What is the recommended dose of duloxetine (Cymbalta) for treating anxiety?

Duloxetine Dosing for Anxiety Disorders

For generalized anxiety disorder (GAD), start duloxetine at 30 mg once daily for one week, then increase to the target dose of 60 mg once daily, which is effective for most patients and has no additional benefit at higher doses. 1

Initial Dosing Strategy

• Begin with 30 mg once daily for the first week to allow patients to adjust to the medication before escalating to the therapeutic dose 1
• Increase to 60 mg once daily after week 1, which is the FDA-approved target dose for GAD in adults under 65 years 1
• For some patients, you may start directly at 60 mg once daily if tolerability is not a concern 1

Target Maintenance Dose

• The optimal dose is 60 mg once daily, which has been demonstrated to be effective across multiple randomized controlled trials 1, 2
• While 120 mg daily has shown efficacy, there is no evidence that doses greater than 60 mg/day confer additional benefit 1, 2
• The 60 mg dose significantly improves Hamilton Anxiety Rating Scale (HAM-A) scores, functional impairment, and quality of life measures compared to placebo 2, 3

Dose Escalation (If Needed)

• If a decision is made to increase beyond 60 mg daily, increase in 30 mg increments 1
• The maximum studied dose is 120 mg daily, though this higher dose is associated with more adverse events without clear additional efficacy 1, 2
• Discontinuation rates due to adverse events increase from 11.3% at 60 mg to 15.3% at 120 mg versus 2.3% for placebo 3

Special Population Adjustments

Geriatric Patients (≥65 years)

• Start at 30 mg once daily for 2 weeks before considering an increase to 60 mg daily 1
• After 2 weeks, increase to the target dose of 60 mg daily 1
• Some elderly patients may benefit from doses above 60 mg, with increases in 30 mg increments up to a maximum of 120 mg daily 1

Pediatric Patients (7-17 years with GAD)

• Initiate at 30 mg once daily for 2 weeks before considering dose escalation 1
• The recommended dosage range is 30-60 mg once daily 1
• If increasing beyond 60 mg, use 30 mg increments up to a maximum of 120 mg daily 1

Administration Guidelines

• Administer once daily with or without food 1
• Swallow capsules whole—do not chew, crush, or open the delayed-release capsules, as this affects the enteric coating 1
• Time of day does not affect efficacy, so dosing can be adjusted based on tolerability (morning if activating, evening if sedating) 4

Expected Timeline for Response

• Symptom improvement typically begins within the first few weeks of treatment 5
• A full therapeutic trial requires at least 4-8 weeks to assess efficacy 6
• Continue treatment for at least 9 months before considering dose reduction to reassess need for ongoing medication 6

Common Pitfalls to Avoid

• Do not escalate to 120 mg simply because 60 mg hasn't worked after 2-3 weeks—allow adequate time (4-8 weeks) at 60 mg before considering the dose ineffective 2, 5
• Do not abruptly discontinue duloxetine—taper over 10-14 days to minimize withdrawal symptoms, especially after treatment longer than 3 weeks 6, 4
• Do not use in patients with severe renal impairment (eGFR <30 mL/min) without dose adjustment—consider a lower starting dose and gradual titration 1

Tolerability Profile

• Most common adverse effects include nausea, dry mouth, headache, constipation, dizziness, and fatigue, which are typically mild to moderate and most prominent in the first week 4, 2, 5
• Nausea is the most common reason for discontinuation 2
• Monitor for increased blood pressure and heart rate, particularly when combining with NSAIDs 4
• Serious but rare adverse effects include hepatic failure, severe skin reactions, suicidal thinking, and serotonin syndrome 4