From the FDA Drug Label
Adverse reactions after discontinuation of duloxetine delayed-release capsules, after abrupt or tapered discontinuation, include: dizziness, headache, nausea, diarrhea, paresthesia, irritability, vomiting, insomnia, anxiety, hyperhidrosis, and fatigue A gradual reduction in dosage rather than abrupt cessation is recommended whenever possible
The patient is experiencing increased sweating (hyperhidrosis) and migraines, which could be related to the medications.
- Duloxetine dose is already at the recommended dosage of 60 mg once daily, and there is no evidence that doses higher than 60 mg once daily confer additional significant benefit.
- Fluoxetine and duloxetine are both serotonin reuptake inhibitors, and their combined use may increase the risk of adverse reactions. Considering the potential risks and benefits, it may be necessary to adjust the doses of these medications to minimize adverse reactions. However, any changes to the medication regimen should be made under the guidance of a healthcare professional, taking into account the patient's individual needs and medical history 1.
From the Research
The patient's fluoxetine and duloxetine doses should be adjusted to mitigate the increased sweating and migraines, with a recommended initial reduction of duloxetine to 30 mg daily while maintaining fluoxetine at 40 mg. This recommendation is based on the understanding that these symptoms are likely side effects of the serotonergic medications, particularly duloxetine, which has a stronger norepinephrine effect that can trigger sweating and headaches 2. The dose adjustments should be made under medical supervision with weekly follow-ups to monitor symptom improvement. Key considerations include:
- Increased fluid intake to help manage side effects
- Avoiding triggers like caffeine and alcohol
- Monitoring for symptoms of serotonin syndrome, such as confusion, rapid heart rate, and fever, due to the combination of two SSRIs/SNRIs 3
- Never stopping these medications abruptly to avoid discontinuation syndrome If symptoms persist after reducing duloxetine, consider gradually tapering fluoxetine to 20 mg daily. It's also worth noting that newer treatments for migraines, such as CGRP receptor antagonists and lasmiditan, have emerged as effective options 4, 2, but the primary concern here is adjusting the current medication regimen to alleviate the patient's symptoms.