What is the recommended dosing for Cymbalta (duloxetine)?

Recommended Duloxetine (Cymbalta) Dosing

For most adults with depression, anxiety, neuropathic pain, or fibromyalgia, duloxetine should be initiated at 30 mg once daily for one week before increasing to the target dose of 60 mg once daily. 1

Standard Dosing by Indication

• Major Depressive Disorder (MDD):

  • Initial: 30 mg once daily for 1 week 1, 2
  • Target: 60 mg once daily 1, 2
  • Maximum: While 120 mg/day has been studied, there is no evidence that doses higher than 60 mg/day provide additional benefit 1, 3

• Generalized Anxiety Disorder (GAD):

  • Adults <65 years: Start with 30 mg once daily for 1 week, then increase to 60 mg once daily 1, 4
  • Geriatric patients: Start with 30 mg once daily for 2 weeks before increasing to 60 mg once daily 1
  • Pediatric patients (7-17 years): Start with 30 mg once daily for 2 weeks before considering an increase to 60 mg once daily 1

• Diabetic Peripheral Neuropathic Pain:

  • Standard: 60 mg once daily 1
  • Lower starting doses may be considered for tolerability concerns 1, 5

• Fibromyalgia:

  • Initial: 30 mg once daily for 1 week 1
  • Target: 60 mg once daily 1

• Chronic Musculoskeletal Pain:

  • Initial: 30 mg once daily for 1 week 1
  • Target: 60 mg once daily 1

Administration Considerations

• Duloxetine may be taken with or without food, though taking with food may improve tolerability, especially at higher starting doses 5
• Taking duloxetine with food is particularly beneficial when starting at 60 mg once daily 5
• Duloxetine can be administered without regard to time of day 4

Special Populations

• Renal Impairment:

  • Not recommended for patients with creatinine clearance <30 mL/min 6, 1
  • For patients with renal impairment, consider lower starting dosage and gradual increase 1

• Hepatic Impairment:

  • Avoid use in patients with chronic liver disease or cirrhosis 1

• Geriatric Patients:

  • Start with 30 mg once daily for 2 weeks before increasing to 60 mg once daily 1

Monitoring and Discontinuation

• Assess for adverse effects at each follow-up visit, particularly those related to higher doses 6, 7
• Monitor blood pressure as duloxetine can cause modest hypertension 6, 8, 7
• Evaluate therapeutic response using standardized pain or depression scales 6, 8, 7
• When discontinuing, taper gradually to minimize withdrawal symptoms (dizziness, headache, nausea, diarrhea, paresthesia, irritability, vomiting, insomnia, anxiety, hyperhidrosis, and fatigue) 6, 1

Common Side Effects

• Most common adverse events include nausea, dry mouth, headache, constipation, dizziness, and fatigue 4, 2, 9
• Most adverse events are mild to moderate in severity 4, 2
• Starting at 30 mg once daily for 1 week can improve initial tolerability 5, 2

Drug Interactions

• 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
• Avoid concomitant use with potent CYP1A2 inhibitors 9
• Use with caution in patients receiving drugs metabolized by CYP2D6 9