Cymbalta – Uses, Side Effects, Interactions

How does this medication work? What will it do for me?

Duloxetine belongs to the class of medications called selective serotonin and norepinephrine reuptake inhibitors (SSNRIs). It is used to treat depression and generalized anxiety disorder. It can also be used to treat diabetes-related nerve pain, fibromyalgia, chronic low back pain, and chronic pain from osteoarthritis of the knee.

For depression and anxiety, duloxetine works by affecting the balance of chemicals in the brain and other parts of the body. For certain types of pain, duloxetine works by affecting the balance of chemicals in the brain and spinal cord that are involved in the experience of pain.

This medication may be available under multiple brand names and/or in several different forms. Any specific brand name of this medication may not be available in all of the forms or approved for all of the conditions discussed here. As well, some forms of this medication may not be used for all of the conditions discussed here.

Your doctor may have suggested this medication for conditions other than those listed in these drug information articles. If you have not discussed this with your doctor or are not sure why you are taking this medication, speak to your doctor. Do not stop taking this medication without consulting your doctor.

Do not give this medication to anyone else, even if they have the same symptoms as you do. It can be harmful for people to take this medication if their doctor has not prescribed it.

What form(s) does this medication come in?

30 mg
Each delayed-release capsule with opaque white body and opaque blue cap, imprinted “30 mg” on the body and “9543” on the cap, contains 30 mg of duloxetine. Nonmedicinal ingredients: FD&C Blue No. 2, gelatin, hydroxypropyl methylcellulose, hydroxypropyl methylcellulose acetate succinate, sodium lauryl sulfate, sucrose, sugar spheres, talc, titanium dioxide, and triethyl citrate.

60 mg
Each delayed-release capsule with opaque green body and opaque blue cap, imprinted “60 mg” on the body and “9542” on the cap, contains 60 mg of duloxetine. Nonmedicinal ingredients: FD&C Blue No. 2, gelatin, hydroxypropyl methylcellulose, hydroxypropyl methylcellulose acetate succinate, sodium lauryl sulfate, sucrose, sugar spheres, talc, titanium dioxide, triethyl citrate, and yellow iron oxide.

How should I use this medication?

The usual recommended dose is 60 mg once daily. Some people may start on a lower dose of 30 mg once daily. Elderly patients with generalized anxiety disorder should be started at a dose of 30 mg once daily. It usually starts to work within 1 to 4 weeks for depression and anxiety and within the first week of treatment for diabetes-related nerve pain, fibromyalgia, chronic back pain, and chronic osteoarthritis knee pain.

Duloxetine should be taken at the same time each day. It can be taken with or without food, but taking it with food may help to reduce nausea that may occur at the start of treatment.

Swallow capsules whole. Do not crush or chew the capsules, and do not sprinkle the contents of the capsule into foods or liquids.

Many things can affect the dose of a medication that a person needs, such as body weight, other medical conditions, and other medications. If your doctor has recommended a dose different from the ones listed here, do not change the way that you are taking the medication without consulting your doctor.

It is important to take this medication exactly as prescribed by your doctor. If you miss a dose by a few hours, take it as soon as you remember and continue with your regular schedule. If most of the day has passed, skip the missed dose and continue with your regular dosing schedule. Do not take a double dose to make up for a missed one. If you are not sure what to do after missing a dose, contact your doctor or pharmacist for advice.

Store this medication at room temperature, protect it from light and moisture, and keep it out of the reach of children.

Do not dispose of medications in wastewater (e.g. down the sink or in the toilet) or in household garbage. Ask your pharmacist how to dispose of medications that are no longer needed or have expired.

Who should NOT take this medication?

Do not take this medication if you:

• are allergic to duloxetine or any ingredients of the medication
• have liver disease causing reduced liver function
• have severely reduced kidney function
• have uncontrolled narrow-angle glaucoma
• are taking fluvoxamine and other medications with a similar effect on drug metabolism in the liver (check with your pharmacist)
• are taking MAO inhibitors (e.g., phenelzine, tranylcypromine, linezolid, methylene blue) or have taken a MAO inhibitor within 2 weeks of starting duloxetine
• are taking quinolone medications (e.g., ciprofloxacin, norfloxacin)
• are taking thioridazine

What side effects are possible with this medication?

Many medications can cause side effects. A side effect is an unwanted response to a medication when it is taken in normal doses. Side effects can be mild or severe, temporary or permanent.

The side effects listed below are not experienced by everyone who takes this medication. If you are concerned about side effects, discuss the risks and benefits of this medication with your doctor.

The following side effects have been reported by at least 1% of people taking this medication. Many of these side effects can be managed, and some may go away on their own over time.

Contact your doctor if you experience these side effects and they are severe or bothersome. Your pharmacist may be able to advise you on managing side effects.

