What is the next dose when tapering from 90mg of Cymbalta (duloxetine)?

Duloxetine Tapering from 90mg: Next Dose Recommendation

When tapering from 90mg of Cymbalta (duloxetine), the next appropriate dose should be 60mg once daily.

Tapering Approach for Duloxetine

• A slow, gradual taper is recommended to minimize withdrawal symptoms when reducing duloxetine 1
• The most effective approach is to reduce the dose by approximately 25-30% of the original dose in the first step of tapering 1
• For a patient on 90mg of duloxetine, reducing by 30mg (approximately 33% reduction) to 60mg daily represents an appropriate first step 2, 1

Rationale for 60mg as Next Dose

• Duloxetine is commonly available in 30mg and 60mg capsules, making 60mg a practical next step in the tapering process 2
• This reduction aligns with the principle of hyperbolic tapering, which reduces serotonin transporter inhibition in a linear manner 3
• Starting with a 33% reduction is consistent with tapering protocols used for other medications that require gradual discontinuation 2

Tapering Schedule After Initial Reduction

• After 1-2 weeks at 60mg daily (with monitoring for withdrawal symptoms), the next step would be to reduce to 30mg daily 1
• Following 1-2 weeks at 30mg, options include:
  • Further reduction to 20mg (if available) 1, 4
  • Alternate day dosing (30mg every other day) 4
  • Extended interval dosing toward the end of the taper 4

Managing Withdrawal Symptoms

• Common duloxetine withdrawal symptoms include dizziness, nausea, headache, paresthesia, irritability, and anxiety 5
• If withdrawal symptoms become problematic during the taper:
  • Return temporarily to the previous dose 2, 1
  • Slow the taper rate to 10% reductions per month for greater tolerability 1, 4
  • Consider adjunctive medications for specific symptoms (e.g., short-term use of gabapentin for insomnia or anxiety) 1

Important Monitoring Considerations

• Schedule follow-up within 1-2 weeks after each dose reduction to assess for withdrawal symptoms 1
• Distinguish between withdrawal symptoms (which typically emerge within days of dose reduction) and recurrence of the original condition (which usually develops more gradually) 3, 5
• Be aware that withdrawal symptoms are often mistaken for relapse, potentially leading to unnecessary long-term medication continuation 3

Cautions and Pitfalls

• Avoid abrupt discontinuation as this significantly increases risk and severity of withdrawal symptoms 5
• Never skip the intermediate steps in tapering; each reduction should be smaller than the previous one 4, 6
• The final stages of tapering (below 30mg) may require the most gradual approach, as even small absolute reductions represent large percentage changes in receptor occupancy 3, 6
• For patients with severe withdrawal symptoms, consider even more gradual tapers with smaller decrements 2, 4