Starting Dose of Cymbalta (Duloxetine)
The recommended starting dose of Cymbalta (duloxetine) is 30 mg once daily for 1 week before increasing to the target therapeutic dose of 60 mg once daily. 1
Dosing Guidelines
The FDA-approved duloxetine dosing recommendations vary by indication:
Major Depressive Disorder (MDD):
- Start with 40 mg/day (given as 20 mg twice daily) to 60 mg/day (given either once daily or as 30 mg twice daily)
- For some patients, starting at 30 mg once daily for 1 week allows adjustment before increasing to 60 mg once daily 1
Generalized Anxiety Disorder (GAD):
- Adults under 65: Start at 60 mg once daily, or 30 mg once daily for 1 week before increasing to 60 mg
- Geriatric patients: Start at 30 mg once daily for 2 weeks before considering an increase to 60 mg/day 1
Diabetic Peripheral Neuropathic Pain:
- Start directly at 60 mg once daily
- For patients with tolerability concerns, a lower starting dose may be considered 1
Fibromyalgia:
- Begin treatment at 30 mg once daily for 1 week before increasing to 60 mg once daily 1
Administration Considerations
- Take with or without food; swallow capsules whole
- Do not chew, crush, or open the capsules as this affects the enteric coating
- If a dose is missed, take it as soon as remembered unless it's almost time for the next dose 1
Tolerability Optimization
Research shows that starting at 30 mg once daily for one week before increasing to 60 mg significantly improves initial tolerability. A clinical trial demonstrated that patients who started at 30 mg once daily had fewer discontinuations due to adverse events (3.6%) compared to those who started at 60 mg once daily (10.2%) when taken without food 2.
Taking duloxetine with food can also improve tolerability, particularly when starting at higher doses. The benefit of taking the drug with food was greatest in patients started at 60 mg once daily 2.
Common Side Effects
The most common side effects include:
Special Populations
- Renal Impairment: Consider a lower starting dose and gradual increase for patients with renal impairment 1
- Elderly Patients: Start at 30 mg once daily for 2 weeks before considering dose increases 1
Clinical Pearls
- Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI) that has noradrenergic effects, which contribute to its efficacy for pain conditions 3
- For painful conditions like diabetic peripheral neuropathy, the maximum recommended dose is 60 mg once daily, as higher doses don't confer additional benefit but increase side effects 1
- Discontinuation-emergent adverse events (most commonly nausea and dizziness) can occur in up to one-third of patients, so gradual tapering is recommended when stopping treatment 4
In summary, while the therapeutic dose of duloxetine is typically 60 mg daily for most indications, starting at 30 mg once daily for one week before increasing to 60 mg daily optimizes tolerability while maintaining efficacy.