How do you safely discontinue Cymbalta (duloxetine) 60 mg?

Safely Discontinuing Cymbalta (Duloxetine) 60 mg

Yes, you can discontinue Cymbalta 60 mg, but it must be done through gradual dose reduction rather than abrupt cessation to minimize withdrawal symptoms and prevent relapse. 1

Critical Safety Warning

Never stop duloxetine abruptly. The FDA label explicitly warns that discontinuation symptoms occur systematically and include dizziness, headache, nausea, diarrhea, paresthesia, irritability, vomiting, insomnia, anxiety, hyperhidrosis, and fatigue. 1 Abrupt cessation can also lead to more severe symptoms including dysphoric mood, agitation, sensory disturbances (electric shock sensations), confusion, emotional lability, hypomania, tinnitus, and seizures. 1

Recommended Tapering Protocol

Initial Dose Reduction

• Reduce from 60 mg to 30 mg daily for at least 1-2 weeks before making further reductions. 2 The FDA label notes that nausea (a common withdrawal symptom) is reduced by using 30 mg once daily. 2

Subsequent Tapering Strategy

• After stabilizing at 30 mg, reduce by 25% of the current dose every 1-2 weeks. 3 This means:

  • Week 1-2: 30 mg daily
  • Week 3-4: 20-22 mg daily (approximately 25% reduction from 30 mg)
  • Week 5-6: 15 mg daily
  • Continue reducing by 25% of the most recent dose

• 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

Extended Tapering for Long-Term Users

• For patients on duloxetine for more than 1 year, extend the taper to 10% reductions per month rather than 25% every 1-2 weeks. 3 This translates to a minimum 6-12 month tapering period. 3

Final Dose Considerations

• Once the smallest available dose is reached, extend the interval between doses before complete discontinuation (e.g., every other day, then every third day). 3

Managing Withdrawal Symptoms

Common Withdrawal Symptoms to Monitor

Monitor for: 3, 1

• Anxiety, tremor, insomnia
• Sweating, tachycardia, headache
• Weakness, muscle aches
• Nausea, confusion
• Dizziness, paresthesias (electric shock sensations)

If Intolerable Symptoms Occur

• Resume the previously prescribed dose immediately. 1 Once symptoms resolve, restart tapering at a slower rate (smaller dose reductions or longer intervals between reductions). 1

• For severe withdrawal symptoms, consider symptomatic management: 3

  • Trazodone 25-200 mg for insomnia (use cautiously in patients with premature ventricular contractions) 2
  • NSAIDs or acetaminophen for muscle aches 3
  • Gabapentin starting at 100-300 mg at bedtime, titrated cautiously for withdrawal symptom mitigation 3

Monitoring Requirements

• Follow up at least monthly during the taper, with more frequent contact during difficult phases. 3
• Monitor for: 3
  • Withdrawal symptoms and their severity
  • Mood changes and suicidal ideation
  • Depression, anxiety, and substance use disorders that may emerge during tapering
  • Return of original symptoms (relapse vs. withdrawal)

Special Considerations

Distinguishing Withdrawal from Relapse

This is the most critical clinical challenge. Withdrawal symptoms (low mood, anxiety, dizziness) can mimic relapse of the original condition. 4 Withdrawal symptoms typically:

• Emerge within days of dose reduction 5
• Improve with reinstatement of the medication 1
• Are often accompanied by physical symptoms (paresthesias, dizziness) not typical of depression/anxiety alone 5

When to Refer to a Specialist

Refer immediately if the patient has: 3

• History of withdrawal seizures
• Unstable psychiatric comorbidities
• Co-occurring substance use disorders
• Previous unsuccessful tapering attempts

Contraindications to Tapering

• Pregnant patients should not taper without specialist consultation, as withdrawal can cause spontaneous abortion and premature labor. 3

Adjunctive Support Strategies

Psychological Support

• Cognitive behavioral therapy (CBT) during the taper significantly increases success rates. 3, 4 Consider initiating CBT before or concurrent with tapering. 4

• Additional supportive measures include: 3

  • Mindfulness and relaxation techniques
  • Sleep hygiene education
  • Exercise and fitness training

Patient Education

• Educate patients about: 3
  • Expected withdrawal symptoms and their typical duration (days to months) 5
  • The difference between withdrawal and relapse
  • The importance of not altering the tapering schedule without consultation
  • Increased overdose risk if they return to previous doses after tolerance is lost 3

Key Pitfalls to Avoid

1. Never taper too quickly. Research shows that even 10% reductions every 3 days resulted in only 24% of patients successfully completing withdrawal. 3

2. Never abandon the patient. Even if tapering is unsuccessful, maintain the therapeutic relationship and consider maintenance therapy. 3

3. Do not confuse withdrawal symptoms with treatment failure. Symptoms emerging within days of dose reduction are likely withdrawal, not relapse. 4, 5

4. Avoid concurrent heavy alcohol use during tapering, as duloxetine combined with heavy alcohol may be associated with severe liver injury. 1

Realistic Timeline

Expect the taper to take a minimum of 6-12 months, possibly longer. 3 The goal is durability of the taper, not speed. 3 Tapers may be considered successful as long as the patient is making progress. 3