Abrupt Discontinuation of Cymbalta, Lithium, and Nexium
Do not stop duloxetine (Cymbalta) 30 mg or lithium 450 mg ER abruptly—both require gradual tapering to prevent withdrawal symptoms and rebound mood episodes. Esomeprazole (Nexium) 40 mg can be stopped without tapering, though rebound acid hypersecretion may occur.
Duloxetine (Cymbalta) 30 mg: Requires Gradual Taper
Abrupt discontinuation of duloxetine causes withdrawal symptoms in 44.3% of patients, compared to 22.9% on placebo. 1 The most common discontinuation-emergent adverse events include dizziness (12.4%), nausea (5.9%), headache (5.3%), paresthesia (2.9%), vomiting (2.4%), irritability (2.4%), and nightmares (2.0%). 1
Recommended Tapering Schedule
- Taper duloxetine gradually over a minimum of 2 weeks before complete discontinuation. 1, 2
- For a patient on 30 mg daily, reduce to 20 mg daily for 1 week, then 10 mg daily for 1 week before stopping. 1
- Most withdrawal symptoms (65%) resolve within 7 days of onset, though 45.1% of symptoms persist beyond the taper period. 1
- Patients rate most symptoms as mild to moderate in severity. 1
Clinical Monitoring During Taper
- Monitor closely for dizziness, nausea, headache, paresthesia, irritability, and mood changes during the first week after each dose reduction. 1
- When stopping duloxetine, taper slowly to decrease risks of discontinuation syndrome, as recommended for all serotonin-norepinephrine reuptake inhibitors. 3
- Withdrawal symptoms typically begin within 24-48 hours of dose reduction and resolve within 1-3 weeks. 4
Lithium 450 mg ER: Requires Gradual Taper
Abrupt lithium discontinuation dramatically increases relapse risk, with over 90% of noncompliant patients relapsing versus 37.5% of compliant patients, especially within 6 months. 5 Withdrawal of maintenance lithium therapy is associated with rebound mania and rapid mood destabilization. 5
Recommended Tapering Schedule
- Taper lithium gradually over 2-4 weeks minimum, never discontinue abruptly. 5
- Reduce the dose by 10-20% of the original dose every 1-2 weeks. 5
- For a patient on 450 mg ER daily, reduce to 360 mg for 1-2 weeks, then 270 mg for 1-2 weeks, then 180 mg for 1-2 weeks before stopping. 5
- Slower tapers extending 4-8 weeks may be necessary for patients with history of rapid relapse or severe episodes. 5
Clinical Monitoring During Taper
- Monitor weekly for return of manic symptoms, mood instability, irritability, sleep disturbance, and suicidal ideation. 5
- If withdrawal symptoms or mood destabilization occur during taper, immediately return to the previous stable dose. 5
- Return of symptoms may occur weeks to months after the last dose, representing relapse rather than withdrawal. 5, 4
- In patients with high suicide risk or history of serious suicide attempts, consider maintaining lithium therapy indefinitely rather than discontinuing. 5
Special Considerations
- Lithium should be tapered slowly, as stopping abruptly can lead to withdrawal symptoms similar to other central nervous system medications. 3
- Sudden cessation of lithium is no more appropriate than abrupt discontinuation of antihypertensives or antihyperglycemics. 3
- Patients with multiple severe episodes, rapid cycling, or poor response to alternative agents should be counseled that indefinite treatment may be necessary. 5
Esomeprazole (Nexium) 40 mg: Can Be Stopped Without Taper
Esomeprazole can be discontinued abruptly without a formal taper, though rebound acid hypersecretion may occur. 3 Proton-pump inhibitors cause symptoms when stopped without tapering, but these are typically mild and self-limited. 6
Expected Effects After Stopping
- Rebound acid hypersecretion may cause temporary worsening of heartburn or reflux symptoms for 1-2 weeks after stopping. 3
- These symptoms typically resolve spontaneously within 2-4 weeks as gastric acid production normalizes. 3
- If symptoms are intolerable, consider a brief taper (40 mg every other day for 1 week, then stop) or use of antacids as needed during the rebound period. 3
Common Pitfalls to Avoid
- Never stop duloxetine or lithium abruptly—both require gradual dose reduction to prevent withdrawal and rebound symptoms. 3, 5, 1
- Do not assume that withdrawal symptoms represent relapse of the underlying condition in the first 1-3 weeks after dose reduction—most withdrawal symptoms are self-limited and resolve spontaneously. 4, 1
- Avoid tapering multiple medications simultaneously—stagger tapers to identify which medication is causing symptoms if withdrawal occurs. 3
- Do not restart medications at full dose if withdrawal symptoms occur—return to the previous taper dose and slow the taper schedule. 5
Summary Algorithm
Duloxetine 30 mg: Taper over 2 weeks minimum (30 mg → 20 mg × 1 week → 10 mg × 1 week → stop). Monitor for dizziness, nausea, headache, irritability. 1, 2
Lithium 450 mg ER: Taper over 2-4 weeks minimum (reduce by 10-20% every 1-2 weeks). Monitor weekly for mood destabilization, manic symptoms, suicidal ideation. 5
Esomeprazole 40 mg: Can stop immediately. Expect possible rebound heartburn for 1-2 weeks. Use antacids as needed. 3, 6