Duloxetine (Cymbalta) Dosing Recommendations
The recommended initial dose of duloxetine is 30 mg once daily for 1 week before increasing to 60 mg once daily, which is the standard effective dose for most indications. 1, 2
General Dosing Guidelines
- Start with 30 mg once daily for 1 week to improve initial tolerability and reduce the risk of nausea 1, 3
- Increase to the target dose of 60 mg once daily after the first week 2
- Duloxetine can be administered with or without food; capsules should be swallowed whole (not chewed, crushed, or opened) 2
- If a dose is missed, take it as soon as remembered unless it's almost time for the next dose 2
Indication-Specific Dosing
Major Depressive Disorder
- Initial dose: 40-60 mg/day (given as 20 mg twice daily or 30-60 mg once daily) 2
- For some patients, starting at 30 mg once daily for 1 week is recommended before increasing to 60 mg once daily 2
- Maximum dose: 120 mg/day, though no additional benefits have been consistently demonstrated beyond 60 mg/day 2, 4
Generalized Anxiety Disorder
- Adults <65 years: Start with 60 mg once daily (or 30 mg once daily for 1 week before increasing) 2
- Geriatric patients: Start with 30 mg once daily for 2 weeks before considering an increase to 60 mg/day 2
- Pediatric patients (7-17 years): Start with 30 mg once daily for 2 weeks before considering an increase to 60 mg/day 2
Diabetic Peripheral Neuropathic Pain
- Standard dose: 60 mg once daily 2, 5
- No evidence that doses higher than 60 mg provide additional significant benefit 2, 6
- Consider lower starting dose with gradual increase for patients with renal impairment 2
Chronic Musculoskeletal Pain (Osteoarthritis, Low Back Pain)
- Recommended dose: 60 mg once daily 7, 5
- Should be taken daily (not as needed) and discontinued only after consultation with the prescribing provider 7
Special Populations
- Renal insufficiency: Consider lower starting dose and more gradual titration 1, 2
- Elderly patients: Titrate more slowly, starting with 30 mg once daily 1, 2
- When discontinuing after >3 weeks of treatment: Taper over at least 2-4 weeks to minimize discontinuation symptoms 7
Safety Considerations
- Most common adverse effects include nausea, headache, dry mouth, dizziness, and decreased appetite 8
- The majority of adverse events occur during the first week of treatment, with fewer additional adverse events during dose escalation 8
- Routine liver enzyme monitoring is generally unnecessary 1
- Duloxetine does not typically produce clinically important electrocardiographic changes or blood pressure changes 1
- Should not be used in combination with CYP1A2 inhibitors or nonselective, irreversible monoamine oxidase inhibitors 3
Clinical Pearls
- For diabetic peripheral neuropathy, pain relief may begin within one week at the 60 mg/day dose 3, 6
- The 60 mg once-daily dosing has demonstrated efficacy across multiple pain conditions including diabetic neuropathy, fibromyalgia, and chronic musculoskeletal pain 5
- Starting at 30 mg daily and titrating to 60 mg after one week significantly reduces the incidence of nausea compared to starting directly at 60 mg 3, 8