• abdominal pain
• changes in sexual desire or ability
• constipation
• decreased appetite
• diarrhea
• difficulty sleeping
• dizziness
• dry mouth
• fatigue
• headache
• increased sweating
• nausea
• restlessness (feeling like you need to keep moving)
• sleepiness
• vomiting

Although most of these side effects listed below don’t happen very often, they could lead to serious problems if you do not seek medical attention.

Check with your doctor as soon as possible if any of the following side effects occur:

• hallucinations (seeing or hearing things that are not there)
• inability to pass urine
• new or worsening emotional or behavioural problems
• overactive thoughts or behaviour
• signs of clotting problems (e.g., unusual nosebleeds, bruising, blood in urine, coughing blood, bleeding gums, cuts that don’t stop bleeding)
• skin rash or hives (with no other symptoms)
• symptoms of glaucoma (e.g., blurred vision, seeing halos of bright colours around lights, red eyes, increased pressure in your eyes, eye pain or discomfort)
• symptoms of high blood sugar (e.g., frequent urination, increased thirst, excessive eating, unexplained weight loss, poor wound healing, infections, fruity breath odour)
• symptoms of liver problems (e.g., nausea, vomiting, or loss of appetite, combined with yellow skin or eyes, dark urine, or itching)
• symptoms of low sodium levels in the blood (e.g., tiredness, weakness, and confusion combined with achy, stiff, or uncoordinated muscles)

Stop taking the medication and seek immediate medical attention if any of the following occur:

• seizures
• signs of an allergic reaction (e.g., shortness of breath or difficulty breathing; hives, itching or rash; swelling of the eyes, mouth, lips, or throat)
• signs of bleeding in the stomach (e.g., bloody, black, or tarry stools, spitting up of blood, vomiting blood or material that looks like coffee grounds)
• signs of a severe skin reaction such as blistering, peeling, a rash covering a large area of the body, a rash that spreads quickly, or a rash combined with fever or discomfort
• symptoms of serotonin syndrome or neuroleptic malignant syndrome (e.g., experiencing most or all of the following: confusion, restlessness, extreme agitation, high fever, sweating, shivering, shaking, hallucinations, fast heartbeat, and sudden muscle jerking)
• thoughts of suicide or self-harm
• vision changes or eye pain

Some people may experience side effects other than those listed. Check with your doctor if you notice any symptom that worries you while you are taking this medication.

Are there any other precautions or warnings for this medication?

Before you begin using a medication, be sure to inform your doctor of any medical conditions or allergies you may have, any medications you are taking, whether you are pregnant or breast-feeding, and any other significant facts about your health. These factors may affect how you should use this medication.

Bleeding: This medication may increase the risk of bleeding, especially if you are also taking medications such as acetylsalicylic acid (ASA), nonsteroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen, naproxen, ketoprofen), or warfarin. If you experience easy bruising, pinpoint-sized red spots on the skin, or unusual bleeding while taking this medication, contact your doctor immediately.

Blood pressure and heart rate: Duloxetine may cause an increase in blood pressure or heart rate. Your doctor will monitor your blood pressure and heart rate before starting this medication and periodically while you are taking this medication. If you have high blood pressure or other types of heart disease, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.

Bone fractures: Duloxetine may increase your risk of breaking a bone, especially if you are a senior, have osteoporosis, or have other risk factors for bone fractures. Take extra care to avoid falling by sitting or lying down if you feel dizzy or lightheaded. Contact your doctor if you experience dizziness or lightheadedness frequently.

Diabetes: This medication may worsen blood sugar control in some people who have diabetes. If you have diabetes, monitor your blood sugar closely and report any changes to your doctor.

If you are at risk for developing diabetes, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.

Drowsiness/reduced alertness: This medication may affect judgment, thinking, or physical abilities and may cause drowsiness or dizziness. Avoid driving, operating machinery, or performing other hazardous tasks until you have determined how this medication affects you.

Glaucoma: This medication may cause the symptoms of glaucoma (increased pressure in the eye) to become worse. If you have controlled narrow-angle glaucoma, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed. Report any changes in vision to your doctor as soon as possible while you are taking this medication.

Kidney function: Duloxetine is not recommended for people with severe kidney problems. If you have kidney problems, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.

Liver function: Decreased liver function or liver disease can cause this medication to build up in the body, causing side effects. If you have liver problems or consume substantial amounts of alcohol, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed. This medication may also cause liver problems. If you experience nausea, abdominal pain, or yellowing of the skin or eyes while taking this medication, contact your doctor immediately.

Seizures: If you have a seizure disorder, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.

Serotonin syndrome/neuroleptic malignant syndrome: Severe reactions are possible when duloxetine is combined with other medications that act on serotonin, such as tricyclic antidepressants and certain migraine medications. These combinations must be avoided. Symptoms of a reaction may include muscle rigidity and spasms, difficulty moving, and changes in mental state including delirium and agitation. Coma and death are possible.

If you are taking antidepressants, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.

