Discontinuing Cymbalta (Duloxetine)
Taper duloxetine gradually over at least 4 weeks, reducing the dose incrementally rather than stopping abruptly, to minimize withdrawal symptoms including dizziness, headache, nausea, paresthesia, and irritability.
Understanding Withdrawal Risk
Duloxetine discontinuation commonly produces withdrawal symptoms that can be distressing but are usually self-limiting 1. The FDA label explicitly warns that discontinuation may cause dizziness, headache, nausea, diarrhea, paresthesia, irritability, vomiting, insomnia, anxiety, hyperhidrosis, and fatigue 1. These symptoms occurred at significantly higher rates than placebo in clinical trials 1. Duloxetine, along with venlafaxine and paroxetine, carries higher withdrawal risk compared to other antidepressants 2.
Recommended Tapering Protocol
Basic Taper Schedule
- Reduce the dose by 25% of the current dose every 1-2 weeks as the foundational approach 3
- Minimum taper duration should be 4 weeks, though longer tapers (weeks to months) are often necessary 2, 4
- For patients on duloxetine longer than 1 year, extend the taper to 10% reductions per month rather than the faster 25% schedule 3
Specific Duloxetine Dosing Considerations
Starting from the standard 60 mg once daily dose:
- Week 1-2: Reduce to 30 mg once daily (50% reduction, using the available 30 mg capsule) 5
- Week 3-4: Reduce to 20 mg once daily (if available) or alternate 30 mg every other day
- Week 5-6: Further reduce or discontinue based on tolerance
The taper rate must be determined by patient tolerance, not a rigid schedule 3. Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 3.
Managing Withdrawal Symptoms
If Symptoms Occur During Taper
- Resume the previous dose immediately if intolerable symptoms develop 1, 4
- Restart at the prior dose and taper more slowly (smaller decrements over longer intervals) 1, 4
- Provide symptomatic management as needed for specific complaints 4
Common Withdrawal Symptoms to Monitor
Monitor specifically for 1, 2:
- Dizziness and headache (most common)
- Nausea and gastrointestinal disturbances
- Paresthesias (electric shock sensations)
- Sleep disturbances
- Mood changes including irritability and anxiety
- Fatigue and flu-like symptoms
Critical Safety Considerations
Never discontinue duloxetine abruptly 1. The FDA label states that a gradual dose reduction rather than abrupt cessation is recommended whenever possible 1. Abrupt discontinuation is no more appropriate than suddenly stopping antihypertensives or antihyperglycemics 3.
Follow-Up Requirements
- Schedule at least monthly follow-up during the taper 3
- More frequent contact may be needed during difficult phases 3
- Monitor for withdrawal symptoms, mood changes, and suicidal ideation 3
- Screen for depression, anxiety, and substance use disorders that may emerge during tapering 3
Special Populations and Situations
When to Refer to a Specialist
Immediate specialist referral is warranted for 3:
- History of withdrawal seizures
- Unstable psychiatric comorbidities
- Co-occurring substance use disorders
- Previous unsuccessful office-based tapering attempts
Pregnant Patients
Do not taper duloxetine during pregnancy without specialist consultation, as withdrawal can cause spontaneous abortion and premature labor 3.
Common Pitfalls to Avoid
- Never taper too quickly - research shows even 10% reductions every 3 days resulted in only 24% successful completion 3
- Never abandon the patient during the taper - ongoing support is essential 3
- Do not assume all patients need the same taper speed - some will tolerate faster tapers while others require months 4
- Do not ignore the first dose reduction - this is the critical test of tolerance and must go well 6
Realistic Timeline
Expect the taper to take 6-12 months minimum, possibly longer 3. While some patients discontinue without difficulty, it is impossible to predict which patients will struggle 6. A "one-size-fits-all" gradual taper approach balances withdrawal prevention with practical feasibility 6.
Patient Education Points
Advise patients 1:
- Not to alter their dosing regimen or stop duloxetine without consulting their healthcare provider
- That withdrawal symptoms, while uncomfortable, are generally self-limiting
- To report symptoms immediately so the taper can be adjusted
- That returning to previous doses after tolerance is lost carries increased risk 3