# A 52-year-old man with major depressive disorder has been on venlafaxine 75 mg PO twice daily for 6 weeks. The dose was increased to 150 mg PO twice daily 4 weeks ago. He now reports persistent headache and tinnitus. Blood pressure measured today is 156/96 mmHg (baseline 124/78). Which action should the nurse take?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375257&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 52-year-old man with major depressive disorder has been on venlafaxine 75 mg PO twice daily for 6 weeks. The dose was increased to 150 mg PO twice daily 4 weeks ago. He now reports persistent headache and tinnitus. Blood pressure measured today is 156/96 mmHg (baseline 124/78). Which action should the nurse take?

## Option

1. Notify the prescriber about the new dose-related blood pressure rise, monitor BP, and review for additional pressor agents. **✔ Correct answer**
2. Increase the venlafaxine dose to 225 mg twice daily, monitor for improved mood, and advise the patient that headache and tinnitus are common.
3. Instruct the patient to stop venlafaxine immediately, and schedule a follow-up appointment for 1 week later to reassess symptoms.
4. Instruct the patient to reduce caffeine and dietary sodium, monitor his blood pressure at home weekly, and return to the clinic in 3 months.

**Correct answer: 1**

## Explanation

Venlafaxine causes a dose-dependent rise in blood pressure, especially at doses above 150 mg/day, due to its noradrenergic activity. Headache, tinnitus, and a measurable rise from baseline indicate a real medication effect, not just lifestyle. The nurse should promptly notify the prescriber so dose, BP monitoring frequency, and other pressor exposures (NSAIDs, decongestants, stimulants) can be reviewed. Increasing the dose worsens hypertension. Deferring the visit ignores a documented adverse effect. Abrupt self-discontinuation risks severe SNRI withdrawal (dizziness, electric-shock sensations, flu-like symptoms).

## In-depth explanation

SNRIs need a baseline BP and rechecks at every dose change — venlafaxine is the SNRI most likely to elevate BP; duloxetine has milder BP effects but still warrants monitoring.

## Clinical scenario

Scenario A 52-year-old man with MDD started venlafaxine 6 weeks ago, currently on 150 mg PO twice daily for 4 weeks. He reports daily headache and tinnitus. BP 156/96 mmHg, HR 88, regular; baseline BP 124/78. No fever, no chest pain. Home meds: venlafaxine 150 mg BID, atorvastatin 20 mg, multivitamin. No NSAIDs, decongestants, or stimulants on review.

## Key concepts

- **SNRI** — Serotonin-Norepinephrine Reuptake Inhibitor — venlafaxine, desvenlafaxine, duloxetine, levomilnacipran. Dual reuptake inhibition treats depression, generalized anxiety, neuropathic pain, fibromyalgia. Class effects: nausea, BP rise (venlafaxine > others), sweating, sexual dysfunction.
- **SNRI discontinuation** — Abrupt SNRI cessation, especially venlafaxine due to short half-life, causes dizziness, vertigo, brain zaps, flu-like symptoms, anxiety, GI upset within 24-48 hours. Tapering over 2-4 weeks or longer is required; severe cases may need a fluoxetine bridge.
- **Venlafaxine BP monitoring** — Baseline BP and serial monitoring after each dose increase, particularly above 150 mg/day. Sustained BP elevation may require dose reduction, switch to duloxetine, or addition of antihypertensive therapy.

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