How to Safely Discontinue Cymbalta (Duloxetine)
Taper duloxetine gradually over several weeks to months rather than stopping abruptly, as discontinuation syndrome occurs frequently and can be severe with this medication. 1
Understanding Discontinuation Syndrome
Duloxetine discontinuation causes withdrawal symptoms in a significant proportion of patients, including dizziness, headache, nausea, diarrhea, paresthesia (electric shock sensations), irritability, vomiting, insomnia, anxiety, hyperhidrosis, and fatigue. 1 These symptoms can range from mild and self-limiting to severe, and may last from days to months depending on the individual and the tapering approach used. 2
Recommended Tapering Protocol
The FDA label explicitly states that gradual dose reduction is recommended whenever possible rather than abrupt cessation. 1
Tapering Timeline
Minimum taper duration: 2-4 weeks for short-term users (less than 6 months of treatment). 2
Extended tapers of several weeks to months are necessary for long-term users (6 months or longer), with some patients requiring tapers extending over several months. 2, 3
The taper rate should be determined by the patient's ability to tolerate dose reductions, with slower tapers (10% reductions of the current dose at each step) needed for patients experiencing withdrawal symptoms. 2
Specific Tapering Strategy
Reduce the dose incrementally every 1-2 weeks, holding at each dose level to assess for withdrawal symptoms before proceeding with further reductions. 2
If moderate to severe withdrawal symptoms emerge, return to the previous dose and hold for an additional 1-2 weeks before attempting a slower reduction. 1, 2
For patients on 60 mg daily, consider reducing to 30 mg for 2-4 weeks, then to 20 mg for 2-4 weeks before complete discontinuation—though patients on long-term therapy may require even more gradual reductions. 2, 3
Managing Withdrawal Symptoms
Monitor closely for discontinuation symptoms including dizziness, sensory disturbances (electric shock sensations), nausea, anxiety, irritability, and mood changes. 1
If intolerable symptoms occur following dose reduction, resume the previously prescribed dose, then continue decreasing at a more gradual rate once symptoms resolve. 1
Consider adjunctive symptomatic treatments for specific withdrawal symptoms (e.g., antiemetics for nausea, though evidence is limited specifically for SNRI discontinuation). 2
Critical Safety Considerations
Distinguish withdrawal symptoms from relapse of the original condition (depression, anxiety, or pain disorder). Withdrawal symptoms typically emerge within days of dose reduction and improve over time, while relapse symptoms develop more gradually and worsen without treatment. 2, 4
Patients with recurrent depression (two or more prior episodes) have higher relapse risk during discontinuation and may require even slower tapers with closer monitoring. 4, 5
Monitor for suicidal ideation during the discontinuation process, particularly in younger patients and those with a history of depression. 2
High-Risk Patients Requiring Slower Tapers
- Patients who have been on duloxetine for more than 1 year 2, 3
- Those with a history of severe withdrawal symptoms from previous antidepressant discontinuation attempts 2
- Patients with comorbid anxiety disorders 2
- Individuals with recurrent depression (two or more episodes) 4, 5
Patient Education Before Starting Taper
Establish a collaborative discontinuation plan that includes clear explanation of why gradual tapering is necessary, discussion of potential withdrawal symptoms, and agreement on the taper schedule. 2
Inform patients that withdrawal symptoms are common but generally self-limiting, and that slower tapering significantly reduces their severity. 1, 2
Advise patients to contact their provider immediately if severe symptoms develop rather than attempting to push through intolerable withdrawal effects. 1
Common Pitfalls to Avoid
Do not taper too rapidly—tapers of 4 weeks or less are associated with high rates of withdrawal symptoms and may be no better than abrupt discontinuation. 4
Do not confuse withdrawal symptoms with relapse—this is the most common error and can lead to unnecessary resumption of long-term medication. 4
Do not discontinue abruptly except in emergencies (e.g., serotonin syndrome, severe allergic reaction)—abrupt cessation significantly increases withdrawal symptom severity. 1, 4