AdultPediatricGeriatricDosage Forms & Strengths capsule, delayed-release 20mg (Cymbalta, Drizalma Sprinkle, generic) 30mg (Cymbalta, Drizalma Sprinkle, generic) 40mg (Drizalma Sprinkle, Irenka) 60mg (Cymbalta, Drizalma Sprinkle, generic) Major Depressive Disorder Indicated for major depressive disorder (MDD) 40-60 mg/day PO initially (in single daily dose or divided q12hr for 1 week if patient needs to adjust to therapy) Consider starting at 30 mg qDay for 1 week to allow for therapy adjustment before increasing to 60 mg qDay Target dosage: 60 mg/day PO; not to exceed 120 mg/day There is no evidence that doses > 60 mg/day confer additional benefit Diabetic Peripheral Neuropathic Pain Indicated for diabetic peripheral neuropathy/neuropathic pain 60 mg PO qDay initially (in single daily dose or divided q12hr); consider lowering initial dose if tolerability is a concern Target dosage: 60 mg/day PO; not to exceed 60 mg/day There is no evidence that doses >60 mg/day confer additional benefit Consider a lower starting dosage and gradually increase dose for patients with renal impairment Generalized Anxiety Disorder Indicated for generalized anxiety disorder (GAD) Age <65 years: 60 mg PO qDay initially Consider starting at 30 mg qDay for 1 week to allow for therapy adjustment before increasing to 60 mg qDay Target dosage: 60 mg/day PO qDay May increase dose in increments of 30 mg qDay; not to exceed 120 mg/day No additional benefit shown with doses >60 mg/day Fibromyalgia Indicated for fibromyalgia 30 mg PO qDay initially for 1 week to allow for therapy adjustment before increasing to 60 mg qDay Target dosage: 60 mg PO qDay; not to exceed 60 mg/day; no additional benefit shown with doses >60 mg Chronic Musculoskeletal Pain Indicated for chronic musculoskeletal pain, including discomfort from osteoarthritis and chronic lower back pain 30 mg PO qDay initially for 1 week to allow for therapy adjustment before increasing to 60 mg qDay Target dosage: 60 mg/day PO; not to exceed 60 mg/day Dosage Modifications Renal impairment Mild-to-moderate (CrCl 30-80 mL/min): Population PK analyses suggest that no significant effect on duloxetine apparent clearance Severe (CrCl <30 mL/min): Avoid use End-stage renal disease (ESRD): Limited data; peak plasma concentration and AUC were 100% greater for patients with ESRD receiving chronic hemodialysis Hepatic impairment Avoid use with all degrees of hepatic impairment Potent CYP1A2 inhibitors Avoid coadministration Dosing Considerations Uncontrolled narrow-angle glaucoma: Use not recommended due to increased risk of mydriasis Monitoring parameters Before initiating treatment, screen for a personal or family history of bipolar disorder, mania, or hypomania GAD and MDD Periodically reassess to determine the continued need for maintenance treatment and appropriate dosage for such treatment Discontinuation Gradually reduce dosage Abrupt discontinuance may result in symptoms (eg, dizziness, nausea, headache, paresthesia, fatigue, vomiting, irritability, insomnia, diarrhea, anxiety, hyperhidrosis) Switching to and from a monoamine oxidase inhibitor (MAOI) Wait ≥14 days after discontinuing MAOI to initiate duloxetine therapy Wait ≥5 days after discontinuing duloxetine therapy to initiate MAOI therapy Other MAO-Is (linezolid or methylene blue) Do not start duloxetine in a patients with linezolid or IV methylene blue due to the potential risk of serotonin syndrome Patients who requires more urgent treatment of a psychiatric condition: Consider other interventions, including hospitalization If linezolid or IV methylene blue must be administered, discontinue duloxetine immediately; monitor for symptoms of serotonin syndrome for 5 days or until 24 hr after the last dose of linezolid or IV methylene blue, whichever comes first Resume duloxetine 24 hr after the last dose of linezolid or IV methylene blue Risk of administering methylene blue by non-IV routes (eg, oral tablets, by local injection) or in IV doses <1 mg/kg with duloxetine is unclear; be aware of potential risk of serotonin syndrome with such use Dosage Forms & Strengths capsule, delayed-release 20mg (Cymbalta, Drizalma Sprinkle, generic) 30mg (Cymbalta, Drizalma Sprinkle, generic) 40mg (Drizalma Sprinkle, Irenka) 60mg (Cymbalta, Drizalma Sprinkle, generic) Generalized Anxiety Disorder Indicated for generalized anxiety disorder (GAD) in adults and pediatric patients aged ≥7 years 7-17 years 30 mg/day PO qDay initially; after 2 weeks; recommended dose range 30-60 qDay May benefit from doses >60 mg/day; if increased >60 mg/day, use increments of 30 mg/day Maximum dose studied was 120 mg/day Fibromyalgia Cymbalta only Indicated for fibromyalgia in adolescents aged 13-17 yr <13 years: Safety and efficacy not established 13-17 years 30 mg PO qDay; may increase to 60 mg PO qDay based on response and tolerability Dosage