What is the recommended dosing for Cymbalta (duloxetine)?

Duloxetine (Cymbalta) Dosing Guidelines

For most conditions, duloxetine should be initiated at 30 mg once daily for 1 week before increasing to the target dose of 60 mg once daily, which is the optimal therapeutic dose for most indications. 1

Dosing by Indication

Diabetic Peripheral Neuropathic Pain

• Starting dose: 30 mg once daily for 1 week
• Target dose: 60 mg once daily
• There is no evidence that doses higher than 60 mg daily provide additional benefit, and higher doses are less well tolerated 1, 2
• For patients with renal impairment, consider a lower starting dose and gradual titration 1

Major Depressive Disorder

• Starting dose: 30 mg once daily for 1 week
• Target dose: 60 mg once daily (can be given as a single dose or as 30 mg twice daily)
• Maximum dose: While 120 mg/day was shown to be effective, there is no evidence that doses greater than 60 mg/day confer additional benefits 1, 3

Generalized Anxiety Disorder

• Adults under 65:
  • Start with 30 mg once daily for 1 week
  • Increase to 60 mg once daily
• Geriatric patients (≥65 years):
  • Start with 30 mg once daily for 2 weeks
  • Consider increasing to 60 mg once daily based on response and tolerability 1, 4
• Pediatric patients (7-17 years):
  • Start with 30 mg once daily for 2 weeks
  • Consider increasing to 60 mg once daily; recommended range is 30-60 mg daily 1

Fibromyalgia

• Starting dose: 30 mg once daily for 1 week
• Target dose: 60 mg once daily
• No evidence that doses greater than 60 mg/day provide additional benefit 1, 5

Chronic Musculoskeletal Pain

• Starting dose: 30 mg once daily for 1 week
• Target dose: 60 mg once daily
• No evidence that higher doses confer additional benefit 1, 5

Special Populations

Renal Impairment

• For severe renal impairment (GFR <30 mL/minute): Avoid use 1
• For moderate renal impairment: Consider lower starting dose and gradual titration 1

Hepatic Impairment

• Avoid use in patients with chronic liver disease or cirrhosis 1

Administration Guidelines

• Administer orally with or without food
• Swallow capsules whole; do not chew, crush, or open the capsules 1
• If a dose is missed, take it as soon as remembered. If it's almost time for the next dose, skip the missed dose and take the next dose at the regular time. Do not take two doses at the same time 1

Discontinuation

• Gradual reduction in dosage rather than abrupt cessation is recommended
• Common discontinuation symptoms include dizziness, headache, nausea, diarrhea, paresthesia, irritability, vomiting, insomnia, anxiety, hyperhidrosis, and fatigue 1

Drug Interactions

• Allow at least 14 days between discontinuing an MAOI and starting duloxetine
• Allow at least 5 days after stopping duloxetine before starting an MAOI 1
• Use caution when combining with other serotonergic drugs due to risk of serotonin syndrome 1

Monitoring

• Assess efficacy using pain scales at baseline and follow-up
• Schedule follow-up within 2-4 weeks of starting treatment to evaluate efficacy and side effects
• Set realistic expectations: aim for 30-50% pain reduction rather than complete pain relief 2, 6

Common Side Effects

• Nausea (most common, can be reduced by starting at lower dose)
• Dry mouth
• Somnolence
• Dizziness
• Constipation
• Fatigue 4, 3

Duloxetine 60 mg once daily has demonstrated consistent efficacy across multiple conditions with an acceptable tolerability profile when properly dosed and monitored.