What is the recommended gradual dose reduction for a patient taking Cymbalta (duloxetine) 90mg?

Gradual Dose Reduction for Duloxetine (Cymbalta) 90mg

For a patient taking Cymbalta (duloxetine) 90mg, the recommended gradual dose reduction is to decrease by 30mg every 2 weeks, slowing to 20mg reductions when reaching 30mg, with the final step being 20mg every other day before discontinuation. 1

Tapering Schedule for Duloxetine 90mg

The tapering schedule should follow this pattern:

• Week 1-2: 90mg daily
• Week 3-4: 60mg daily
• Week 5-6: 30mg daily
• Week 7-8: 20mg daily
• Week 9-10: 20mg every other day
• Week 11: Discontinue

Rationale for Gradual Tapering

Duloxetine requires careful tapering to minimize discontinuation syndrome, which can include:

• Dizziness
• Headache
• Nausea
• Paresthesia (electric shock sensations)
• Irritability
• Anxiety
• Insomnia
• Hyperhidrosis (excessive sweating)
• Fatigue 2

The FDA drug label specifically states: "A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible" 2. This is because abrupt discontinuation can lead to severe withdrawal symptoms that significantly impact patient quality of life.

Risk Factors for More Severe Withdrawal

Certain patients may require an even more gradual taper:

• Those with history of severe withdrawal symptoms
• Patients who have been on duloxetine for >1 year
• Patients with anxiety disorders 1

For these high-risk patients, consider reducing by only 10-15% of the current dose every 2 weeks rather than fixed decrements.

Managing Withdrawal Symptoms

If significant withdrawal symptoms occur during tapering:

1. Pause the taper at the current dose
2. Wait 1-2 weeks for symptoms to stabilize
3. Resume tapering at a slower rate (5% reduction instead of larger decrements) 1

Adjunctive Medications for Symptom Management

The following medications can help manage specific withdrawal symptoms:

• Hydroxyzine or gabapentin for anxiety
• Trazodone or mirtazapine for sleep disturbances
• NSAIDs or acetaminophen for headaches/pain 1

Monitoring During Tapering

Schedule follow-up visits at least every 2 weeks during the tapering process to monitor for:

• Withdrawal symptoms (insomnia, nausea, headache, diarrhea, anxiety)
• Changes in mood or suicidal thoughts
• Need for adjunctive treatments 1

Common Pitfalls to Avoid

1. Tapering too rapidly: This is the most common mistake and can lead to severe withdrawal symptoms and treatment failure
2. Inadequate symptom management: Failure to address emerging symptoms can lead to taper failure
3. Insufficient follow-up: Regular monitoring is essential to adjust the taper as needed
4. Abrupt discontinuation: This should never be done with duloxetine due to high risk of discontinuation syndrome 1

By following this gradual tapering schedule and monitoring closely for withdrawal symptoms, the risk of discontinuation syndrome can be minimized while successfully reducing and eventually stopping duloxetine 90mg.