What are the considerations for prescribing Cymbalta (duloxetine) to an elderly patient over 85 years old?

From the Guidelines

Prescribing Cymbalta (duloxetine) to an 86-year-old patient should be done with caution, considering a "start low, go slow" approach, due to the potential for adverse effects and interactions with other medications, as highlighted in the study by 1. When prescribing Cymbalta to elderly patients, it's essential to begin with a lower dose, typically 20-30 mg once daily, rather than the standard adult starting dose of 60 mg. This approach allows for gradual dose adjustments, with at least 1-2 weeks between increases, to monitor for adverse effects. Elderly patients often experience altered drug metabolism and elimination due to age-related changes in liver and kidney function, making them more susceptible to side effects. Some key considerations when prescribing Cymbalta to elderly patients include:

• Increased risk of falls, orthostatic hypotension, cognitive impairment, hyponatremia, and drug interactions, especially if the patient is on multiple medications
• Renal function should be assessed before starting therapy and periodically thereafter, with dose adjustments for patients with significant renal impairment
• Close monitoring for adverse effects is essential, particularly during the initial weeks of treatment
• Patients and caregivers should be educated about potential side effects, including dizziness, somnolence, dry mouth, and the need to discontinue the medication gradually to avoid withdrawal symptoms
• Regular follow-up appointments are necessary to evaluate treatment efficacy and tolerability, as recommended by 1 and 1. It's also important to consider the patient's overall health, including their physical and cognitive function, quality of life, and life expectancy, when making decisions about prescribing Cymbalta, as emphasized in the study by 1.

From the FDA Drug Label

In the MDD, GAD, DPNP, FM, OA, and CLBP studies, no overall differences in safety or effectiveness were generally observed between these patients and younger adult patients, and other reported clinical experience has not identified differences in responses between these geriatric and younger adult patients, but greater sensitivity of some older patients cannot be ruled out SSRIs and SNRIs, including duloxetine delayed-release capsules have been associated with clinically significant hyponatremia in geriatric patients, who may be at greater risk for this adverse reaction [see WARNINGS AND PRECAUTIONS (5. 13)] . In an analysis of data from all placebo-controlled-trials, duloxetine delayed-release capsules-treated patients reported a higher rate of falls compared to placebo-treated patients. The increased risk appears to be proportional to a patient’s underlying risk for falls. Underlying risk appears to increase steadily with age As geriatric patients tend to have a higher prevalence of risk factors for falls such as medications, medical comorbidities and gait disturbances, the impact of increasing age by itself on falls during duloxetine delayed-release capsules treatment is unclear Falls with serious consequences including bone fractures and hospitalizations have been reported with duloxetine delayed-release capsules use [see WARNINGS AND PRECAUTIONS (5.3) and ADVERSE REACTIONS (6. 1)] .

Key Considerations for Prescribing Cymbalta to an Elderly Patient Over 85 Years Old:

• Greater Sensitivity: Older patients may be more sensitive to the effects of duloxetine.
• Hyponatremia Risk: Geriatric patients are at a higher risk for clinically significant hyponatremia.
• Fall Risk: Elderly patients have a higher risk of falls, which may be increased by duloxetine treatment.
• Dose Adjustment: No dosage adjustment is necessary based on age alone, but caution should be exercised when prescribing to elderly patients due to the potential for increased sensitivity and adverse reactions.
• Monitoring: Close monitoring of the patient's condition, including falls risk and hyponatremia, is recommended when prescribing duloxetine to an elderly patient 2.

From the Research

Considerations for Prescribing Cymbalta to Elderly Patients

When prescribing Cymbalta (duloxetine) to an elderly patient over 85 years old, several considerations must be taken into account.

• The patient's medical history, including any comorbidities and current medications, should be carefully reviewed to minimize the risk of adverse interactions 3.
• Elderly patients are more prone to develop adverse side-effects to usual dosages of medications, and the side-effects are even more frequent in elderly than in younger patients 3.
• The choice of appropriate medication for each particular disease is a complex process and can cause "therapeutic confusion", especially among younger GPs in the field 3.
• Professional geriatric societies have developed lists of potentially inappropriate medications for the elderly, such as The Beers Criteria list and STOPP/START criteria, which should be consulted when administering therapy to elderly patients 3.

Efficacy and Tolerability of Duloxetine

Studies have shown that duloxetine does not seem to provide a significant advantage in efficacy over other antidepressive agents for the acute-phase treatment of major depression 4.

• When compared with escitalopram or venlafaxine, there was a higher rate of drop out due to any cause in the patients randomized to duloxetine 4.
• There was also some weak evidence suggesting that patients taking duloxetine experienced more adverse events than paroxetine 4.
• However, the efficacy and tolerability of duloxetine in elderly patients specifically may vary, and caution should be exercised when prescribing this medication to this population 5.

Caution and Responsible Practice

It is especially important for prescribing psychiatric advanced practice nurses to update, review, and cross-reference older patients' lists of medications at every appointment 5.

• Prudent, responsible, cautious practice should be exercised to ensure that elderly patients achieve improved functionality, maintain safety, reduce risks, and enhance their quality of life 5.
• Although the obstacles to treating older adults may appear daunting, careful consideration and monitoring can help minimize potential risks and maximize benefits 5.