Slowed stomach emptying: If you have a condition that slows emptying from the stomach (e.g., diabetes), discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.

Stopping the medication: Stopping this medication suddenly may lead to side effects such as dizziness, abnormal dreams, difficulty sleeping, numbness or tingling sensations, irritability, anxiety, nausea, vomiting, diarrhea, sweating, muscle pain, or other symptoms. Stopping this medication gradually as directed by your doctor can minimize these effects. If you are thinking of stopping the medication, check with your doctor first.

Sucrose: This medication contains sucrose. If you have a rare hereditary problem of fructose intolerance, glucose-galactose malabsorption, or sucrose metabolism, you should not take this medication.

Suicidal or agitated behaviour: People taking this medication may feel agitated (restless, anxious, aggressive, emotional, and feeling not like themselves), or they may want to hurt themselves or others. If you experience these side effects or notice them in a family member who is taking this medication, contact your doctor immediately. Your doctor will monitor you closely for these side effects while you are taking this medication.

Urinary tract symptoms: Some people who take this medication experience difficulty starting urine flow or emptying the bladder. If you notice these changes, contact your doctor.

Pregnancy: It has been reported that babies born to women who took medications similar to duloxetine during the last trimester of their pregnancy may experience adverse effects (such as breathing problems, seizures, trouble feeding, jitteriness, irritability, and constant crying). Women who take duloxetine during pregnancy may be at increased risk of bleeding after childbirth. This medication should not be used during pregnancy unless the benefits outweigh the risks. If you become pregnant while taking this medication, contact your doctor immediately.

Breast-feeding: This medication passes into breast milk. If you are a breast-feeding mother and are taking duloxetine, it may affect your baby. Talk to your doctor about whether you should continue breast-feeding.

Children and adolescents: The safety and effectiveness of this medication have not been established for children. Children under 18 years old are at an increased risk of suicidal thoughts or behaviour if they take duloxetine.

What other drugs could interact with this medication?

There may be an interaction between duloxetine and any of the following:

• abiraterone acetate
• acetylsalicylic acid (ASA)
• alcohol
• aldesleukin
• aliskiren
• alpha-agonists (e.g., clonidine, methyldopa)
• alpha/beta-agonists (e.g., epinephrine, norepinephrine)
• alpha-blockers (e.g., alfuzosin, doxazosin, tamsulosin)
• amphetamines (e.g., dextroamphetamine, lisdexamfetamine)
• angiotensin-converting enzyme inhibitors (ACEIs; captopril, enalapril, ramipril)
• angiotensin receptor blockers (ARBs; e.g., candesartan, irbesartan, losartan)
• antiarrhythmics (e.g., amiodarone, dipyridamole, flecainide, propafenone, quinidine)
• antipsychotics (e.g., chlorpromazine, clozapine, haloperidol, olanzapine, quetiapine, risperidone)
• apixaban
• atomoxetine
• beta-adrenergic blockers (e.g., atenolol, propranolol, sotalol)
• brimonidine
• bromocriptine
• bupropion
• buspirone
• cabergoline
• calcium channel blockers (e.g., amlodipine, diltiazem, nifedipine, verapamil)
• cannabis
• carbamazepine
• celecoxib
• chloroquine
• chlorpheniramine
• cinacalcet
• clopidogrel
• cyclobenzaprine
• cyproterone
• dabigatran
• deferasirox
• delavirdine
• dextromethorphan
• diuretics (water pills; e.g., furosemide, hydrochlorothiazide, triamterene)
• doxorubicin
• edoxaban
• eliglustat
• ergot alkaloids (e.g., ergotamine, dihydroergotamine)
• fesoterodine
• glucosamine
• guanfacine
• heparin
• hydralazine
• linezolid
• lithium
• lopinavir
• low-molecular-weight heparins (e.g., dalteparin, enoxaparin, tinzaparin)
• methadone
• methoxsalen
• methylene blue
• metoclopramide
• minoxidil
• mirabegron
• mirtazapine
• monoamine oxidase inhibitors (MAOIs; e.g., moclobemide, phenelzine, rasagiline, selegiline, tranylcypromine)
• meperidine
• methylphenidate
• multivitamins with minerals
• nitrates (e.g., nitroglycerin, isosorbide dinitrate, isosorbide mononitrate)
• nonsteroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen, naproxen, ketoprofen)
• omega-3 fatty acids
• paclitaxel
• phenobarbital
• pramipexole
• prasugrel
• primaquine
• primidone
• pseudoephedrine
• quinine
• quinolone antibiotics (e.g., ciprofloxacin, norfloxacin)
• rifampin
• ritonavir
• rivaroxaban
• ropinirole
• St. John’s wort
• selective serotonin reuptake inhibitors (SSRIs; e.g., citalopram, fluoxetine, paroxetine, sertraline)
• serotonin antagonists (anti-emetic medications; e.g., granisetron, ondansetron)
• other serotonin/norepinephrine reuptake inhibitors (SNRIs; e.g., desvenlafaxine, venlafaxine)
• tamoxifen
• tapentadol
• ticagrelor
• ticlopidine
• tobacco (smoked)
• tolcapone
• tramadol
• trazodone
• tricyclic antidepressants (e.g., imipramine, amitriptyline, nortriptyline, desipramine)
• “triptan” medications (e.g., sumatriptan, rizatriptan)
• tryptophan
• tyrosine kinase inhibitors (e.g., dasatinib, imatinib, nilotinib, vemurafenib)
• vitamin E
• warfarin

