What are the considerations for prescribing Cymbalta (duloxetine) to geriatric patients at risk of falls?

From the Guidelines

Prescribing Cymbalta (duloxetine) to geriatric patients at risk of falls should be done with caution, considering the potential for increased fall risk due to side effects such as orthostatic hypotension, dizziness, somnolence, and balance disturbances, as highlighted in studies such as 1. When considering the use of Cymbalta in elderly patients, it is essential to weigh the benefits against the potential risks. The medication can be effective for managing depression, anxiety, and pain, but the risk of falls, particularly in geriatric patients, must be carefully assessed.

Key Considerations

• Start with lower doses (20-30 mg once daily) and gradually titrate based on response and tolerability, as recommended for elderly patients.
• Close monitoring is crucial, especially during the initial weeks of treatment or after dose increases, due to the potential for increased fall risk.
• Patients should be advised to rise slowly from sitting or lying positions and to report any dizziness or balance issues immediately.
• Renal and hepatic function should be assessed before initiating therapy, as decreased clearance in elderly patients may lead to higher blood levels and increased side effects.

Alternative Treatments

Consider alternative treatments with lower fall risk profiles if the patient has a history of falls, significant orthostatic hypotension, or cognitive impairment. The American Geriatric Society (AGS) recommends multifactorial risk assessment with multicomponent interventions in older adults who have had 2 falls in the past year (1 fall if combined with gait or balance problems), have gait or balance problems, or present with an acute fall, as noted in 1.

Fall Prevention Strategies

In addition to careful medication management, other fall prevention strategies should be considered, including exercise and physical therapy interventions, such as group classes and at-home physiotherapy strategies, as well as vitamin D supplementation, as recommended by the U.S. Preventive Services Task Force (USPSTF) in 1 and 1.

Patient Assessment

A brief assessment of individual risk in primary care can help identify older persons at increased risk for falls, using factors such as age, history of falls, history of mobility problems, and poor performance on the timed Get-Up-and-Go test, as discussed in 1 and 1.

From the FDA Drug Label

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

When prescribing Cymbalta (duloxetine) to geriatric patients at risk of falls, consider the following key points:

• Increased risk of falls: Geriatric patients may be at a higher risk of falls due to various factors such as medications, medical comorbidities, and gait disturbances.
• Underlying risk factors: The risk of falls appears to be proportional to the patient's underlying risk factors, which increase steadily with age.
• Serious consequences: Falls can have serious consequences, including bone fractures and hospitalizations.
• Caution and monitoring: It is essential to exercise caution and closely monitor geriatric patients for falls when prescribing Cymbalta, especially if they have a history of falls or are at high risk of falling 2.

From the Research

Considerations for Prescribing Cymbalta to Geriatric Patients at Risk of Falls

• Geriatric patients are at a higher risk of falls due to various factors, including environmental hazards, medications, vision problems, and impairments in strength, gait, or balance 3
• A multifactorial fall-risk assessment is recommended for all older adults who present with a fall or problem with gait or balance, including a review of medications 3
• Antidepressant use, including medications like Cymbalta (duloxetine), has been associated with an increased risk of falls in geriatric patients 4, 5, 6
• The use of psychotropic medications, such as antidepressants, can increase the risk of falls by causing sedation, impaired balance and reaction time, hypotension, and drug-induced Parkinson's disease 6
• A study found that recent changes in psychotropic medications, including selective serotonin reuptake inhibitor (SSRI) antidepressants and non-SSRI/tricyclic antidepressants, were associated with a substantial increase in risk of hospital admission for falls and fractures 5
• Geriatric conditions, such as a history of falls and dependency in activities of daily living, can increase the risk of adverse drug reactions, including falls 7
• Physicians should be aware of the high-risk condition of elderly hospitalized patients with a history of falls and dependency in activities of daily living when prescribing new drugs, including Cymbalta 7