziness
  • Sleepiness or fatigue (lack of energy)
  • Weight gain or weight loss
  • Headaches
  • Dry mouth

Adverse/Serious side effects of Viibryd may include:

  • Suicidal thoughts and behaviors
  • Discontinuation syndrome, which is also called withdrawal syndrome
  • Allergic reactions
  • Angle-closure glaucoma (a kind of eye disease). Signs may include:
    • Seeing halos around lights
    • Blurry vision
    • Eye pain that’s often severe
  • Serotonin syndrome
  • Mania or hypomania. Signs may include:
    • Feeling restless or out of control
    • Increase in energy
    • Racing thoughts
  • Bleeding. Signs may include:
    • Blood in urine or stool
    • Bruising 
    • Nosebleeds 
  • Seizures. Signs may include:
    • Falling
    • Loss of consciousness
    • Sudden jerky movements of arms or legs
  • Hyponatremia. Signs may include:
    • Trouble concentrating
    • Fainting
    • Feeling lightheaded
    • Dizziness

[Note: Remember, this list may not cover all possible side effects. Always consult with your healthcare giver for medical advice about side effects.]

Viibryd Warnings

Withdrawal: Stopping Viibryd suddenly, known as going “cold turkey,” can lead to withdrawal symptoms. This reaction is referred to as discontinuation syndrome. Because your body adjusts to the medication, quitting abruptly might make you feel unwell. Withdrawal symptoms can persist from several days to weeks. If you plan to switch to a different medication or stop taking Viibryd, it is crucial to reduce your dosage gradually. Withdrawal symptoms may include:

  • Sweating
  • Flu-like symptoms
  • Tremors
  • Seizures
  • Tinnitus (ringing in the ears)
  • Anxiety
  • Nausea and vomiting
  • Insomnia
  • Electric shock sensations (brain zaps)
  • Headaches
  • Irritability
  • Vivid dreams
  • Mood changes

If you’re considering discontinuing Viibryd or changing your medication, consult your doctor. They can assist in safely adjusting your dose to prevent feeling sick.

Viibryd Boxed Warning

FDA Boxed Warning: Suicidal Thoughts and Behaviors Viibryd carries a boxed warning, the most severe type of warning issued by the Food and Drug Administration (FDA). This warning is used to inform doctors and patients about potential serious risks from the medication. Individuals who are 24 years old or younger may face an increased risk of suicidal thoughts and behaviors when taking antidepressants like Viibryd, according to findings from short-term clinical studies. If you are using Viibryd, your doctor will closely monitor you for any signs of suicidal thoughts and behaviors. It is also advisable for family members and friends to watch for these symptoms. Further research is necessary to determine the safety and effectiveness of Viibryd in children.

Viibryd Precautions

Before starting Viibryd, discuss your medical history with your doctor to determine if it’s safe for you. Viibryd may not be suitable if you have certain health conditions or factors that could be affected by the medication. These include:

  • Bipolar Disorder: If you have bipolar disorder, taking Viibryd might trigger hypomania or mania, which are states of high energy and racing thoughts. It is important to be screened for bipolar disorder before beginning treatment with Viibryd.
  • Seizures: Like other antidepressants, Viibryd may increase the risk of seizures. If you have a history of seizures, inform your doctor before taking this medication.
  • Glaucoma: If you suffer from untreated angle-closure glaucoma, Viibryd could suddenly trigger symptoms of this condition. Discuss alternative treatments for major depressive disorder with your doctor if you have this form of glaucoma.
  • Alcohol: You should avoid drinking alcohol while taking Viibryd. Although there isn’t a direct interaction between Viibryd and alcohol, the side effects of Viibryd, such as dizziness and drowsiness, can worsen when combined with alcohol. These effects might make it unsafe to operate vehicles or heavy machinery. Discuss the potential risks with your doctor to determine if Viibryd is suitable for you if you consume alcohol.
  • Pregnancy: The safety of Viibryd during pregnancy remains unknown. There have been no clinical studies on Viibryd in pregnant individuals. In animal studies, Viibryd did not cause birth defects even at doses much higher than those used in humans, but animal study outcomes do not always predict human responses. Like other SSRIs (selective serotonin reuptake inhibitors), Viibryd could potentially lead to complications in newborns, such as prolonged hospitalization, respiratory issues, and, in some cases, increased blood pressure in the lungs. If you are pregnant or planning to become pregnant, it is crucial to discuss with your doctor whether the benefits of using Viibryd outweigh the potential risks. 
  • Birth Control: The safety of Viibryd during pregnancy has not been established. If there’s a possibility that you or your sexual partner could become pregnant, it’s important to discuss effective birth control methods with your doctor while you are using Viibryd.
  • Breastfeeding: It is unclear whether Viibryd passes into breast milk or if it is safe to breastfeed while taking this medication. If you are breastfeeding or plan to breastfeed, you should consult your doctor to determine if continuing Viibryd is appropriate for your situation.