Modifications Renal impairment Mild-to-moderate (CrCl 30-80 mL/min): Population PK analyses suggest that no significant effect on duloxetine apparent clearance Severe (CrCl <30 mL/min): Avoid use End-stage renal disease (ESRD): Limited data; peak plasma concentration and AUC were 100% greater for patients with ESRD receiving chronic hemodialysis Hepatic impairment Avoid use with all degrees of hepatic impairment Dosing Considerations Monitoring parameters Before initiating treatment, screen for a personal or family history of bipolar disorder, mania, or hypomania GAD and MDD Periodically reassess to determine the continued need for maintenance treatment and appropriate dosage for such treatment Discontinuation Gradually reduce dosage Abrupt discontinuance may result in symptoms (eg, dizziness, nausea, headache, paresthesia, fatigue, vomiting, irritability, insomnia, diarrhea, anxiety, hyperhidrosis) Switching to and from a monoamine oxidase inhibitor (MAOI) Wait ≥14 days after discontinuing MAOI to initiate duloxetine therapy Wait ≥5 days after discontinuing duloxetine therapy to initiate MAOI therapy Other MAO-Is (linezolid or methylene blue) Do not start duloxetine in patients taking linezolid or IV methylene blue owing to potential risk of serotonin syndrome Patients who requires more urgent treatment of a psychiatric condition: Consider other interventions, including hospitalization If linezolid or IV methylene blue must be administered, discontinue duloxetine immediately; monitor for symptoms of serotonin syndrome for 5 days or until 24 hr after the last dose of linezolid or IV methylene blue, whichever comes first Resume duloxetine 24 hr after the last dose of linezolid or IV methylene blue Risk of administering methylene blue by non-IV routes (eg, oral tablets, by local injection) or in IV doses much <1 mg/kg with duloxetine is unclear; be aware of potential risk of serotonin syndrome with such use Generalized Anxiety Disorder Indicated for generalized anxiety disorder (GAD) ≥65 years: 30 mg/day PO qDay initially; after 2 weeks, consider increasing to target dose of 60 mg/day May benefit from doses >60 mg/day; if increased >60 mg/day, use increments of 30 mg/day Maximum dose studied was 120 mg/dayInteraction CheckerEnter a drug name and duloxetineNo Results No Interactions Found Interactions FoundContraindicatedSerious - Use AlternativeSignificant - Monitor CloselyMinorAll Interactions Sort By: SeverityName Contraindicated (8)eliglustatduloxetine increases levels of eliglustat by affecting hepatic enzyme CYP2D6 metabolism. Contraindicated. If coadministered with strong or moderate CYP2D6 inhibitors, reduce eliglustat dose from 84 mg BID to 84 mg once daily in extensive and intermediate metabolizers; eliglustat is contraindiated if strong or moderate CYP2D6 inhibitors are given concomitantly with strong or moderate CYP3A inhibitors.iobenguane I 123duloxetine decreases effects of iobenguane I 123 by pharmacodynamic antagonism. Contraindicated. If clinically appropriate, discontinue drugs that decrease uptake of NE for at least 5 half-lives; may cause false-negative imaging results.isocarboxazidisocarboxazid and duloxetine both increase serotonin levels. Contraindicated.phenelzinephenelzine and duloxetine both increase serotonin levels. Contraindicated.procarbazineprocarbazine and duloxetine both increase serotonin levels. Contraindicated. Combination is contraindicated within 2 weeks of MAOI use.safinamideduloxetine, safinamide. Either increases toxicity of the other by serotonin levels. Contraindicated. Concomitant use could result in life-threatening serotonin syndrome.selegilineselegiline and duloxetine both increase serotonin levels. Contraindicated. At least 14 days should elapse between discontinuation of selegiline and initiation of treatment with a serotonergic drug.tranylcyprominetranylcypromine and duloxetine both increase serotonin levels. Contraindicated.Serious - Use Alternative (87)abametapirabametapir will increase the level or effect of duloxetine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. For 2 weeks after abametapir application, avoid taking drugs that are CYP1A2 substrates. If not feasible, avoid use of abametapir.amitriptylineduloxetine and amitriptyline both increase serotonin levels. Avoid or Use Alternate Drug.amobarbitalamobarbital will decrease the level or effect of duloxetine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug.amoxapineduloxetine and amoxapine both increase serotonin levels. Avoid or Use Alternate Drug.apixabanduloxetine and apixaban both increase anticoagulation. Avoid or Use Alternate Drug.armodafinilarmodafinil will decrease the level or effect of duloxetine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug.artemether/lumefantrineartemether/lumefantrine will increase the level or effect of duloxetine