From the Guidelines
For neuropathic pain, Cymbalta (duloxetine) is typically started at 30 mg once daily for one week before increasing to the therapeutic dose of 60 mg once daily, as recommended by the most recent and highest quality study 1. This gradual titration helps minimize initial side effects like nausea, dizziness, and somnolence. The medication should be taken at the same time each day with or without food. If after 2-4 weeks at 60 mg daily there is inadequate pain relief, the dose may be increased to 60 mg twice daily (120 mg total), though this higher dose may increase side effects without significantly improving efficacy in many patients. Some key points to consider when prescribing Cymbalta for neuropathic pain include:
- Starting with a lower dose of 20 mg daily for elderly patients or those with renal impairment, as suggested by 1 and 1.
- Tapering the medication gradually to avoid discontinuation symptoms, as advised by 1 and 1.
- Being aware that the full analgesic effect may take 1-2 weeks to develop, as noted in 1 and 1.
- Monitoring for potential adverse effects, such as nausea, dizziness, and somnolence, and adjusting the dose accordingly, as recommended by 1. Cymbalta works by increasing serotonin and norepinephrine levels in the central nervous system, which enhances descending pain inhibitory pathways. It is essential to follow the prescribing recommendations and guidelines for first-line medications, including Cymbalta, as outlined in 1 and 1. Additionally, considering the patient's individual needs and medical history, such as cardiac disease or renal insufficiency, is crucial when prescribing Cymbalta, as highlighted in 1 and 1.
From the FDA Drug Label
2.4 Dosage for Treatment of Diabetic Peripheral Neuropathic Pain in Adults Administer 60 mg once daily in adults with diabetic peripheral neuropathic pain. There is no evidence that doses higher than 60 mg once daily confer additional significant benefit and the higher dosage is clearly less well tolerated. For patients for whom tolerability is a concern, a lower starting dose may be considered
The recommended starting dose of duloxetine for neuropathy is 60 mg once daily. However, for patients where tolerability is a concern, a lower starting dose may be considered 2.
From the Research
Cymbalta Dosing for Neuropathy
- The recommended dosing for Cymbalta (duloxetine) in the treatment of neuropathic pain associated with diabetic peripheral neuropathy is 60 mg daily 3, 4.
- Studies have shown that duloxetine at 60 mg daily is effective in treating painful diabetic peripheral neuropathy in the short-term, with a risk ratio for 50% pain reduction at 12 weeks of 1.65 (95% CI 1.34 to 2.03) and a number needed to treat (NNT) of 6 (95% CI 5 to 10) 3.
- Duloxetine at 60 mg daily has also been shown to be effective in treating fibromyalgia over 12 weeks (RR for 50% reduction in pain 1.57,95% CI 1.20 to 2.06; NNT 8,95% CI 5 to 17) and over 28 weeks (RR 1.58,95% CI 1.10 to 2.27) 3, 4.
- Adverse events were common in both treatment and placebo arms, but more common in the treatment arm, with a dose-dependent effect. Most side effects were minor, but 16% of participants stopped the drug due to side effects 3, 4.
Comparison with Other Treatments
- A study comparing the safety and tolerability of duloxetine, pregabalin, and duloxetine plus gabapentin in patients with diabetic peripheral neuropathic pain found that all three treatments were generally safe and tolerable, but with different adverse event profiles 5.
- Another study comparing the efficacy and safety of gabapentin, duloxetine, and pregabalin in patients with painful diabetic peripheral neuropathy found that all three treatments produced a clinically and subjectively meaningful pain relief, with no statistically significant difference between the groups 6.
- A cost-effectiveness analysis of initiating treatment for painful diabetic neuropathy with pregabalin, duloxetine, gabapentin, or desipramine found that starting with duloxetine was the most cost-effective option when the willingness-to-pay was greater than $22,867/QALY 7.