Viibryd Contraindications

  • Patients should avoid taking monoamine oxidase inhibitors (MAOIs) within 14 days before or after using Viibryd. Combining these medications can significantly increase the risk of serotonin syndrome, a potentially serious condition. Symptoms of serotonin syndrome may include nausea, vomiting, a racing heartbeat, and excessive sweating.

Viibryd Missed Dose

  • If you forget to take a dose, take it as soon as you remember unless it is nearly time for your next dose.
  • Do not take two doses at the same time to make up for a missed dose. If your next dose is due soon, just skip the missed dose and continue with your regular schedule.
  • If you miss more than one dose, especially if your usual dose is 20 mg or 40 mg per day, contact your doctor.
  • Your doctor may need to adjust your dosage to safely get back to your treatment regimen.
  • Set a reminder on your phone to take your medication at the same time every day.
  • Consider using a medication timer or app that can help remind you when it’s time to take your next dose.

[Note: If you have missed a dose of your medication and are unsure about when to take the next one, immediately consult your doctor or pharmacist.]

Viibryd Overdose

Taking more than the recommended dose of Viibryd can result in serious side effects. Symptoms of an overdose may include:

  • Fatigue or feeling unusually sluggish
  • Restlessness
  • Disorientation or confusion, making it difficult to think or concentrate
  • Serotonin syndrome, characterized by excessively high levels of serotonin
  • Hallucinations, such as seeing things that aren’t present

If you suspect you have overdosed on Viibryd, immediately contact your doctor. You can also reach out to the American Association of Poison Control Centers at 800-222-1222 or use their online tool for guidance. However, if your symptoms are severe, do not hesitate to call 911 or visit the nearest emergency room immediately.

[Note: If you consumed more than the recommended dose, get medical help right away or call the Poison Help line at 1-800-222-1222.]

Viibryd Storage

  • Keep Viibryd tablets at room temperature, ideally at 77°F (25°C).
  • Store the tablets in a tightly sealed container to protect them from moisture and light.
  • Do not store the medication in damp or wet places, such as bathrooms, to prevent damage.
  • If you have unused Viibryd tablets, it is important to dispose of them properly.
  • Safe disposal prevents accidental ingestion by children or pets and helps protect the environment.
  • Consult your pharmacist or a local waste management authority for guidance on how to safely dispose of the medication.

[Note: Discuss with your healthcare professional about the proper disposal of any unused medicine and any questions you may have regarding its storage.]

Viibryd Interactions

Viibryd may interact with various medications, supplements, and certain foods, leading to diverse effects. Some interactions may affect the effectiveness of the drug, while others could intensify side effects or make them more severe. It’s important to discuss all medications, supplements, and significant dietary habits with your healthcare provider to ensure that Viibryd is safe and effective for your use.

Interactions with Other Medications

Below is a summary of some medications that may interact with Viibryd:

