Is duloxetine (Cymbalta) safe for someone with a medical history of glaucoma?

From the Guidelines

Cymbalta (duloxetine) is generally not recommended for people with a history of glaucoma, particularly narrow-angle glaucoma, due to its potential to trigger or worsen glaucoma by dilating the pupil and increasing intraocular pressure. This medication belongs to the SNRI (serotonin-norepinephrine reuptake inhibitor) class of antidepressants, which can influence pupil dilation and potentially block drainage channels in the eye, raising intraocular pressure 1. The risk is especially high for uncontrolled or narrow-angle glaucoma. If you have a history of glaucoma, you should avoid taking Cymbalta unless specifically approved by both your ophthalmologist and the prescribing physician.

The mechanism behind this concern relates to duloxetine's effects on norepinephrine, which can influence pupil dilation and potentially block drainage channels in the eye, raising intraocular pressure. This pressure increase can damage the optic nerve and potentially lead to vision loss. According to the primary open-angle glaucoma preferred practice pattern guidelines, patients with glaucoma should be educated about the disease process, the rationale and goals of intervention, and the relative benefits and risks of alternative interventions 1.

If you're currently taking Cymbalta and have glaucoma, contact your healthcare provider immediately to discuss alternative medications. Other antidepressant options with potentially lower risk for glaucoma patients might include certain SSRIs, though all medication choices should be made in consultation with healthcare providers who know your complete medical history. It's essential to prioritize the management of glaucoma and consider the potential impact of medications on intraocular pressure, as highlighted in the primary open-angle glaucoma preferred practice pattern guidelines 1.

Key considerations for patients with glaucoma include:

• Educating patients about the disease process and treatment options
• Monitoring intraocular pressure and adjusting treatment as needed
• Considering alternative medications with lower risk for glaucoma patients
• Prioritizing the management of glaucoma to prevent vision loss
• Consulting with healthcare providers who know the patient's complete medical history to make informed decisions about medication choices.

From the FDA Drug Label

Angle-Closure Glaucoma — Advise patients that taking duloxetine delayed-release capsules can cause mild pupillary dilation, which in susceptible individuals, can lead to an episode of angle-closure glaucoma. Pre-existing glaucoma is almost always open-angle glaucoma because angle-closure glaucoma, when diagnosed, can be treated definitively with iridectomy Open-angle glaucoma is not a risk factor for angle-closure glaucoma. Patients may wish to be examined to determine whether they are susceptible to angle-closure, and have a prophylactic procedure (e.g., iridectomy), if they are susceptible [see WARNINGS AND PRECAUTIONS (5. 9)]. The pupillary dilation that occurs following use of many antidepressant drugs including duloxetine delayed-release capsules may trigger an angle closure attack in a patient with anatomically narrow angles who does not have a patent iridectomy. have glaucoma

Cymbalta (duloxetine) may not be suitable for someone with a medical history of glaucoma, especially if they have narrow angles and no patent iridectomy, as it can cause mild pupillary dilation and potentially trigger an angle-closure glaucoma attack. Patients with pre-existing open-angle glaucoma are not at increased risk of angle-closure glaucoma. It is recommended that patients with glaucoma be examined to determine their susceptibility to angle-closure and consider a prophylactic procedure if necessary 2, 2, 2.

From the Research

Cymbalta and Glaucoma Safety

• Cymbalta, also known as duloxetine, is a serotonin norepinephrine reuptake inhibitor (SNRI) used to treat depression and chronic pain.
• According to a case report published in 3, there is a probable association between duloxetine and bilateral acute angle-closure glaucoma.
• The study suggests that the mechanism responsible for the precipitation of acute angle-closure glaucoma by SNRIs, including duloxetine, is likely a result of mydriasis caused by their adrenergic effects, weak anticholinergic activities, or the increased levels of serotonin.
• However, a review of literature published in 4 states that selective serotonin and noradrenaline reuptake inhibitors, such as duloxetine, are the best evidenced as having no association with glaucoma.

Considerations for Patients with Glaucoma

• Patients with glaucoma or glaucoma risk factors should be cautious when using SNRIs, including duloxetine, as they may increase the risk of acute angle-closure glaucoma 3.
• Clinicians should be aware of the possible psychotropic drug-induced glaucoma and monitor at-risk patients closely to prevent this condition 4.
• A meta-analysis published in 5 found that the use of SSRIs was not associated with a higher risk of glaucoma, and IOP was lower in participants exposed to antidepressants, including SNRIs.
• However, the study also notes that high heterogeneity of included studies limits the establishment of causal inferences.

Monitoring and Precautions

• Ophthalmological consultations should be considered before starting and during treatment with any SNRI, including duloxetine, in patients with glaucomatous risk factors, especially those who are elderly 6.
• Ambulatory IOP monitoring may provide clinicians with discrete data that could improve patient outcomes, as it measures IOP outside of office hours and at different times of day and night 7.