Starting Dose for Duloxetine (Cymbalta)
The recommended starting dose for duloxetine (Cymbalta) is 30 mg once daily for one week before increasing to the target dose of 60 mg once daily. 1
Dosing Recommendations by Indication
Major Depressive Disorder
- Start with 30 mg once daily for 1 week to allow patients to adjust to the medication
- Increase to 60 mg once daily (target dose) after the first week
- Maximum dose: 120 mg daily (although no additional benefits have been demonstrated beyond 60 mg daily) 1
Generalized Anxiety Disorder
- Adults under 65: Start with 30 mg once daily for 1 week, then increase to 60 mg once daily
- Geriatric patients: Start with 30 mg once daily for 2 weeks before considering an increase to 60 mg daily 1
Diabetic Peripheral Neuropathic Pain
- Standard dose: 60 mg once daily
- For patients with tolerability concerns, a lower starting dose (30 mg daily) may be considered 1
- No evidence that doses higher than 60 mg provide additional benefit 1
Chronic Pain Conditions
- Start with 30 mg once daily
- Titrate according to response to treatment and tolerability to a maximum of 60 mg once daily 2
- For neuropathic pain, duloxetine has shown significant efficacy at 60 mg daily, with a 30-50% relative risk benefit in pain reduction 2
Administration Guidelines
- Administer orally with or without food
- Swallow capsules whole; do not chew, crush, or open the capsules 1
- Take at the same time each day for consistent blood levels
- If a dose is missed, take it as soon as remembered unless it's almost time for the next dose 1
Special Considerations
Renal Impairment
- Consider a lower starting dose and gradual increase for patients with renal impairment 1
- Avoid use in patients with creatinine clearance <30 mL/min 3
Hepatic Impairment
- Avoid use in patients with hepatic impairment 3
Food Interactions
- Taking duloxetine with food can improve tolerability, especially when starting at higher doses
- The benefit of taking with food is greatest in patients started at 60 mg once daily 4
Common Side Effects
- Nausea (most common reason for discontinuation)
- Dry mouth
- Constipation or diarrhea
- Sedation
- Headache
- Fatigue
- Anxiety
- Reduced appetite 2
Switching from Other Antidepressants
- Patients can be switched directly from SSRIs or venlafaxine to duloxetine 60 mg once daily without intermediate tapering or titration
- This direct switching approach has been shown to be well tolerated 5
Key Considerations for Optimal Use
- Starting at 30 mg once daily for one week significantly improves initial tolerability
- Most adverse events occur during the first week of treatment and are mild and transient 6
- Taking duloxetine with food can further improve tolerability, particularly when starting at higher doses 4
- Avoid abrupt discontinuation; taper gradually to prevent withdrawal symptoms
Duloxetine's efficacy and tolerability profile make it an effective option for multiple conditions, with the starting dose of 30 mg once daily for one week being the optimal approach to minimize side effects while establishing treatment.