  • Interactions with CYP3A4 Inducers: Medications known as CYP3A4 inducers can decrease the level of Viibryd in your body, potentially reducing its effectiveness. If you take a CYP3A4 inducer for at least two weeks while on Viibryd, you might require a higher dose of Viibryd. Your doctor would typically adjust your dose gradually, potentially increasing it to 60 mg or 80 mg over one to two weeks. Conversely, if you stop taking a CYP3A4 inducer while on Viibryd, your doctor will need to reduce your Viibryd dose gradually, also over one to two weeks, to avoid excessive levels of the medication in your body. Common examples of CYP3A4 inducers include:
    • Dilantin (phenytoin), used primarily for managing seizures.
    • Tegretol (carbamazepine), used for seizures and various other conditions.
    • Rifadin (rifampin), an antibiotic used to treat bacterial infections.
  • Interactions with Adderall: Viibryd works by increasing serotonin levels in your body, a chemical that affects mood. Adderall, an amphetamine used primarily to treat attention disorders, can also increase serotonin levels. Combining Viibryd and Adderall may lead to excessively high serotonin levels, a condition known as serotonin syndrome. Symptoms of serotonin syndrome include a racing heartbeat, sweating, and fluctuations in blood pressure, which can be serious.
  • Interactions with MAOIs: If you are considering Viibryd and are currently taking a monoamine oxidase inhibitor (MAOI), it is crucial to discuss this with your doctor. MAOIs can significantly increase your risk of developing serotonin syndrome, a potentially life-threatening condition if not addressed promptly. Symptoms of serotonin syndrome include rapid heart rate, confusion, high blood pressure, and fever, among others. Viibryd should not be taken within 14 days of stopping an MAOI to avoid this risk. Always consult your doctor if you have questions about the compatibility of MAOIs with Viibryd or if you’re considering any changes in your medication regimen. If you experience any symptoms of serotonin syndrome, contact your doctor immediately. Examples of MAOIs include:
    • ProvayBlue (methylene blue), used to treat methemoglobinemia, a blood disorder.
    • Zyvox (linezolid), an antibiotic for treating bacterial infections.
  • Interactions with CYP3A4 inhibitors: Taking Viibryd in doses above 20 mg alongside medications known as CYP3A4 inhibitors can lead to increased side effects because these inhibitors raise the levels of Viibryd in your body. If you need to stop using a CYP3A4 inhibitor while taking Viibryd, it’s important to consult with your doctor, who may need to adjust your dose of Viibryd accordingly. Always discuss with your healthcare provider the potential interactions and necessary dose adjustments when combining Viibryd with these or other CYP3A4 inhibitors. Examples of CYP3A4 inhibitors include:
    • Biaxin (clarithromycin), an antibiotic used to treat bacterial infections.
    • Vfend (voriconazole) and Sporanox (itraconazole), which are antifungal medications.
  • Interactions with Xanax: If you are taking Viibryd along with Xanax (alprazolam), which is commonly prescribed for anxiety, it’s important to assess how you feel before engaging in activities that require alertness, such as operating heavy machinery or driving. Although there isn’t a direct pharmacological interaction between Viibryd and Xanax, both medications impact the brain and nervous system. This can lead to side effects like dizziness, drowsiness, or fatigue, which could impair your ability to safely perform certain tasks if you are using Xanax or other medications to manage anxiety; discuss with your doctor how to safely use Viibryd alongside these treatments.
  • Interactions with Certain Migraine Medications: Using Viibryd in combination with specific migraine medications can increase your risk of developing serotonin syndrome, a serious condition that necessitates immediate medical attention. Symptoms of serotonin syndrome include agitation, hallucinations, rapid heart rate, and changes in blood pressure, among others. If you experience any of these symptoms, it is crucial to contact your doctor immediately. Before starting Viibryd, inform your doctor if you are taking any migraine medications. This allows your doctor to monitor you more closely for potential side effects and to consider alternative treatments for migraines if necessary. Migraine medications known to interact with Viibryd include:
    • Maxalt (rizatriptan)
    • Imitrex (sumatriptan)
    • Frova (frovatriptan)
    • Relpax (eletriptan)
    • Axert (almotriptan)
  • Interactions with Drugs that Can Increase the Risk of Bleeding: Taking Viibryd may heighten your risk of experiencing bleeding events. This risk becomes even more significant when Viibryd is used in conjunction with other medications known to increase bleeding tendencies, such as antiplatelets and anticoagulants, which are typically prescribed to prevent blood clots. These medications thin the blood and can elevate the likelihood of bleeding. It’s crucial to monitor for signs of bleeding if you are on Viibryd, especially symptoms like bruising, nosebleeds, or the presence of blood in your urine or stool. If you are taking any medications that might increase bleeding risks, it’s important to discuss this with your doctor before starting Viibryd. Examples of anticoagulants and antiplatelets include:
    • Xarelto (rivaroxaban)
    • Coumadin (warfarin)
    • Pradaxa (dabigatran)
    • Plavix (clopidogrel)
  • Interactions with Certain Depression or Anxiety Medications: When taking Viibryd along with other medications for depression or anxiety, there is an elevated risk of developing serotonin syndrome, a potentially life-threatening condition. Symptoms can include confusion, rapid heart rate, high blood pressure, and excessive sweating, among others. If you experience any of these symptoms, it is critical to inform your doctor immediately. Before beginning treatment with Viibryd, make sure to tell your doctor if you are already taking any medications for depression or anxiety. This is important because your doctor might need to monitor you more closely for adverse effects or consider prescribing a different medication based on your specific needs. Some of the medications for depression or anxiety that are known to interact with Viibryd include:
    • Lexapro (escitalopram)
    • Paxil (paroxetine)
    • Celexa (citalopram)
    • Effexor (venlafaxine)
    • Prozac (fluoxetine)
    • Amitriptyline (amitriptyline)
  • Interactions with Digoxin: If you are prescribed the heart medication Lanoxin (digoxin) while also taking Viibryd, you may require a lower dose of digoxin than normally prescribed. Viibryd has the potential to increase the levels of digoxin in your body, which could lead to heightened effects or side effects. To ensure that digoxin levels remain within a safe and effective range, your doctor will likely conduct more frequent monitoring. 
  • Interactions with Drugs Not Used for Clotting Disorders: Medications not primarily used for treating clotting disorders may also raise bleeding risks, including other antidepressants and nonsteroidal anti-inflammatory drugs (NSAIDs) such as:
    • Bayer (aspirin)
    • Advil (ibuprofen)
    • Aleve (naproxen)
Viibryd and herbs and supplements

Before using any herbal products or supplements while on Viibryd, it’s essential to consult with your doctor or pharmacist. Some supplements might alter the levels of Viibryd in your body, potentially affecting its efficacy and safety. Additionally, supplements like tryptophan and St. John’s wort are known to possibly increase the risk of serotonin syndrome, a serious medical condition, although definitive studies confirming these interactions are lacking. 