If you are taking any of these medications, speak with your doctor or pharmacist. Depending on your specific circumstances, your doctor may want you to:

• stop taking one of the medications,
• change one of the medications to another,
• change how you are taking one or both of the medications, or
• leave everything as is.

An interaction between two medications does not always mean that you must stop taking one of them. Speak to your doctor about how any drug interactions are being managed or should be managed.

Medications other than those listed above may interact with this medication. Tell your doctor or prescriber about all prescription, over-the-counter (non-prescription), and herbal medications you are taking. Also tell them about any supplements you take. Since caffeine, alcohol, the nicotine from cigarettes, or street drugs can affect the action of many medications, you should let your prescriber know if you use them.

All material copyright MediResource Inc. 1996 – 2021. Terms and conditions of use. The contents herein are for informational purposes only. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Source: www.medbroadcast.com/drug/getdrug/Cymbalta

Duloxetine delayed-release capsules

What is this medicine?

DULOXETINE (doo LOX e teen) is used to treat depression, anxiety, and different types of chronic pain.

This medicine may be used for other purposes; ask your health care provider or pharmacist if you have questions.

COMMON BRAND NAME(S): Cymbalta, Drizalma, Irenka

What should I tell my health care provider before I take this medicine?

They need to know if you have any of these conditions:

• bipolar disorder
• glaucoma
• high blood pressure
• kidney disease
• liver disease
• seizures
• suicidal thoughts, plans or attempt; a previous suicide attempt by you or a family member
• take medicines that treat or prevent blood clots
• taken medicines called MAOIs like Carbex, Eldepryl, Marplan, Nardil, and Parnate within 14 days
• trouble passing urine
• an unusual reaction to duloxetine, other medicines, foods, dyes, or preservatives
• pregnant or trying to get pregnant
• breast-feeding

How should I use this medicine?

Take this medicine by mouth with a glass of water. Follow the directions on the prescription label. Do not crush, cut or chew some capsules of this medicine. Some capsules may be opened and sprinkled on applesauce. Check with your doctor or pharmacist if you are not sure. You can take this medicine with or without food. Take your medicine at regular intervals. Do not take your medicine more often than directed. Do not stop taking this medicine suddenly except upon the advice of your doctor. Stopping this medicine too quickly may cause serious side effects or your condition may worsen.

A special MedGuide will be given to you by the pharmacist with each prescription and refill. Be sure to read this information carefully each time.

Talk to your pediatrician regarding the use of this medicine in children. While this drug may be prescribed for children as young as 7 years of age for selected conditions, precautions do apply.

Overdosage: If you think you have taken too much of this medicine contact a poison control center or emergency room at once.

NOTE: This medicine is only for you. Do not share this medicine with others.

What if I miss a dose?

If you miss a dose, take it as soon as you can. If it is almost time for your next dose, take only that dose. Do not take double or extra doses.

What may interact with this medicine?

Do not take this medicine with any of the following medications:

• desvenlafaxine
• levomilnacipran
• linezolid
• MAOIs like Carbex, Eldepryl, Marplan, Nardil, and Parnate
• methylene blue (injected into a vein)
• milnacipran
• thioridazine
• venlafaxine

This medicine may also interact with the following medications:

• alcohol
• amphetamines
• aspirin and aspirin-like medicines
• certain antibiotics like ciprofloxacin and enoxacin
• certain medicines for blood pressure, heart disease, irregular heart beat
• certain medicines for depression, anxiety, or psychotic disturbances
• certain medicines for migraine headache like almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan
• certain medicines that treat or prevent blood clots like warfarin, enoxaparin, and dalteparin
• cimetidine
• fentanyl
• lithium
• NSAIDS, medicines for pain and inflammation, like ibuprofen or naproxen
• phentermine
• procarbazine
• rasagiline
• sibutramine
• St. John’s wort
• theophylline
• tramadol
• tryptophan

This list may not describe all possible interactions. Give your health care provider a list of all the medicines, herbs, non-prescription drugs, or dietary supplements you use. Also tell them if you smoke, drink alcohol, or use illegal drugs. Some items may interact with your medicine.

What should I watch for while using this medicine?

