Starting Dose of Duloxetine (Cymbalta) for Treatment
The recommended starting dose of duloxetine is 30 mg once daily for 1-2 weeks before increasing to the target therapeutic dose of 60 mg daily. 1, 2
Dosing Recommendations by Condition
Diabetic Peripheral Neuropathic Pain
- Start with 30 mg once daily for 1 week
- Increase to 60 mg once daily (target dose)
- Maximum dose: 60 mg daily (higher doses don't provide additional benefit) 1, 2
Major Depressive Disorder
- Start with 30 mg once daily for 1 week
- Increase to 60 mg once daily (target dose)
- Can be given as 30 mg twice daily or 60 mg once daily
- Maximum dose: 120 mg daily (though no additional benefit over 60 mg has been demonstrated) 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
Fibromyalgia
- Start with 30 mg once daily for 1 week
- Increase to 60 mg once daily (target dose) 1
Administration Considerations
Timing and Food
- Can be taken with or without food 1
- Taking duloxetine with food may improve initial tolerability, particularly when starting at higher doses 3
- Swallow capsules whole; do not chew, crush, or open the capsule 1
Special Populations
Elderly Patients
- Start at 30 mg once daily for 1-2 weeks
- Maximum recommended dose is 60 mg once daily
- Requires closer monitoring for side effects 2
Renal Impairment
- Consider lower starting dose with gradual increase for patients with renal impairment
- Duloxetine is contraindicated in patients with severe renal impairment (CrCl <30 mL/min) 2, 4
Hepatic Impairment
- Avoid duloxetine in patients with hepatic disease 2
Common Side Effects
- Nausea (most common reason for discontinuation)
- Dry mouth
- Headache
- Dizziness
- Somnolence or insomnia
- Constipation or diarrhea
- Decreased appetite 4
Important Considerations
- Lower starting doses (30 mg daily) are associated with better tolerability and lower discontinuation rates compared to starting directly at 60 mg daily 3
- Approximately 16% of patients may discontinue due to adverse effects 5
- For chemotherapy-induced peripheral neuropathy, an initial dose of 30 mg daily for the first week is recommended to reduce the likelihood of nausea, followed by an increase to 60 mg daily 4
Monitoring
- Schedule follow-up within 2-4 weeks to evaluate efficacy and side effects
- Assess pain reduction using a numerical pain rating scale (0-10)
- Set realistic expectations: aim for 30-50% pain reduction rather than complete pain relief 2
Starting at a lower dose of 30 mg daily and gradually increasing to 60 mg daily provides the best balance between efficacy and tolerability for most patients requiring duloxetine therapy.