Symptoms of serotonin syndrome include high body temperature, agitation, increased reflexes, tremor, sweating, dilated pupils, and diarrhea. If you experience any of these symptoms, contact your doctor immediately. If you are currently taking tryptophan or St. John’s wort, make sure to inform your doctor. Depending on your situation, your doctor may advise you to discontinue these supplements while being treated with Viibryd to prevent any potential adverse effects.

[Note: This isn’t a complete list, and there could be other drugs that interact with Viibryd. Make sure to tell your doctor about any prescription, over-the-counter medicines, and herbal products you’re taking.]

Viibryd Alternatives

[Note: Your doctor will choose what’s best for you. Don’t use any of these alternative medications without consulting your healthcare provider. Taking them by yourself may cause serious side effects.]

Frequently Asked Questions Based On Viibryd

Is Viibryd an SSRI?

Yes, Viibryd is classified as a selective serotonin reuptake inhibitor (SSRI). SSRIs work by increasing the level of serotonin, a brain chemical that is believed to influence mood, in your body. The exact mechanism of how Viibryd works isn’t fully understood. What makes Viibryd distinct from other SSRIs is its additional action on serotonin receptors. These receptors are like docking stations on the surface of cells where serotonin can attach. By binding to these receptors, Viibryd mimics the action of serotonin. This dual action is thought to help balance serotonin levels in the brain more effectively. Due to these unique properties, Viibryd is also considered a miscellaneous antidepressant, slightly different from typical SSRIs.

Is Viibryd a controlled substance?

No, Viibryd is not classified as a controlled substance. Controlled substances are drugs that are subject to stricter regulations due to their potential for misuse, dependence, or addiction. Viibryd does not fall into this category, meaning it is regulated like other regular prescription medications rather than requiring the additional restrictions that apply to controlled substances.

Is weight gain a side effect of Viibryd?

Weight gain is not commonly reported as a side effect by people taking Viibryd, according to clinical studies. However, like many antidepressants, Viibryd can potentially cause changes in appetite, which may lead to weight gain or weight loss. It’s important to note that while Viibryd does not frequently cause weight gain, individual reactions can vary. Some antidepressants, such as Remeron (mirtazapine), are more likely to lead to weight gain compared to others. If you are concerned about weight changes while taking Viibryd, it’s a good idea to discuss this with your doctor. They can help you manage any potential weight changes by reviewing and possibly adjusting your diet and exercise routine.

Does Viibryd cause any sexual side effects?

Yes, Viibryd can cause sexual side effects, as reported in clinical studies. These side effects may include erectile dysfunction, changes in orgasm, decreased sex drive, and abnormal ejaculation. During the studies, up to 4% of individuals taking Viibryd experienced these issues, compared to up to 1% of those who received a placebo (a treatment without any active medication).

Sexual side effects are relatively common with antidepressants and can also occur with medications used for treating depression and anxiety. However, some antidepressants, such as bupropion (Wellbutrin XL) and mirtazapine (Remeron), are generally associated with fewer sexual side effects. If you are experiencing bothersome sexual side effects while taking Viibryd, it is important to discuss this with your doctor. They can offer treatment options or consider prescribing a different medication that may have a lower risk of these side effects.

How long does it take to work?

You might not notice significant improvements in your depression symptoms immediately after starting Viibryd. Typically, it can take about 2 to 4 weeks for you to start feeling better, though the timing can vary from person to person. Sometimes, others might notice improvements in your symptoms before you do. If you find your symptoms worsening or experience changes in thinking or mood after beginning treatment with Viibryd, it is crucial to discuss these changes with your doctor.

Is Viibryd safe for older adults who have depression?

Yes, Viibryd is approved for treating major depressive disorder (MDD) in adults, including those who are older. However, older adults might be more susceptible to certain side effects compared to younger individuals, such as hyponatremia—a condition characterized by low sodium levels in the blood. Symptoms of hyponatremia include dizziness, weakness, and headaches, and these can be serious.

While the dosing recommendations for Viibryd are generally the same for older adults as for younger adults, it is advisable for older adults to start with a lower dose. The dose can then be adjusted slowly if needed, based on how well the initial dose is tolerated.

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