What is the recommended dosing for duloxetine (Cymbalta)?

Duloxetine (Cymbalta) Dosing Recommendations

The recommended dosing for duloxetine varies by indication, with most adult patients requiring 60 mg once daily as the target therapeutic dose, which can be initiated directly or titrated from a starting dose of 30 mg daily for one week to improve tolerability. 1

General Administration Guidelines

• Administer duloxetine orally with or without food
• Swallow capsules whole; do not chew, crush, or open the delayed-release capsule
• If a dose is missed, take it as soon as remembered unless it's almost time for the next dose
• Do not take two doses at the same time

Indication-Specific Dosing

Major Depressive Disorder (MDD)

• Starting dose: 40 mg/day (20 mg twice daily) to 60 mg/day (once daily or 30 mg twice daily)
• For some patients, start at 30 mg once daily for 1 week before increasing to 60 mg
• Maximum effective dose is 60 mg/day; no additional benefit shown with 120 mg/day 1

Generalized Anxiety Disorder (GAD)

• Adults <65 years: 60 mg once daily
• Geriatric patients: 30 mg once daily for 2 weeks before considering increase to 60 mg/day
• Pediatric patients (7-17 years): 30 mg once daily for 2 weeks before considering increase to 60 mg/day
• Dose range: 30-60 mg once daily 1

Diabetic Peripheral Neuropathic Pain

• Standard dose: 60 mg once daily
• No evidence that doses higher than 60 mg provide additional benefit
• Consider lower starting dose for patients with tolerability concerns 1

Chronic Musculoskeletal Pain (Low Back Pain, Osteoarthritis)

• Recommended dose: 60 mg once daily 2

Neuropathic Pain (Including Sciatica)

• Starting dose: 30 mg daily
• Target dose: 60-120 mg/day 3

Special Populations

Renal Impairment

• Consider lower starting dose and gradual increase for patients with renal impairment
• Particularly important for diabetic patients who often have comorbid renal disease 1

Hepatic Impairment

• Duloxetine is contraindicated in patients with liver disease 3

Elderly Patients

• More susceptible to side effects
• May require lower doses (start at 30 mg daily) 3

Tolerability Considerations

• Taking duloxetine with food can improve tolerability, especially when starting at 60 mg 4
• Starting at 30 mg once daily for one week before increasing to 60 mg can reduce initial side effects 4
• Most adverse events occur during the first week of treatment and are transient 5

Common Side Effects to Monitor

• Nausea (most common reason for discontinuation)
• Dry mouth
• Headache
• Constipation
• Dizziness
• Fatigue 6, 7

Important Precautions

• Do not stop duloxetine abruptly; requires gradual tapering to avoid withdrawal symptoms 3
• Monitor for somnolence and dizziness, especially when initiating therapy
• Use caution in patients on anticoagulants or with bleeding disorders due to increased bleeding risk
• Avoid heavy alcohol use due to risk of severe liver injury 3

Clinical Pearl

When initiating duloxetine for chronic pain conditions, the 60 mg once-daily dosing has been shown to be effective across multiple pain syndromes, making it a versatile option for patients who may also have comorbid depression or anxiety 2.