What is the recommended dosing for Cymbalta (duloxetine) for anxiety?

Duloxetine Dosing for Anxiety

For anxiety disorders, duloxetine should be started at 30 mg once daily for 1 week before increasing to the recommended effective dose of 60 mg once daily. 1

Initial Dosing and Titration

• Starting dose: 30 mg once daily for 1 week

  • This lower initial dose helps patients adjust to duloxetine and reduces the risk of side effects, particularly nausea 1

• Target dose: 60 mg once daily

  • This is the FDA-approved effective dose for generalized anxiety disorder (GAD)
  • 60 mg once daily has been shown to be as effective as higher doses 2

• Administration: Take with or without food, swallow capsule whole

  • Do not chew, crush, or open the delayed-release capsule 1

Dosing Considerations for Special Populations

• Geriatric patients (≥65 years):

  • Start at 30 mg once daily for 2 weeks
  • Then consider increasing to 60 mg once daily if tolerated 1
  • Maximum studied dose was 120 mg per day

• Pediatric patients (7-17 years with GAD):

  • Start at 30 mg once daily for 2 weeks
  • Then consider increasing to 60 mg once daily
  • Recommended range is 30-60 mg once daily 1

• Patients with renal impairment:

  • Consider lower starting dose and gradual titration 1

Efficacy and Evidence

Duloxetine has demonstrated superior efficacy compared to placebo in multiple clinical trials for anxiety disorders:

• Short-term efficacy (9-10 weeks) established at 60-120 mg/day 3
• Long-term treatment prevents relapse in responders 3
• Improvements seen in:
  • Anxiety symptoms (HAM-A scores)
  • Functional impairment
  • Quality of life measures 3, 4

Common Side Effects

• Nausea (most common)
• Dry mouth
• Headache
• Constipation
• Dizziness
• Fatigue
• Diaphoresis 2, 3

Important Precautions

• Avoid in patients with:

  • Uncontrolled narrow-angle glaucoma
  • Concurrent use of MAOIs
  • CYP1A2 inhibitors (e.g., fluvoxamine, ciprofloxacin) 1, 5

• Monitor for:

  • Suicidal thinking and behavior (especially in young adults)
  • Serotonin syndrome when combined with other serotonergic agents
  • Blood pressure increases
  • Hepatic effects 2, 5

Duration of Treatment

• Adequate trial requires at least 4 weeks 2
• For long-term management, periodically reassess the need for continued treatment 1

Clinical Pearls

• While higher doses (up to 120 mg/day) have been studied, there is no consistent evidence that doses above 60 mg/day provide additional benefit for anxiety 1, 3
• Duloxetine has a long enough half-life (12 hours) to allow for once-daily dosing 3
• Discontinuation should be gradual to minimize withdrawal symptoms 3
• Duloxetine may be particularly useful in patients with comorbid pain conditions 6

Remember that while duloxetine is effective for anxiety, some patients may paradoxically experience increased anxiety or even panic attacks when initiating treatment, requiring close monitoring during the first few weeks 7.