What is an appropriate tapering schedule for duloxetine (Cymbalta) 60 mg daily in an adult?

Tapering Duloxetine 60 mg Daily

Taper duloxetine 60 mg daily gradually over at least 2–4 weeks by reducing to 30 mg daily for 1–2 weeks, then to 30 mg every other day for 1 week, before complete discontinuation. 1, 2

Recommended Tapering Schedule

Standard taper protocol:

• Week 1–2: Reduce from 60 mg daily to 30 mg daily 1
• Week 3–4: Continue 30 mg daily (total 2–4 weeks at 30 mg) 1, 2
• Week 5: Reduce to 30 mg every other day 1
• Week 6: Discontinue completely 1

This schedule minimizes discontinuation-emergent adverse events while maintaining a practical timeline for most patients. 2, 3

Alternative Slower Taper for High-Risk Patients

For patients with a history of severe withdrawal symptoms or prolonged treatment (>6 months), use a more gradual approach: 1

• Weeks 1–2: 60 mg → 50 mg daily (if 30 mg capsules available, alternate 60/30 mg)
• Weeks 3–4: 40 mg daily (alternate 30 mg daily with 60 mg every other day)
• Weeks 5–6: 30 mg daily
• Week 7: 30 mg every other day
• Week 8: Discontinue

Use small increments at intervals of at least one week at each dose level to allow adequate observation. 1

Expected Withdrawal Symptoms

Discontinuation-emergent adverse events occur in approximately 44% of patients stopping duloxetine, compared to 23% with placebo. 3 The most common symptoms include:

• Dizziness (12.4%) – most frequently reported 3
• Nausea (5.9%) 3
• Headache (5.3%) 3
• Paresthesia/electric shock sensations (2.9%) 3
• Irritability (2.4%) 3
• Vomiting, insomnia, anxiety, hyperhidrosis, and fatigue 2, 4

Most symptoms are mild to moderate in severity, and 65% resolve within 7 days of onset. 3 However, gradual tapering significantly reduces both the incidence and severity of these symptoms. 2, 3

Critical Monitoring During Taper

Assess patients weekly during the taper for: 1

• Withdrawal symptoms: Use a standardized symptom checklist at each visit focusing on dizziness, nausea, paresthesias, and mood changes 3
• Return of underlying condition: Monitor for recurrence of depression, anxiety, or pain using the same scales used to track initial treatment response 1
• Blood pressure and pulse: Duloxetine withdrawal can cause autonomic instability 5

Common Pitfalls to Avoid

Do not stop duloxetine abruptly. Abrupt discontinuation significantly increases the risk and severity of withdrawal symptoms, particularly at the 60 mg dose. 2, 3

Do not assume all patients tolerate the same taper speed. Elderly patients, those with renal impairment, or patients who experienced significant side effects during initiation require slower tapers with smaller dose decrements. 1, 2

Do not confuse withdrawal symptoms with relapse of the underlying condition. Withdrawal symptoms typically emerge within 1–3 days of dose reduction and improve within 1–2 weeks, whereas relapse develops more gradually over weeks. 3

Do not use "as needed" dosing during the taper. Duloxetine must be taken on a consistent daily schedule throughout the taper to maintain stable plasma levels and minimize withdrawal. 1

Special Populations Requiring Modified Approach

Geriatric patients (≥65 years): Use smaller dose increments (e.g., 60 mg → 45 mg → 30 mg → 20 mg → 10 mg → stop) with at least one week at each dose level due to increased sensitivity to withdrawal effects. 1

Patients with renal impairment (CrCl 30–60 mL/min): Extend the taper duration by an additional 1–2 weeks, as duloxetine clearance is reduced. 2, 6

Patients discontinuing due to adverse effects: A more rapid taper (e.g., 2 weeks total) may be necessary, but requires closer monitoring for withdrawal symptoms. 7

Symptomatic Management of Withdrawal

If withdrawal symptoms emerge despite gradual taper: 1

• Temporarily hold the dose reduction and maintain the current dose for an additional 1–2 weeks before attempting further reduction
• Consider symptomatic treatment: antiemetics for nausea, NSAIDs for headache/myalgias, short-term benzodiazepines for severe anxiety (use cautiously)
• In severe cases: briefly return to the previous higher dose, stabilize for 1 week, then resume taper at a slower rate

When to Consider Substitution Rather Than Taper

If the patient requires ongoing antidepressant or pain treatment, consider cross-tapering to an alternative agent rather than complete discontinuation. 5 Fluoxetine has the longest half-life and may provide a "self-tapering" effect, though direct switching protocols vary by indication. 5