Duloxetine Discontinuation Protocol for 20 mg Dose
Duloxetine at 20 mg should be tapered gradually over 2-4 weeks by reducing to 20 mg every other day for 1-2 weeks before complete discontinuation to minimize withdrawal symptoms.
Understanding Duloxetine Discontinuation
Duloxetine, a serotonin-norepinephrine reuptake inhibitor (SNRI), requires careful discontinuation to prevent withdrawal symptoms. Even at the relatively low dose of 20 mg, abrupt discontinuation can lead to significant discontinuation effects.
Withdrawal Symptoms to Monitor
Discontinuation-emergent adverse events (DEAEs) occur in approximately 44% of patients discontinuing duloxetine 1. The most common symptoms include:
- Dizziness (12.4%)
- Nausea (5.9%)
- Headache (5.3%)
- Paresthesia ("brain zaps") (2.9%)
- Irritability (2.4%)
- Vomiting (2.4%)
- Nightmares (2.0%)
Recommended Tapering Protocol for 20 mg Dose
- Weeks 1-2: Change from daily dosing to alternate-day dosing (20 mg every other day)
- Weeks 3-4: Further reduce to 20 mg every third day
- End of Week 4: Complete discontinuation
This gradual approach aligns with guidelines recommending that antidepressants be tapered slowly to minimize withdrawal effects 2.
Special Considerations
- Monitoring period: Continue monitoring for withdrawal symptoms for 2-4 weeks after complete discontinuation
- Symptom management: Mild symptoms can often be managed with reassurance that they are typically transient 3
- Adjustment if needed: If significant withdrawal symptoms occur, return to the previous dose and slow the taper further
When to Slow the Taper Further
For patients experiencing significant withdrawal symptoms during the standard taper, consider an extended taper:
- Reduce by smaller increments (e.g., opening the capsule and removing a portion of the beads)
- Extend the interval between dose reductions to 2-3 weeks
- For severe symptoms, return to the previous well-tolerated dose before attempting a slower taper
Important Cautions
- Misdiagnosis risk: Withdrawal symptoms may be mistaken for physical illness or depression relapse 3
- Severity assessment: Most patients rate withdrawal symptoms as mild to moderate 1
- Resolution timeline: The majority (65%) of withdrawal symptoms resolve within 7 days of onset 1
Follow-up Recommendations
Schedule a follow-up appointment 1-2 weeks after initiating the taper to assess for withdrawal symptoms and adjust the tapering schedule if needed.
By following this protocol, the risk of significant discontinuation symptoms can be minimized while safely discontinuing duloxetine 20 mg.