Recommended Dosing for Duloxetine (Cymbalta)
For most adults with various conditions, duloxetine should be initiated at 30 mg once daily for 1 week before increasing to the target dose of 60 mg once daily. 1
Dosing by Indication
Diabetic Peripheral Neuropathic Pain
- Standard dose: 60 mg once daily 1, 2
- For patients with tolerability concerns, start at 30 mg once daily for one week before increasing to 60 mg 1
- No evidence that doses higher than 60 mg daily confer additional benefit 1, 2
Generalized Anxiety Disorder (GAD)
- Adults under 65: Start with 60 mg once daily; may start at 30 mg once daily for 1 week to improve tolerability 1
- Geriatric patients (≥65 years): Start at 30 mg once daily for 2 weeks before considering increase to 60 mg 1
- Maximum studied dose: 120 mg per day, though no evidence shows additional benefit beyond 60 mg 1, 3
Fibromyalgia
- Start at 30 mg once daily for 1 week, then increase to 60 mg once daily 1
- No evidence that doses greater than 60 mg daily provide additional benefit 1, 2
Chronic Musculoskeletal Pain
- Start at 30 mg once daily for 1 week, then increase to 60 mg once daily 1, 2
- No evidence that higher doses confer additional benefit 1
Special Populations
Renal Impairment
- Consider lower starting dose and gradual increase for patients with renal impairment 1
- Avoid use in severe renal impairment (GFR <30 mL/minute) 1
Hepatic Impairment
- Avoid use in patients with chronic liver disease or cirrhosis 1
Administration Considerations
Food and Timing
- May be administered without regard to food or time of day 1, 3
- Taking duloxetine with food may improve tolerability, particularly when starting at 60 mg once daily 4
- The benefit of starting at 30 mg once daily is greatest when taking the drug without food 4
Discontinuation
- Gradual reduction in dosage rather than abrupt cessation is recommended 1
- Common discontinuation symptoms include dizziness, headache, nausea, diarrhea, paresthesia, irritability, vomiting, insomnia, anxiety, hyperhidrosis, and fatigue 1
Monitoring
- Assess for adverse effects at each follow-up visit, particularly those related to higher doses 5
- Monitor blood pressure as duloxetine can cause modest hypertension 5
- Common adverse events include nausea, dry mouth, headache, constipation, dizziness, and fatigue 3, 6
Important Precautions
- Allow at least 14 days between discontinuation of an MAOI and initiation of duloxetine 1
- Allow at least 5 days after stopping duloxetine before starting an MAOI 1
- Do not start duloxetine in patients being treated with linezolid or intravenous methylene blue due to risk of serotonin syndrome 1