Tell your doctor if your symptoms do not get better or if they get worse. Visit your doctor or healthcare provider for regular checks on your progress. Because it may take several weeks to see the full effects of this medicine, it is important to continue your treatment as prescribed by your doctor.

This medicine may cause serious skin reactions. They can happen weeks to months after starting the medicine. Contact your healthcare provider right away if you notice fevers or flu-like symptoms with a rash. The rash may be red or purple and then turn into blisters or peeling of the skin. Or, you might notice a red rash with swelling of the face, lips, or lymph nodes in your neck or under your arms.

Patients and their families should watch out for new or worsening thoughts of suicide or depression. Also watch out for sudden changes in feelings such as feeling anxious, agitated, panicky, irritable, hostile, aggressive, impulsive, severely restless, overly excited and hyperactive, or not being able to sleep. If this happens, especially at the beginning of treatment or after a change in dose, call your healthcare provider.

You may get drowsy or dizzy. Do not drive, use machinery, or do anything that needs mental alertness until you know how this medicine affects you. Do not stand or sit up quickly, especially if you are an older patient. This reduces the risk of dizzy or fainting spells. Alcohol may interfere with the effect of this medicine. Avoid alcoholic drinks.

This medicine can cause an increase in blood pressure. This medicine can also cause a sudden drop in your blood pressure, which may make you feel faint and increase the chance of a fall. These effects are most common when you first start the medicine or when the dose is increased, or during use of other medicines that can cause a sudden drop in blood pressure. Check with your doctor for instructions on monitoring your blood pressure while taking this medicine.

Your mouth may get dry. Chewing sugarless gum or sucking hard candy, and drinking plenty of water, may help. Contact your doctor if the problem does not go away or is severe.

What side effects may I notice from receiving this medicine?

Side effects that you should report to your doctor or health care professional as soon as possible:

• allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
• anxious
• breathing problems
• confusion
• changes in vision
• chest pain
• confusion
• elevated mood, decreased need for sleep, racing thoughts, impulsive behavior
• eye pain
• fast, irregular heartbeat
• feeling faint or lightheaded, falls
• feeling agitated, angry, or irritable
• hallucination, loss of contact with reality
• high blood pressure
• loss of balance or coordination
• palpitations
• redness, blistering, peeling or loosening of the skin, including inside the mouth
• restlessness, pacing, inability to keep still
• seizures
• stiff muscles
• suicidal thoughts or other mood changes
• trouble passing urine or change in the amount of urine
• trouble sleeping
• unusual bleeding or bruising
• unusually weak or tired
• vomiting
• yellowing of the eyes or skin

Side effects that usually do not require medical attention (report to your doctor or health care professional if they continue or are bothersome):

• change in sex drive or performance
• change in appetite or weight
• constipation
• dizziness
• dry mouth
• headache
• increased sweating
• nausea
• tired

This list may not describe all possible side effects. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Where should I keep my medicine?

Keep out of the reach of children.

Store at room temperature between 15 and 30 degrees C (59 to 86 degrees F). Throw away any unused medicine after the expiration date.

NOTE: This sh

Differences, similarities, and which is better for you

Drug overview & main differences | Conditions treated | Efficacy | Insurance coverage and cost comparison | Side effects | Drug interactions | Warnings | FAQ

Cymbalta (duloxetine) and Effexor (venlafaxine) are brand-name medications used to treat psychiatric conditions such as depression and anxiety. They are usually prescribed as antidepressants to help relieve the symptoms of major depressive disorder. Symptoms of major depressive disorder may include persistent sadness and a severe loss of interest in daily activities.

Cymbalta and Effexor both belong to a class of drugs called serotonin and norepinephrine reuptake inhibitors (SNRIs). They work by increasing the availability of serotonin and norepinephrine in the brain. These chemicals, or neurotransmitters, are believed to play a role in the occurrence of mental health disorders.

For the purposes of this comparison, the name Effexor may also refer to Effexor XR, the only brand-name Effexor currently available on the market.

What are the main differences between Cymbalta and Effexor?

Cymbalta

Cymbalta is the brand name for duloxetine. It is available as an oral delayed-release capsule with strengths of 20 mg, 30 mg, or 60 mg. It is usually dosed as one capsule by mouth once daily depending on the condition being treated. The maximum dose per day is 120 mg although there is no evidence that doses greater than 60 mg provide a significant increase in benefit.

Cymbalta has a half-life of around 12 hours. It is primarily metabolized and eliminated through the liver and kidneys. Its use should be avoided in those with severe liver or kidney impairment.

Effexor

Effexor is the brand name for venlafaxine. However, brand-name Effexor is only available as Effexor XR, or venlafaxine extended-release tablets. Immediate-release Effexor was discontinued because it needs to be dosed multiple times throughout the day and causes more nausea than the extended-release version.

Effexor XR comes in oral capsules with strengths of 37.5 mg, 75 mg, and 150 mg. Dosing may vary depending on the condition being treated. However, Effexor XR is usually taken once daily with a target daily dose of 75 mg and a maximum daily dose of 225 mg.

