Discontinuing Duloxetine and Starting Amitriptyline for Nerve Pain
When switching from duloxetine (Cymbalta) to amitriptyline for nerve pain, a gradual taper of duloxetine over 2-4 weeks is strongly recommended, followed by starting amitriptyline at 10mg daily after a brief washout period of 1-2 days.
Duloxetine Discontinuation Process
Duloxetine requires careful discontinuation to avoid withdrawal symptoms, which can be significant:
Common withdrawal symptoms: Dizziness, headache, nausea, diarrhea, paresthesia, irritability, vomiting, insomnia, anxiety, hyperhidrosis, and fatigue 1
Recommended taper schedule:
- If on 60mg daily: Reduce to 30mg daily for 1-2 weeks, then 30mg every other day for 1-2 weeks, then discontinue
- If on 30mg daily: Reduce to 30mg every other day for 1-2 weeks, then discontinue
- If on 120mg daily: Reduce to 60mg daily for 1 week, then 30mg daily for 1-2 weeks, then 30mg every other day for 1 week, then discontinue
Monitoring during taper: Watch for emergence of withdrawal symptoms; if they occur, slow the taper further 1
Starting Amitriptyline
After completing the duloxetine taper, allow a brief washout period of 1-2 days before starting amitriptyline:
Initial dosing: Start at 10mg once daily at bedtime as indicated in your prescription 2, 3
Titration: The dose can be gradually increased by 10-25mg every 1-2 weeks based on response and tolerability, with a typical target dose of 25-75mg daily for neuropathic pain 3
Administration timing: Take amitriptyline at bedtime to minimize daytime sedation 3
Rationale for Medication Switch
The switch from duloxetine to amitriptyline may be appropriate for certain patients:
Efficacy considerations: Both medications have evidence for neuropathic pain management, though the evidence for amitriptyline is considered moderate quality 2, 4
Comparative efficacy: In diabetic peripheral neuropathy, both medications have shown similar efficacy, with a recent high-quality crossover trial showing comparable pain reduction 5
Cost considerations: Amitriptyline is generally less expensive than duloxetine, which may be a factor in medication selection
Special Considerations and Monitoring
Avoid abrupt discontinuation of duloxetine as this significantly increases risk of withdrawal symptoms 1
Serotonin syndrome risk: Monitor for signs of serotonin syndrome during the transition period, especially if there is any overlap between medications 1
Anticholinergic effects: Amitriptyline has more pronounced anticholinergic effects than duloxetine (dry mouth, constipation, urinary retention, blurred vision) 3
Cardiac considerations: Amitriptyline has greater potential for cardiac effects than duloxetine; caution in patients with cardiovascular disease 3
Sedation: Amitriptyline is more sedating than duloxetine, which can be beneficial for patients with sleep disturbances but problematic for daytime functioning 3, 6
Expected Outcomes
Pain relief: Expect gradual improvement in nerve pain over 2-4 weeks after reaching an effective dose of amitriptyline 7, 8
Response rates: Clinical trials suggest approximately 38% of patients achieve meaningful pain relief with amitriptyline compared to 16% with placebo 7
Combination therapy: If pain relief is inadequate with amitriptyline monotherapy, adding pregabalin may provide additional benefit 5
The transition from duloxetine to amitriptyline requires careful management but can be accomplished safely with appropriate tapering and monitoring.