What is the recommended dosage of Cymbalta (duloxetine)?

Cymbalta (Duloxetine) Recommended Dosages

Start duloxetine at 30 mg once daily for 1 week, then increase to the therapeutic dose of 60 mg once daily for most indications. 1, 2

Standard Dosing by Indication

Major Depressive Disorder and Generalized Anxiety Disorder

• Initial dose: 30 mg once daily for 1 week (reduces nausea, the most common adverse effect) 1
• Target dose: 60 mg once daily 2
• Maximum dose: 120 mg daily if needed, increased in 30 mg increments 2
• The 30 mg starting dose allows patients to adjust to the medication before reaching therapeutic levels 1

Diabetic Peripheral Neuropathic Pain

• Standard dose: 60 mg once daily 2
• No evidence that doses higher than 60 mg provide additional benefit, and higher doses are clearly less well tolerated 2
• For tolerability concerns, consider starting lower, particularly since diabetes is frequently complicated by renal disease 2

Fibromyalgia

• Initial dose: 30 mg once daily for 1 week 2
• Target dose: 60 mg once daily 2
• Some patients may respond to the 30 mg starting dose 2
• No evidence that doses greater than 60 mg/day confer additional benefit, even in non-responders, and higher doses increase adverse reactions 2

Chronic Musculoskeletal Pain (including osteoarthritis and low back pain)

• Initial dose: 30 mg once daily for 1 week 2
• Target dose: 60 mg once daily 2
• Higher dosages do not provide additional benefit and are associated with higher adverse reaction rates 2

Chemotherapy-Induced Peripheral Neuropathy

• Initial dose: 30 mg daily for 1 week 1
• Target dose: 60 mg daily 1
• Better response seen in cisplatin-treated patients compared to taxane-treated patients 1

Special Populations

Geriatric Patients (≥65 years)

• Initial dose: 30 mg once daily for 2 weeks before increasing 2
• Target dose: 60 mg once daily 2
• May benefit from doses above 60 mg once daily; if increasing, use 30 mg increments 2
• Maximum studied dose: 120 mg daily 2

Pediatric Patients (7-17 years with GAD)

• Initial dose: 30 mg once daily for 2 weeks 2
• Recommended range: 30-60 mg once daily 2
• Some patients may benefit from doses above 60 mg once daily, increased in 30 mg increments 2
• Maximum studied dose: 120 mg daily 2

Hepatic Impairment

• Avoid use in patients with chronic liver disease or cirrhosis 2
• Dose reduction required in hepatic disease 1

Renal Impairment

• Avoid use in severe renal impairment (creatinine clearance <30 mL/min) 2
• Consider lower starting dose and gradual increase for patients with renal impairment 2

Monitoring Requirements

• Blood pressure monitoring is necessary as duloxetine can cause modest hypertension 1, 3
• Assess for adverse effects at each follow-up visit, particularly with higher doses 1, 3
• Evaluate therapeutic response using standardized pain or depression scales 1, 4
• Monitor for sedation, dizziness, nausea, hyperhidrosis 4

Discontinuation Protocol

Taper gradually rather than stopping abruptly to minimize withdrawal symptoms including dizziness, headache, nausea, diarrhea, paresthesia, irritability, vomiting, insomnia, anxiety, hyperhidrosis, and fatigue 2

Recommended Tapering Approach

• Use a slower taper over 3-4 weeks with smaller dose decrements (e.g., 120 mg → 100 mg → 80 mg → 60 mg) for patients with history of withdrawal symptoms 1
• Use small increments at intervals allowing adequate observation, usually at least one week at each dose level 1

Critical Drug Interactions

• At least 14 days must elapse between discontinuing an MAOI and starting duloxetine 2
• At least 5 days must elapse after stopping duloxetine before starting an MAOI 2
• Avoid concomitant use with potent CYP1A2 inhibitors 2
• Use caution with drugs extensively metabolized by CYP2D6, particularly those with narrow therapeutic index 2

Common Pitfalls to Avoid

• Do not start at 60 mg in most patients—the 30 mg starting dose for 1 week significantly reduces nausea and improves tolerability 1
• Do not exceed 60 mg/day for diabetic neuropathy, fibromyalgia, or chronic musculoskeletal pain without clear rationale, as higher doses lack additional efficacy and increase adverse effects 2
• Do not use in patients with severe renal or hepatic impairment 2
• Do not abruptly discontinue—always taper to minimize withdrawal symptoms 2