Cymbalta

(duloxetine)

Forms/Strengths

•  Capsules: 20 mg, 30 mg, 60 mg

Dosing

• Age: 7 years for GAD
• Considerations: Monitor for suicidal thoughts and behaviors, especially during initial treatment or dosage changes. Regularly monitor weight and growth in pediatric patients.
• Initial Dose:
  • Major Depressive Disorder (MDD): Start with 40–60 mg/day (e.g., 20 mg BID or 30 mg QD).
  • Generalized Anxiety Disorder (GAD):
    • Adults: Start with 60 mg QD.
    • Pediatrics (≥ 7 years): Start with 30 mg QD, increase to 60 mg QD after 1 week.
• Titration: Increase to 60 mg/day after one week if tolerated
• Max Dose: 120 mg/day

Quick Facts

• Inhibits serotonin (5-HT) and norepinephrine (NE) reuptake for mood regulation and pain relief
• Improves mood, alleviates anxiety, modulates pain
• Oral capsule; doses >60 mg/day typically divided (e.g., 30 mg BID)
• Common side effects: nausea, dry mouth, dizziness, constipation, fatigue
• Dual action on mood and pain symptoms; monitor for suicidal ideation in younger patients

Indications

•  Generalized Anxiety Disorder (F41.1)

Off-Label Uses

• Major Depressive Disorder (F32.x)
• Diabetic Peripheral Neuropathic Pain (G63.2)
• Chronic Musculoskeletal Pain (M79.1)

How to Take

• Take once daily, preferably at the same time each day.
• Can be taken with or without food; taking with food may help reduce nausea.
• Swallow capsule whole; do not crush, chew, or open.
• Do not abruptly stop; tapering is required to prevent withdrawal symptoms.
  

Side Effects

•  Common: Nausea, diarrhea, decreased weight, dizziness, decreased appetite, vomiting, fatigue
• Serious: Suicidal thoughts and behaviors, severe skin reactions, activation of mania or hypomania, angle-closure glaucoma, seizures, blood pressure increases, hyponatremia

Monitoring / Labs

• Monitor for suicidal thoughts and behaviors.
• Regularly monitor weight and growth.
• Monitor blood pressure periodically.

Education

• When to Call the Doctor:

  • Severe mood changes, suicidal thoughts, or unusual behavior.
  • Symptoms of serotonin syndrome (e.g., confusion, rapid heart rate, muscle rigidity, high fever).
  • Signs of liver damage (e.g., yellowing of the skin/eyes, dark urine, persistent nausea).
  • Unusual bruising or bleeding.
  • Severe dizziness, fainting, or difficulty urinating.

• Safety Tips:

  • Monitor blood pressure regularly, as Cymbalta may increase blood pressure.
  • Use caution when driving or operating machinery, as drowsiness and dizziness may occur.
  • Avoid alcohol, as it may increase the risk of liver toxicity.
  • May cause sexual dysfunction; discuss with provider if problematic.
  • Taper gradually if discontinuing to minimize withdrawal effects (e.g., dizziness, nausea, irritability).

• Parent Tips for Pediatric Patients:

  • Monitor for suicidal thoughts, mood changes, or behavioral changes, especially during the first few weeks.
  • May cause drowsiness or agitation; observe how the child responds to the medication.
  • Encourage hydration and a balanced diet to help with potential nausea.
  • If taken for chronic pain or fibromyalgia, assess response regularly.

Additional Information

• Contraindications:

  • Hypersensitivity to duloxetine or formulation components.
  • Use within 14 days of MAOI therapy (risk of serotonin syndrome).
  • Uncontrolled narrow-angle glaucoma.
  • Severe hepatic or renal impairment.

• Pregnancy:

  • Category C; use only if benefits outweigh risks.
  • May cause withdrawal symptoms in newborns if taken in the third trimester.

• Lactation:

  • Excreted in breast milk; use with caution as effects on the infant are unknown.

• Drug Interactions:

  • Serotonergic drugs (e.g., SSRIs, SNRIs, MAOIs, St. John’s Wort) increase serotonin syndrome risk.
  • CYP1A2 and CYP2D6 inhibitors (e.g., fluvoxamine, quinidine) may increase duloxetine levels.
  • NSAIDs, anticoagulants, and antiplatelets may increase bleeding risk.
  • May enhance the hypertensive effects of stimulants or decongestants.