Like Cymbalta, Effexor is metabolized in the liver and has a total half-life of up to 11 hours. It can be used in those with liver or kidney impairment if lower doses are taken.

Conditions treated by Cymbalta and Effexor

Cymbalta is FDA approved to treat major depressive disorder (MDD) and generalized anxiety disorder (GAD). It can also be used to treat pain from fibromyalgia and diabetic neuropathy, as well as general pain in the muscles, tendons, ligaments, and bones. Cymbalta may sometimes be used off-label for other anxiety disorders.

Effexor XR is FDA approved to treat major depressive disorder (MDD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), and panic disorder (PD). It is also sometimes used off-label to treat obsessive-compulsive disorder (OCD), premenstrual dysphoric disorder (PMDD), and pain.

Is Cymbalta or Effexor more effective?

The effectiveness of Cymbalta or Effexor depends on the condition being treated. Very few studies have directly compared Cymbalta and Effexor. However, when compared to placebo, Cymbalta and Effexor are both more effective for treating conditions like major depression.

One study pooled several clinical trials and found that venlafaxine is a better short-term treatment option for major depression than duloxetine. Venlafaxine, the active ingredient of Effexor, may also be preferred for those who don’t respond well to initial treatment with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs). However, the study found that there were no significant differences in response and response rate between duloxetine and venlafaxine.

Another systematic review compared venlafaxine, duloxetine, and other antidepressants like paroxetine, fluoxetine, and fluvoxamine. Compared to the other options, venlafaxine was found to be one of the more effective antidepressants. However, both venlafaxine and duloxetine were ranked as some of the least tolerable antidepressants, regarding side effects.

Consult a healthcare provider who specializes in psychiatry for the best treatment option for you.

Coverage and cost comparison of Cymbalta vs. Effexor

Cymbalta is a brand-name prescription drug used for depression. The generic version, duloxetine, is usually covered by Medicare and insurance plans. For a 30-day supply, the average retail price can more than $470. With a SingleCare Cymbalta coupon, the price for the generic version starts at $15 at participating pharmacies.

Effexor XR tablets are available for purchase with a prescription. Generic Effexor XR tablets are often covered by Medicare and insurance plans. With an average price of around $145, Effexor XR is cheaper than Cymbalta. However, using an Effexor XR coupon from SingleCare can bring the cost down even further. Ask your pharmacist for the generic and get it for approximately $15.

Common side effects of Cymbalta vs. Effexor

The most common side effects of Cymbalta include nausea, headache, dry mouth, somnolence or drowsiness, constipation, and fatigue. Cymbalta may also cause diarrhea, decreased appetite, increased sweating, and abdominal pain, among other side effects.

The most common side effects of Effexor are nausea, headache, dry mouth, weakness, and somnolence. Effexor may also cause insomnia, constipation, dizziness, diarrhea, and decreased appetite.

Both Cymbalta and Effexor can also cause decreased sex drive (libido). However, Effexor has been shown to cause more sexual dysfunction problems than Cymbalta.

See the table below for other common side effects of Cymbalta and Effexor.

*not reported
Frequency is not based on data from a head-to-head trial. This may not be a complete list of adverse effects that can occur. Please refer to your doctor or healthcare provider to learn more.
Source: DailyMed (Cymbalta), DailyMed (Effexor)

Drug interactions of Cymbalta vs. Effexor

Cymbalta and Effexor should not be used with monoamine oxidase inhibitors (MAOIs) such as selegiline and phenelzine. Cymbalta or Effexor should not be used within 14 days of discontinuing an MAOI. Otherwise, there is an increased risk of serotonin syndrome, a severe condition that may require emergency medical attention.

There may also be a risk of serotonin syndrome when Cymbalta or Effexor is taken alongside another serotonergic drug. Serotonergic drugs include selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). Caution should be used when using serotonergic drugs with Cymbalta or Effexor.

Drugs like paroxetine or fluoxetine can interfere with the metabolism of Cymbalta and increase its blood levels. This could lead to an increased risk of serious side effects with Cymbalta.

Cymbalta and Effexor should be used with caution or avoided with nonsteroidal anti-inflammatory drugs (NSAIDs) and anticoagulants. Using these drugs together can increase the risk of bleeding.

Consult a healthcare professional for other possible drug interactions

Warnings of Cymbalta and Effexor

Liver failure has been reported with the use of Cymbalta. In those with a history of alcohol abuse or liver dysfunction, Cymbalta should be avoided. The use of Cymbalta should be discontinued in those who develop signs of liver failure, such as jaundice.

The use of Cymbalta or Effexor carries a risk of serotonin syndrome, which occurs when there is an excess of serotonin in the brain. Symptoms of serotonin syndrome may include fast heart rate, increased blood pressure, sweating, tremors, and fever.

