Duloxetine Treats Multiple Conditions Beyond Neuropathic Pain
Duloxetine is FDA-approved for major depressive disorder, generalized anxiety disorder, diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain in adults. 1
FDA-Approved Indications
Duloxetine has five primary FDA-approved indications in adults 1:
- Major depressive disorder 1
- Generalized anxiety disorder (also approved for pediatric patients ≥7 years) 1
- Diabetic peripheral neuropathic pain 1
- Fibromyalgia 1
- Chronic musculoskeletal pain 1
Evidence-Based Applications in Pain Management
Diabetic Peripheral Neuropathic Pain
- Duloxetine 60 mg daily is a first-line pharmacologic treatment for neuropathic pain in diabetes 2
- Demonstrates a risk ratio of 1.73 for ≥50% pain reduction at 12 weeks, with a number needed to treat (NNT) of 5 3
- More pronounced effect in platinum-based chemotherapy-induced peripheral neuropathy compared to taxane-induced neuropathy 2
Fibromyalgia
- Effective at 60 mg daily with RR 1.57 for ≥50% pain reduction at 12 weeks (NNT 8) 3
- Benefits sustained through 28 weeks of treatment 3
- May achieve effect through greater improvement in mental symptoms than somatic physical pain 3
Chronic Musculoskeletal Pain
- Second-line treatment for chronic knee osteoarthritis when topical NSAIDs are insufficient or multiple joints are affected 4
- Demonstrates small to moderate benefits for pain and function at 3-6 months and 6-12 months 4
- More effective in older patients (>65 years) and specifically in knee osteoarthritis compared to hip osteoarthritis 4
- Also approved for chronic low back pain 1, 5
Chemotherapy-Induced Peripheral Neuropathy (CIPN)
- Only drug studied in a large randomized trial showing moderate clinical benefit for painful CIPN 2
- In 231 patients, achieved higher pain reduction rate versus placebo (59% versus 38%) 2
- Recommended as first-line treatment with Level I, B evidence 2
Psychiatric Indications
Major Depressive Disorder
- Improves both emotional symptoms and somatic symptoms of depression, including pain 6
- Effective for painful physical symptoms in depression with RR 1.37 (NNT 8) 3
Generalized Anxiety Disorder
- Provides beneficial effects compared with placebo 6
- Improves quality of life, wellbeing, and general health 6
Standard Dosing Approach
Start with 30 mg once daily for one week, then increase to 60 mg once daily 7, 4:
- This titration schedule reduces nausea, the most common adverse effect 7, 4
- 60 mg once daily is as effective as 60 mg twice daily for pain conditions 7, 4
- In elderly patients, use lower starting doses and slower titration to minimize adverse events 4
Important Clinical Considerations
- Contraindicated in severe hepatic and renal impairment 7
- Unlike tricyclic antidepressants, does not produce clinically important ECG or blood pressure changes 2, 4
- Small increase in A1C reported in longer-term diabetes studies 2
- Must be taken daily (not as needed) and tapered over 2-4 weeks when discontinuing after >3 weeks of treatment 4
- Adverse events are common but mostly minor; 16% discontinue due to side effects 3