Discontinuing Cymbalta (Duloxetine) 20mg
Yes, you can stop Cymbalta from 20mg, but you must taper gradually over at least 2-4 weeks minimum to avoid discontinuation syndrome, even at this relatively low dose. 1, 2
Why Tapering is Essential
Duloxetine is associated with discontinuation syndrome characterized by dizziness, headache, nausea, diarrhea, paresthesia, irritability, vomiting, insomnia, anxiety, hyperhidrosis, and fatigue. 2 The FDA label explicitly warns against abrupt cessation and recommends gradual dose reduction whenever possible 2. Discontinuation symptoms can occur at rates of 1% or greater compared to placebo, with symptoms potentially lasting days to months 2, 3.
Recommended Tapering Protocol for 20mg
Since your patient is on 20mg (a subtherapeutic dose below the standard 30-60mg range), the taper can be relatively straightforward but should still be gradual:
Week-by-Week Taper Schedule
- Weeks 1-2: Reduce to 20mg every other day (effectively 10mg/day average) 1
- Weeks 3-4: Reduce to 20mg every third day, then discontinue 1
For patients on short-term therapy (less than 3 months), the minimum taper duration is 2-4 weeks. 1 For patients who have been on duloxetine longer than 3 months, consider extending the taper to several months with 10% reductions of the current dose at each step 1.
Managing Withdrawal Symptoms During Taper
If moderate to severe discontinuation symptoms emerge, reinstitute the previous dose and hold at that level for an additional 1-2 weeks before attempting further reduction. 1 The taper rate is ultimately determined by the patient's ability to tolerate dose reductions 1.
Common withdrawal symptoms to monitor include 2, 3:
- Dizziness and paresthesias (most common)
- Nausea and gastrointestinal disturbances
- Headache and fatigue
- Insomnia and anxiety
- Flu-like symptoms
Critical Monitoring Points
- Monitor closely during the taper for emergence of withdrawal symptoms, return of original psychiatric symptoms (if treated for depression/anxiety), and suicidal ideation. 1
- Nausea and GI disturbances are among the most common withdrawal effects, similar to the adverse effects seen when initiating duloxetine. 1
- Establish a collaborative plan before initiating taper that includes clear explanation of why gradual tapering is necessary and discussion of potential withdrawal symptoms. 1
Special Considerations for 20mg Dose
At 20mg, your patient is below the typical therapeutic range of 30-60mg 1, 2, which may make discontinuation somewhat easier than stopping from higher doses. However, the risk of discontinuation syndrome exists even at low doses, particularly if the patient has been on the medication for more than a few weeks. 2
What NOT to Do
- Never stop duloxetine abruptly - this significantly increases risk of severe discontinuation symptoms 1, 2
- Do not assume the low dose (20mg) eliminates discontinuation risk - taper is still required 2
- Do not increase taper speed if mild symptoms occur - slow down or pause the taper instead 1
Alternative Approach for Patients with Risk Factors
For high-risk patients (history of severe withdrawal symptoms with other medications, comorbid anxiety disorders, or longer treatment duration), use an even slower taper with smaller decrements. 1 Consider:
- Reducing by 10% of current dose every 1-2 weeks
- Extending total taper duration to 6-8 weeks or longer
- More frequent monitoring (weekly during active taper)