Guidelines for Prescribing Duloxetine
Duloxetine should be prescribed as a second-line or combination treatment for osteoarthritis pain and as a first-line option for neuropathic pain, with careful consideration of patient-specific factors and appropriate dosing protocols. 1, 2
Indications for Duloxetine
Osteoarthritis Pain
- Duloxetine is recommended as a second-line or combination treatment for osteoarthritis of the hip and knee when initial treatments (topical NSAIDs, acetaminophen, oral NSAIDs) provide inadequate pain relief 1
- Particularly effective in older patients (>65 years) and those with knee osteoarthritis 1
- Small to moderate benefits for pain and function at short-term assessment (3-6 months) 1
Neuropathic Pain
- First-line option for diabetic peripheral neuropathy 2
- Effective for neuropathic pain with evidence of significant pain reduction 3
- Consider as part of a step-wise approach, either as monotherapy or in combination with gabapentin for refractory cases 2
Other Approved Indications
- Major Depressive Disorder
- Generalized Anxiety Disorder
- Fibromyalgia
- Chronic musculoskeletal pain
Dosing Protocol
Initial Dosing
- Osteoarthritis: Start at 30 mg/day and increase to goal of 60 mg/day 1
- Neuropathic Pain: Start at 30-60 mg/day 2
- Generalized Anxiety Disorder:
- Adults <65 years: 60 mg once daily (may start at 30 mg once daily for 1 week to allow adjustment) 4
- Geriatric patients: 30 mg once daily for 2 weeks before considering increase to 60 mg/day 4
- Pediatric patients (7-17 years): 30 mg once daily for 2 weeks before considering increase to 60 mg once daily 4
Administration
- Take orally with or without food
- Swallow capsules whole - do not chew, crush, or open capsules 4
- Administer once daily or divided into twice daily dosing depending on indication
Dose Adjustments
- For renal impairment: Dose adjustment required 2
- Avoid in patients with GFR <30 mL/min 2
- Avoid in patients with chronic liver disease 2
Monitoring and Follow-up
Initial Response Assessment
- Assess response after 4-6 weeks of treatment 2
- If inadequate response, consider:
- Dose optimization
- Switching to alternative agent
- Combination therapy
Long-term Monitoring
- Periodically reassess need for continued treatment 4
- Monitor for:
Important Precautions
Discontinuation
- Do not abruptly discontinue - taper over at least 2-4 weeks for those treated longer than 3 weeks 1
- Discontinuation-emergent adverse events (commonly nausea and dizziness) occur in up to one-third of patients 5
Special Populations
- Elderly: More susceptible to CNS effects and falls 2
- Cardiac disease: Monitor for cardiovascular effects 2
- Pregnancy: Consider risks/benefits
Drug Interactions
- Use caution with CYP1A2 inhibitors 5
- Use caution with drugs metabolized by CYP2D6, particularly those with narrow therapeutic index 5
Patient Education Points
- Duloxetine is taken daily (not as needed) 1
- Discontinue only after consultation with prescribing provider 1
- Full effects may take several weeks
- Common side effects include nausea, dry mouth, headache, constipation, dizziness, and fatigue 5
- Report worsening depression or suicidal thoughts immediately
Contraindications
- Concomitant use of MAOIs
- Uncontrolled narrow-angle glaucoma
- Severe renal impairment (GFR <30 mL/min) 2
- Chronic liver disease 2
Duloxetine has demonstrated efficacy across multiple pain conditions with a generally acceptable safety profile. Most adverse events are mild to moderate, with nausea being the most common reason for discontinuation. When prescribed according to these guidelines with appropriate monitoring, duloxetine can be an effective component of pain management strategies.