# Cymbalta

### (duloxetine)

<table border="1" id="bkmrk-prescribing-info" style="border-collapse: collapse; width: 100%; border-width: 0px; background-color: rgb(230, 126, 35);"><tbody><tr><td style="background-color: rgb(194, 224, 244); border-width: 0px; width: 50%;">[**Full Prescribing Information**](https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=2f7d4d67-10c1-4bf4-a7f2-c185fbad64ba&type=display)</td><td class="align-right" style="background-color: rgb(251, 238, 184); border-width: 0px; width: 50%;">[**DailyMed Drug Information**](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2f7d4d67-10c1-4bf4-a7f2-c185fbad64ba)</td></tr></tbody></table>

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**Forms/Strengths**

- **Capsules:** 20 mg, 30 mg, 60 mg

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### **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.
- <div class="src_paragraph_p__y9RVL ask_oe_light_with_citations_paragraph_p__6oofJ"><span class="MuiTypography-root MuiTypography-serif mui-style-1vritj8">**Titration:** Increase to 60 mg/day after one week if tolerated</span></div>
- <span class="MuiTypography-root MuiTypography-serif mui-style-1vritj8">**Max Dose:** 120 mg/day</span>

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### **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 &gt;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

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### **Indications**

- **Generalized Anxiety Disorder** (F41.1)

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### **Off-Label Uses**

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

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### **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.

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### **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

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### **Monitoring / Labs**

- <div class="src_paragraph_p__y9RVL ask_oe_light_with_citations_paragraph_p__6oofJ"><span class="MuiTypography-root MuiTypography-serif mui-style-1vritj8">Monitor for suicidal thoughts and behaviors.</span></div>
- <div class="src_paragraph_p__y9RVL ask_oe_light_with_citations_paragraph_p__6oofJ"><span class="MuiTypography-root MuiTypography-serif mui-style-1vritj8">Regularly monitor weight and growth.</span></div>
- <div class="src_paragraph_p__y9RVL ask_oe_light_with_citations_paragraph_p__6oofJ"><span class="MuiTypography-root MuiTypography-serif mui-style-1vritj8">Monitor blood pressure periodically.</span></div>

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### **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.

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### **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.