Tapering Cymbalta 60 mg Daily in an Inpatient Setting
In an inpatient setting, reduce duloxetine 60 mg daily by 30 mg (to 30 mg daily) for 1-2 weeks, then discontinue completely while monitoring closely for withdrawal symptoms. 1
Rationale for Inpatient Tapering Approach
The inpatient setting allows for a faster taper than outpatient protocols because of continuous monitoring and immediate symptom management. 2 While the FDA label recommends gradual dose reduction whenever possible, it does not specify exact protocols, leaving room for clinical judgment based on setting and patient factors. 1
Specific Tapering Protocol
Week 1-2:
- Reduce from 60 mg daily to 30 mg daily 3, 1
- Monitor daily for withdrawal symptoms including dizziness, headache, nausea, paresthesia, irritability, insomnia, anxiety, and hyperhidrosis 1
Week 2-3:
- Discontinue completely after 1-2 weeks at 30 mg daily 3
- The 30 mg dose serves as a bridge to minimize abrupt discontinuation effects 2
Managing Withdrawal Symptoms
Common withdrawal symptoms to anticipate: 1, 4
- Nausea and dizziness (most common)
- Headache, paresthesia, irritability
- Insomnia, anxiety, hyperhidrosis, fatigue
- Gastrointestinal complaints and flu-like symptoms 5
Symptomatic management strategies:
- For insomnia: Consider short-term non-benzodiazepine sleep aids 3
- For nausea: Antiemetics as needed
- For anxiety: Avoid benzodiazepines if possible due to risk of dependence; consider non-pharmacologic interventions 2
- For muscle aches: NSAIDs or acetaminophen 2
Critical Monitoring Points
If severe withdrawal symptoms emerge: 3
- Return to 60 mg daily and slow the taper further
- Consider extending the 30 mg phase to 2-4 weeks before complete discontinuation
- Document symptom severity to guide subsequent taper adjustments
Distinguish withdrawal from relapse: 5
- Withdrawal symptoms typically emerge within days of dose reduction
- Relapse of underlying condition (depression, anxiety, pain) typically occurs weeks to months after discontinuation
- Withdrawal includes physical symptoms (dizziness, paresthesia) not typical of the original condition
Important Caveats
The inpatient taper is faster than recommended outpatient protocols because continuous monitoring allows for immediate intervention if problems arise. 2 Outpatient guidelines recommend 10% reductions every 2-4 weeks over 2-12 months, but this extended timeline is impractical in most inpatient settings. 3
Do not abruptly discontinue - even in the inpatient setting, some tapering is essential as duloxetine has well-documented withdrawal syndromes similar to venlafaxine. 2, 1
Consider the indication for duloxetine - if treating neuropathic pain, depression, or anxiety, ensure alternative management strategies are in place before complete discontinuation to prevent symptom recurrence. 2
Hyperbolic tapering principles suggest that even smaller final doses may be needed to minimize receptor-level changes, but this is more relevant for long-term outpatient tapers than acute inpatient discontinuation. 6, 7