Starting Dose of Cymbalta (Duloxetine)
The recommended starting dose of Cymbalta (duloxetine) is 30 mg once daily for 1 week before increasing to the target dose of 60 mg once daily. 1
Dosing Recommendations by Indication
Diabetic Peripheral Neuropathic Pain
- Standard target dose: 60 mg once daily
- For patients with tolerability concerns: Start at 30 mg once daily for 1 week before increasing to 60 mg
- Maximum effective dose: 60 mg daily (higher doses don't provide additional benefit) 1
Major Depressive Disorder
- Starting dose: 40 mg/day (given as 20 mg twice daily) to 60 mg/day (given either once daily or as 30 mg twice daily)
- For patients needing adjustment time: 30 mg once daily for 1 week before increasing to 60 mg once daily
- Maximum effective dose: 60 mg daily (although 120 mg has been studied, no additional benefits were demonstrated) 1
Generalized Anxiety Disorder
- Adults under 65: 60 mg once daily (may start at 30 mg once daily for 1 week to improve tolerability)
- Geriatric patients: 30 mg once daily for 2 weeks before considering increase to 60 mg daily 1
Fibromyalgia
- Starting dose: 30 mg once daily for 1 week
- Target dose: 60 mg once daily 1
Administration Guidelines
- Take with or without food
- Swallow capsules whole (do not chew, crush, or open the capsule)
- Can be taken at any time of day 1
Tolerability Considerations
Starting at 30 mg once daily for one week significantly improves initial tolerability. Research has shown that patients who start at 30 mg once daily have fewer discontinuations due to adverse events compared to those starting at 60 mg once daily (3.6% vs. 10.2%) when taken without food 2.
Taking duloxetine with food can also improve tolerability, particularly when starting at the higher 60 mg dose 2. This strategy can help reduce nausea, which is one of the most common side effects.
Special Populations
Renal Impairment
- Consider lower starting dose with gradual increase for patients with renal impairment 1
Hepatic Impairment
- Avoid use in patients with significant liver disease 3
Elderly Patients
Common Side Effects
The most common treatment-emergent adverse events include:
- Nausea
- Dry mouth
- Headache
- Constipation
- Dizziness
- Fatigue 4
Most side effects are mild to moderate in severity and often diminish over time. Nausea is the most common reason for early discontinuation 2.
Clinical Pearl
For optimal tolerability when initiating duloxetine therapy, consider one of these approaches:
- Start at 30 mg once daily for 1 week, then increase to 60 mg once daily
- Take the medication with food, especially if starting at 60 mg daily 2
These strategies can significantly reduce early discontinuation due to adverse effects while still achieving therapeutic efficacy.