Duloxetine (Cymbalta) Dosing Recommendations
The recommended dosing for duloxetine is 60mg once daily for most indications, with an initial starting dose of 30mg daily for one week to improve tolerability before increasing to the therapeutic dose of 60mg daily. 1, 2
Standard Dosing by Indication
Diabetic Peripheral Neuropathic Pain
- Starting dose: 30mg once daily for 1 week
- Target dose: 60mg once daily
- No evidence that doses higher than 60mg provide additional benefit for neuropathic pain 1, 2
- For patients with renal impairment, consider lower starting dose with gradual increase 1
Major Depressive Disorder
- Starting dose: 30mg once daily for 1 week (to improve tolerability)
- Target dose: 60mg once daily
- Maximum dose: 120mg daily (60mg twice daily)
- While 120mg daily was shown effective, there is no evidence that doses greater than 60mg provide additional benefits 1
Generalized Anxiety Disorder
- Adults under 65: 60mg once daily (may start at 30mg daily for 1 week)
- Geriatric patients: 30mg once daily for 2 weeks before increasing to 60mg daily
- Pediatric patients (7-17 years): 30mg once daily for 2 weeks before considering increase to 60mg daily 1
Chronic Musculoskeletal Pain (Osteoarthritis, Low Back Pain)
- Standard dose: 60mg once daily 3
Administration Guidelines
- Take with or without food (taking with food may improve tolerability, especially at higher starting doses) 1, 4
- Swallow capsules whole - do not chew, crush, or open the capsule 1
- If a dose is missed, take it as soon as remembered unless it's almost time for the next dose 1
Dose Titration Considerations
- For patients with tolerability concerns, starting at 30mg daily for 1 week before increasing to 60mg daily significantly improves tolerability 4, 2
- Taking duloxetine with food can reduce nausea, particularly when starting at 60mg 4
- For patients with partial response at 60mg daily, dose may be increased to a maximum of 120mg daily (60mg twice daily) 2, 5
- When discontinuing duloxetine, especially at higher doses, a gradual taper over 2-4 weeks is strongly recommended to minimize withdrawal symptoms 2
Special Populations
- Renal impairment: Lower starting dose with gradual increase for patients with creatinine clearance <30 mL/min 1
- Hepatic impairment: Avoid use 1
- Elderly patients: Start at 30mg once daily for 2 weeks before considering dose increase 1
Monitoring and Safety
- Most adverse events occur during the first week of treatment and tend to resolve with continued therapy 5
- Common side effects include nausea, headache, dry mouth, dizziness, and decreased appetite 5
- Monitor for changes in blood pressure and heart rate, particularly in patients with hypertension 6
Clinical Pearls
- Duloxetine's analgesic effect is independent of its antidepressant activity and occurs at lower doses 7
- For neuropathic pain, if inadequate relief (<30% reduction) after 4 weeks at maximum tolerated dose, consider switching to an alternative first-line medication 2
- The therapeutic effect may begin within 1-2 weeks at the 60mg daily dose 8
- Duloxetine ranks highly as a treatment option for various pain conditions including diabetic neuropathy and fibromyalgia 7
By following these dosing recommendations and considering patient-specific factors, duloxetine can be effectively and safely used across its approved indications.