When can duloxetine (Cymbalta) 30 mg daily be stopped in an inpatient setting?

Duloxetine Discontinuation in the Inpatient Setting

Duloxetine should be tapered gradually over at least 2 weeks when discontinuing treatment, especially after therapy lasting longer than 3 weeks, to prevent withdrawal symptoms. 1, 2

Discontinuation Considerations

• Abrupt discontinuation of duloxetine is associated with a discontinuation-emergent adverse event (DEAE) profile similar to other SSRIs and SNRIs 2
• Common discontinuation symptoms include dizziness (12.4%), nausea (5.9%), headache (5.3%), paresthesia (2.9%), vomiting (2.4%), irritability (2.4%), and nightmares (2.0%) 2
• Most patients rate these symptoms as mild to moderate in severity 2
• Higher doses (120 mg/day) are associated with more discontinuation symptoms compared to lower doses 2

Tapering Protocol for Inpatient Setting

• For patients on 30 mg daily (standard starting dose), reduce to 20 mg daily for 1 week, then 10 mg daily for 1 week before discontinuation 1, 2
• For patients on higher doses, implement more gradual dose reductions (e.g., 25% reduction per week) 2
• If rapid discontinuation is necessary in the inpatient setting, be prepared to manage withdrawal symptoms 2

Monitoring During Discontinuation

• Monitor for emergence of discontinuation symptoms, particularly dizziness and nausea 2
• Most discontinuation symptoms resolve within 7 days (65% of cases), though some may persist longer 2
• Extended treatment beyond 8-9 weeks does not appear to increase the incidence or severity of discontinuation symptoms 2

Special Considerations

• Patients with renal or hepatic impairment may require more gradual tapering due to altered drug metabolism 1
• Consider the reason for discontinuation when planning the tapering schedule:
  • If switching to another antidepressant, cross-tapering may be appropriate 1
  • If discontinuing due to adverse effects, a more rapid taper may be necessary but with closer monitoring 3

Clinical Pitfalls to Avoid

• Never stop duloxetine abruptly after treatment longer than 3 weeks 2
• Do not underestimate the potential severity of discontinuation symptoms, which can impact patient comfort and compliance 2
• Avoid scheduling discharge immediately after discontinuation, as symptoms may emerge after leaving the hospital 2
• Remember that duloxetine is used for multiple indications (depression, anxiety, pain), so consider whether another medication needs to be substituted 4, 1

By following these guidelines, clinicians can minimize discontinuation symptoms and ensure patient comfort when stopping duloxetine therapy in the inpatient setting.