Cymbalta and Effexor can cause an increase in blood pressure. Those with a history of high blood pressure should be monitored while on treatment with Cymbalta or Effexor.

Cymbalta and Effexor should be used with caution in those with a history of bipolar disorder or seizures. These antidepressants may activate mania, hypomania, or seizures in some people.

Consult a healthcare provider for other possible warnings and precautions with Cymbalta and Effexor.

Frequently asked questions about Cymbalta vs. Effexor

What is Cymbalta?

Cymbalta is the brand name of duloxetine. It is used for the treatment of major depression and anxiety disorders. It is also used to treat pain from diabetic neuropathy and fibromyalgia. Cymbalta is available in extended-release capsules in strengths of 20 mg, 30 mg, or 60 mg.

What is Effexor?

Effexor is the brand name of venlafaxine. It is used for the treatment of major depressive disorder, generalized anxiety disorder, social anxiety disorder, and panic disorder. Regular Effexor has been discontinued; however, Effexor XR tablets are available in strengths of 37.5 mg, 75 mg, and 150 mg.

Are Cymbalta and Effexor the same?

Cymbalta and Effexor are both serotonin and norepinephrine reuptake inhibitors (SNRIs). But they are not the same drug. In addition to treating major depression and anxiety, Cymbalta is also FDA approved to treat certain types of nerve pain. On the other hand, Effexor is FDA approved to treat panic attacks and social anxiety.

Is Cymbalta or Effexor better?

The better antidepressant depends on the condition being treated and other medications a person may be taking. Venlafaxine may be a more effective short-term treatment option for depression. However, it may have a lower tolerability than Cymbalta in terms of side effects, such as sexual dysfunction.

Can I use Cymbalta or Effexor while pregnant?

No conclusive studies have shown that Cymbalta or Effexor may be safe during pregnancy. An antidepressant should only be used during pregnancy if the benefits outweigh the potential risks. In some cases, Cymbalta or Effexor may need to be used to control symptoms of depression during pregnancy. Consult a healthcare provider for medical advice before using Cymbalta or Effexor while pregnant.

Can I use Cymbalta or Effexor with alcohol?

Alcohol in moderation is likely safe while taking Cymbalta or Effexor. However, drinking alcohol while starting treatment with Cymbalta or Effexor may lead to increased dizziness or drowsiness. It may be advised to discontinue drinking alcohol until it has been a few days after starting treatment.

Does Effexor affect memory?

There is no evidence that Effexor directly affects memory. Effexor XR has been known to cause hyponatremia, or low sodium levels in the blood, especially if diuretics are also being taken. Signs and symptoms of hyponatremia include headache, confusion, and memory impairment. Your doctor may recommend stopping Effexor XR until the hyponatremia resolves.

What is a good alternative to Cymbalta?

Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor (SNRI). Other SNRIs include Effexor (venlafaxine), Pristiq (desvenlafaxine), and Savella (milnacipran). Talk to a healthcare provider about potential antidepressant treatment options for you.

How bad is Effexor withdrawal?

The dose of Effexor should be slowly tapered to help prevent serious withdrawal symptoms. Abrupt discontinuation of Effexor can lead to symptoms like nausea, dizziness, vomiting, nightmares, irritability, and headaches. Effexor withdrawal symptoms may also include paresthesias, or tingling sensations on the skin.

Duloxetine (Cymbalta): Dosage, Uses, Side Effects

See more

If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.

Duloxetine (brand name Cymbalta) originally came to market in 2004 to treat depression. However, it quickly became the first drug FDA-approved to treat nerve pain, too. Since then, it has also been approved to treat other conditions, like anxiety and fibromyalgia. Read on to learn more about this versatile drug, including its uses, side effects, dosage, and more. 

Cymbalta and generic duloxetine are serotonin-norepinephrine reuptake inhibitors or SNRIs, frequently used for depression and anxiety. Many healthcare providers also use Cymbalta for pain conditions, including diabetic nerve pain, fibromyalgia, etc.

Duloxetine works by affecting brain chemicals, called neurotransmitters, that help your nervous system communicate. The neurotransmitters are released in the spaces between the cells. Then, they are slowly reabsorbed back into the cells to use again in the future. Duloxetine works by blocking the reabsorption of two neurotransmitters—serotonin and norepinephrine—meaning the chemicals stay in the spaces between the nerves for longer and can continue communicating. Both of these neurotransmitters are important for mental health (Dhaliwal, 2020). 

