What is the recommended titration schedule for Cymbalta (duloxetine)?

Duloxetine (Cymbalta) Titration Schedule

For most adults with depression, anxiety, or pain conditions, duloxetine should be initiated at 30 mg once daily for 1 week before increasing to 60 mg once daily to minimize side effects and improve tolerability. 1, 2

Standard Titration Protocol

• Start with 30 mg once daily for 1 week to allow patients to adjust to duloxetine before increasing to the target dose of 60 mg once daily 1
• For elderly patients (≥65 years) with generalized anxiety disorder, start with 30 mg once daily for 2 weeks before considering an increase to 60 mg once daily 1
• For pediatric patients (7-17 years) with generalized anxiety disorder, start with 30 mg once daily for 2 weeks before considering an increase to 60 mg once daily 1
• Administer duloxetine orally with or without food; capsules should be swallowed whole (do not chew, crush, or open the capsule) 1

Dose Adjustments Based on Indication

Major Depressive Disorder

• Initial: 30 mg once daily for 1 week, then increase to 60 mg once daily 1
• Maximum: While 120 mg/day was shown to be effective, there is no evidence that doses greater than 60 mg/day provide additional benefits 1

Generalized Anxiety Disorder

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

Diabetic Peripheral Neuropathic Pain

• Start directly with 60 mg once daily; for patients with tolerability concerns, a lower starting dose may be considered 1
• For patients with renal impairment, consider a lower starting dose with gradual increase 1

Fibromyalgia

• Start with 30 mg once daily for 1 week, then increase to 60 mg once daily 1
• No evidence that doses greater than 60 mg/day provide additional benefit 1

Monitoring During Titration

• During initial titration and dose adjustments, maintain weekly contact by telephone 3
• The titration phase typically requires 2-4 weeks to complete 3
• Systematically assess for side effects such as nausea, dizziness, sedation, hyperhidrosis, and modest hypertension 4
• Monitor blood pressure regularly as duloxetine can cause modest hypertension 3, 4
• Evaluate therapeutic response using standardized pain or depression scales 3, 4

Strategies to Improve Tolerability

• Taking duloxetine with food can significantly improve tolerability, particularly when starting at 60 mg once daily 2
• If tolerability is a concern, starting at 30 mg once daily is associated with fewer discontinuations due to adverse events compared to starting directly at 60 mg daily 2
• Most common adverse events include nausea, dry mouth, headache, constipation, dizziness, and fatigue 5

Maintenance Phase

• After titration, follow-up appointments should be made at least monthly until symptoms have stabilized 3
• Periodically reassess to determine the need for maintenance treatment and appropriate dosage 1
• If discontinuation is necessary, taper the dose gradually to minimize withdrawal symptoms 3

Common Pitfalls to Avoid

• Avoid starting directly at 60 mg/day without food in patients with known sensitivity to medications, as this may lead to higher discontinuation rates due to adverse events 2
• Do not administer duloxetine to patients with creatinine clearance <30 mL/min 3
• Never abruptly discontinue duloxetine; always taper gradually to minimize withdrawal symptoms 3
• Do not open, crush, or chew the delayed-release capsules as this affects the enteric coating 1