by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.bupropionduloxetine increases toxicity of bupropion by unspecified interaction mechanism. Avoid or Use Alternate Drug. May lower seizure threshold; keep bupropion dose as low as possible.buspironeduloxetine and buspirone both increase serotonin levels. Avoid or Use Alternate Drug.butabarbitalbutabarbital will decrease the level or effect of duloxetine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug.butalbitalbutalbital will decrease the level or effect of duloxetine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug.carbamazepinecarbamazepine will decrease the level or effect of duloxetine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug.cigarette smokingcigarette smoking will decrease the level or effect of duloxetine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug.cimetidinecimetidine will increase the level or effect of duloxetine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug.citalopramcitalopram and duloxetine both increase serotonin levels. Avoid or Use Alternate Drug. Combination may increase risk of serotonin syndrome or neuroleptic malignant syndrome-like reactions.clomipramineduloxetine will increase the level or effect of clomipramine by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.duloxetine and clomipramine both increase serotonin levels. Avoid or Use Alternate Drug.cyclobenzaprineduloxetine and cyclobenzaprine both increase serotonin levels. Avoid or Use Alternate Drug.dacomitinibdacomitinib will increase the level or effect of duloxetine by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug. Avoid use with CYP2D6 substrates where minimal increases in concentration of the CYP2D6 substrate may lead to serious or life-threatening toxicities. desipramineduloxetine and desipramine both increase serotonin levels. Avoid or Use Alternate Drug.desvenlafaxineduloxetine and desvenlafaxine both increase serotonin levels. Avoid or Use Alternate Drug.dextromethorphanduloxetine will increase the level or effect of dextromethorphan by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.duloxetine and dextromethorphan both increase serotonin levels. Avoid or Use Alternate Drug.dolasetrondolasetron, duloxetine. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.dosulepinduloxetine and dosulepin both increase serotonin levels. Avoid or Use Alternate Drug.doxepinduloxetine and doxepin both increase serotonin levels. Avoid or Use Alternate Drug.erythromycin baseerythromycin base will increase the level or effect of duloxetine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug.erythromycin ethylsuccinateerythromycin ethylsuccinate will increase the level or effect of duloxetine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug.erythromycin lactobionateerythromycin lactobionate will increase the level or effect of duloxetine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug.erythromycin stearateerythromycin stearate will increase the level or effect of duloxetine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug.fluoxetinefluoxetine will increase the level or effect of duloxetine by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.duloxetine and fluoxetine both increase serotonin levels. Avoid or Use Alternate Drug.fluvoxaminefluvoxamine will increase the level or effect of duloxetine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug.fluvoxamine and duloxetine both increase serotonin levels. Avoid or Use Alternate Drug.givosirangivosiran will increase the level or effect of duloxetine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of sensitive CYP1A2 substrates with givosiran. If unavoidable, decrease the CYP1A2 substrate dosage in accordance with approved product labeling.givosiran will increase the level or effect of duloxetine by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of sensitive CYP2D6 substrates with givosiran. If unavoidable, decrease the CYP2D6 substrate dosage in accordance with approved product labeling.granisetrongranisetron, duloxetine. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.imipramineduloxetine and imipramine both increase serotonin levels. Avoid or Use Alternate Drug.iobenguane I 131duloxetine will decrease the level or effect of iobenguane I 131 by Other (see comment). Avoid or Use Alternate Drug. Based on the mechanism of action of iobenguane, drugs that reduce catecholamine uptake or that deplete catecholamine stores may interfere with iobenguane uptake into cells, and thus, reduce iobenguane efficacy. Discontinue interfering drugs for at least 5 half-lives before administration of either the dosimetry or an iobenguane dose. Do not administer these drugs until at least 7 days after each iobenguane dose.leniolisibleniolisib will increase the level or effect of duloxetine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate