Duloxetine Guide (Cymbalta)

0:00 This talk is a guide to the psychiatric medication duloxitine. In this talk, I've attempted to put everything a psychiatrist needs to know about duloxitine on a single slide in less than 5 minutes. Duloxitine is also known by the brand name symbola and often looks like a blue capsule. It is an SNRI anti-depressant and works by inhibiting the serotonin transporter and norepinephrine transporter, thus increasing the neurotransmitter serotonin and norepinephrine in the brain. I consider it to be a moderate risk medication as it has moderate side effects, requires some monitoring, and has only rare serious side effects. I also consider it to be a lowcost medication as a 1-mon supply usually cost $10 or less. It is FDA approved for treatment of MDD and GAD in adults and

0:46 GAD in children. However, it is often used off label for other indications. The usual dose range is 30 to 60 mg and the average halfife is 12 hours. It is therefore often dosed twice per day. The usual onset of therapeutic action is within 1 to two weeks, though maximum therapeutic effects are usually not achieved until 4 to 6 weeks. Withdrawal effects may occur and are uncomfortable but not life-threatening. To avoid withdrawal effects, the medication dose should be reduced gradually over at least 2 to 4 weeks. I usually recommend reducing the dose of anti-depressants by no more than 50% every 1 week. It requires monitoring with regular blood pressure measurements and sometimes requires monitoring of renal function with creatinine levels and liver function with liver function tests. It

1:31 has some drug interactions as it is a moderate inhibitor of CYP2D6. Common side effects include weight loss, GI effects such as abdominal pain, decreased appetite, nausea, vomiting, and dry mouth and neuro effects such as sedation, fatigue, and headaches. Rare but serious side effects include angle closure glaucoma, bleeding, cataracts, fragility fractures, hyponetriia, SIADH, liver failure, manic activation, QT prolongation, serotonin syndrome and suicidal thoughts and behaviors. Its use is relatively contraindicated if the patient has an allergy to duloxitine. If the patient has hypatic failure, renal failure or narrow angle glaucoma or if the patient is concurrently taking lenasal and MAI anti-depressant,

2:17 methylene blue, pimizide, vioradine or a strong cyp2 inhibitor and it has a blackbox warning for increased suicidal thoughts and behaviors in children and young adults. Let's next review special cases. Duloxitine is cleared by the liver and can contribute to hippatic failure and its serum levels are increased in patients with renal failure. As such, it should generally be avoided in patients with either renal or hpatic failure or at least used with significant caution. Duloxitine is not a preferred anti-depressant in pregnant patients and is associated with risks to both the mother and to the fetus including preeacclampsia, spontaneous abortion, neonatal adaptation syndrome, and persistent pulmonary hypertension of the newborn. Additionally, duloxitine is

3:03 present in breast milk. Let's next discuss dosing. For simplicity, the doses given here are those used for MDD. I'll review the usual initial dose, the maximum dose, goal dose, and titration schedule. Duloxitine may be dosed anywhere in the range of 20 to 120 mg. The initial dose is 30 mg for adults, 30 mg for 7 to 18 year olds, and 20 mg for those 65 and older. The FDA maximum dose for all ages is 120 mg. For MDD and adults, the goal dose is 60 mg. And for GAD and adults, the goal dose is also 60 mg. For pediatric patients, the goal doses are 30 to 60 mg for both MDD and GAD. And for geriatric patients, the

3:48 goal doses are also 30 to 60 mg for both MDD and GAD. As you can see, in most cases, the goal dose will be from 30 to 60 mg. And the usual titration schedule is 30 mg every 2 to 3 weeks. I'd like to conclude with a few final tips. Duloxitine is also FDA indicated for several pain disorders including diabetic neuropathy, neuropathy related to chemotherapy, fibromyalgia, and chronic muscularkeeletal pain and is therefore a great option for treating depression and anxiety in patients who have comorbid pain disorders. Additionally, one of the most rigorous meta analyses to date comparing different anti-depressants in the treatment of adults with MDD found that duloxitine was in the top three of most effective anti-depressants, though in the bottom 10 of most acceptable

4:35 anti-depressants. Finally, you should always complete an interaction check with the patients current medications prior to starting a new medication. And for more information, I usually direct patients to the website for the National Alliance on Mental Illness. That's the end of this talk. I hope this is a useful guide to duloxitine. Thank you.