What is the recommended duration of duloxetine (selective serotonin-norepinephrine reuptake inhibitor) treatment for persistent paroxysmal perceptual dizziness?

Treatment Duration of Duloxetine for Persistent Paroxysmal Perceptual Dizziness

Duloxetine treatment for persistent paroxysmal perceptual dizziness should be continued for at least 1 year with effectiveness sustained throughout this period, based on the most recent evidence.

Medication Selection and Mechanism

• Duloxetine, a selective serotonin-norepinephrine reuptake inhibitor (SSNRI), is an appropriate medication choice for persistent paroxysmal perceptual dizziness (PPPD) due to its effectiveness in treating both the underlying neurological symptoms and associated anxiety 1
• The medication works by inhibiting the reuptake of serotonin and norepinephrine, which helps modulate both pain pathways and emotional responses that can exacerbate dizziness symptoms 1
• Serotonergic medication is considered one of the key therapeutic principles in multimodal treatment of PPPD, alongside cognitive-behavioral therapy and vestibular rehabilitation exercises 2

Dosing and Duration Recommendations

• Start with duloxetine 30 mg once daily for 1 week before increasing to 60 mg once daily to reduce the risk of nausea, which is the most common adverse effect 1
• 60 mg once daily appears to be as effective as 60 mg twice daily, with simpler dosing 1
• Treatment effectiveness has been shown to be sustained for 1 year in open-label trials, supporting long-term use for chronic conditions like PPPD 1
• For optimal results, continue treatment for at least 1 year, as PPPD is a chronic disorder with fluctuating symptoms that typically requires extended therapy 2

Monitoring and Follow-up

• Reassess symptoms frequently to evaluate pain relief and health-related quality of life 1
• If substantial symptom relief occurs (e.g., average pain/dizziness reduced to ≤3/10) with tolerable side effects, continue treatment for the full recommended duration 1
• If partial relief occurs (e.g., symptoms remain ≥4/10) after an adequate trial, consider adding other first-line treatments such as vestibular rehabilitation 1, 2
• If inadequate relief occurs (e.g., <30% reduction in symptoms) at target dosage after an adequate trial, consider switching to an alternative medication 1

Safety Considerations

• Unlike tricyclic antidepressants, duloxetine does not appear to produce clinically important electrocardiographic or blood pressure changes 1
• Routine aminotransferase monitoring is unnecessary according to recent reviews 1
• Be aware that abrupt discontinuation of duloxetine is associated with discontinuation-emergent adverse events in approximately 44.3% of patients 3
• Common discontinuation symptoms include dizziness (12.4%), nausea (5.9%), headache (5.3%), and paresthesia (2.9%) 3

Discontinuation Protocol

• When discontinuing duloxetine, gradually reduce the dose over no less than 2 weeks to minimize discontinuation symptoms 3
• Most discontinuation symptoms are mild to moderate in severity and resolve within 7 days 3
• The risk of discontinuation symptoms appears higher with 120 mg/day compared to lower doses 3

Multimodal Approach

• Duloxetine should be part of a comprehensive treatment plan that includes:
  • Cognitive-behavioral therapy to address anxiety components that may exacerbate PPPD 2, 4
  • Vestibular rehabilitation exercises to improve balance and reduce dizziness 2
  • Patient education about the condition and its management 2
• Follow-up observations after multimodal interdisciplinary therapy reveal improvement in symptoms in most patients with chronic dizziness 2

Special Considerations

• For patients with comorbid anxiety disorders, which are common precipitating conditions for PPPD, duloxetine offers the advantage of treating both the dizziness and anxiety symptoms 4
• Extended treatment beyond 8-9 weeks does not appear to be associated with increased incidence or severity of discontinuation symptoms 3
• PPPD is the most common cause of chronic vestibular symptoms, emphasizing the importance of appropriate long-term management 5