Duloxetine is FDA approved to treat (FDA, 2019):

• Major depressive disorder (MDD or unipolar depression): MDD is a mental health condition where people experience a lack of desire to do anything, persistently sad moods, a sense of hopelessness or guilt, poor appetite, and other symptoms that disrupt day-to-day life (Bains, 2021).
• Generalized anxiety disorder (GAD): People with GAD feel excessive worry about many things, like home life, work stresses, personal relationships, etc., which can affect their ability to function. Taking Cymbalta for anxiety may help (Munir, 2021).
• Peripheral diabetic neuropathy: People with diabetes may experience numbness, tingling, and/or burning in their hands and feet (Bodman, 2021).
• Fibromyalgia: This is a widespread chronic pain condition related to problems processing pain in the brain (Bhargava, 2020).
• Chronic musculoskeletal pain: If you suffer from knee osteoarthritis or low back pain, your healthcare provider may recommend Cymbalta for the pain (UptoDate, n.d.). 

Sometimes healthcare providers use medications to treat conditions other than the FDA-approved ones. This is called using a drug “off label,” and such uses of duloxetine include (UptoDate, n.d.):

• Chemotherapy-induced peripheral neuropathy
• Stress urinary incontinence

If you’ve been prescribed Cymbalta for anxiety, pain, or another condition, you may be curious about potential side effects. Duloxetine is generally well-tolerated, but like many medications, it can cause adverse effects.

The U.S. Food and Drug Administration (FDA) has issued a black box warning for duloxetine and other antidepressants, noting worsening depression and an increased risk of suicidal thoughts and behavior in children, adolescents, and young adults (FDA, 2019).

Some of the common side effects of duloxetine include (Dhaliwal, 2020):

• Nausea
• Dry mouth
• Constipation
• Weight loss
• Decreased appetite
• Abdominal pain
• Drowsiness
• Headache
• Trouble sleeping

If you decide to stop taking duloxetine, talk to your healthcare provider first. Sudden discontinuation may lead to duloxetine withdrawal symptoms, including dizziness, nausea, and headache, among other symptoms (Hirsch, 2020).

Like many other antidepressants, sexual side effects can occur with Cymbalta, including abnormal orgasms, erectile dysfunction, decreased sex drive, and priapism (a painful and persistent erection) (UptoDate, n.d.). 

Serious side effects may occur, including suicidality, serotonin syndrome, liver problems, manic episodes (in people with undiagnosed bipolar disorder), bleeding, bone fractures, and SIADH (a condition that causes the body to retain too much water) (UptoDate, n.d.). 

Cymbalta and alcohol: risks and side effects

Rarely, people experience severe skin reactions, including erythema multiforme and Stevens-Johnson Syndrome (SJS)—symptoms may include blisters, a peeling skin rash, or hypersensitivity. Another possible side effect is acute angle-closure glaucoma (a sudden spike in eye pressure), which can cause eye pain and lead to permanent vision loss if not treated immediately (UptoDate, n.d.). 

If you experience any serious effects or develop an allergic reaction to duloxetine, seek medical advice immediately. 

This list does not include all possible adverse effects, and others may exist. Check with your pharmacist or healthcare provider for more information.

Duloxetine is available in delayed-release capsules in doses of 20 mg, 30 mg, and 40 mg. Your healthcare provider may prescribe from 20 mg to 60 mg daily, split into one to three doses, depending on the condition being treated and other factors. 

Before starting duloxetine, tell your healthcare provider about any other medications or supplements you’re taking to avoid potential drug interactions. Some medicines can increase the risk of adverse effects, while others may make duloxetine less effective.

The most serious potential drug interaction is serotonin syndrome, where serotonin levels become dangerously high in the body. Symptoms of serotonin syndrome include changes in mental status, increased heart rate, high blood pressure, loss of coordination, muscle rigidity or twitching, sweating, nausea, and vomiting. It can be fatal in severe circumstances (Simon, 2021). 

Duloxetine, as an SNRI, works by increasing the levels of serotonin and norepinephrine. However, too much serotonin can lead to serotonin syndrome, a serious potential side effect of duloxetine and other antidepressant drugs, like SSRIs (selective serotonin reuptake inhibitors). 

SSRIs: everything you need to know

Some people have developed serotonin syndrome when taking duloxetine alone. However, the risk is higher if duloxetine is taken in combination with monoamine oxidase inhibitors (MAOIs), which may also be used to treat depression. Examples of MAOIs include SNRIs, SSRIs, or other medications and supplements that boost serotonin, including methylene blue, linezolid, and phenelzine. Do not take duloxetine five days before or 14 days after you have used an MAOI drug (FDA, 2019)

MAOIs are not the only drugs that may interact with Cymbalta to cause serotonin syndrome. Other medications that may increase serotonin levels include triptans, tricyclic antidepressants, lithium, tramadol, thioridazine, buspirone, amphetamines, and over-the-counter St. John’s Wort (Simon, 2021).

Another class of medications that can lead to potential drug interactions are CYP1A2 and CYP2D6 inhibitors. CYP1A2 and CYP2D6 are liver enzymes that break down duloxetine. Drugs that inhibit these enzymes may affect your duloxetine dose as these medications can increase the level of duloxetine in the blood. Examples include cimetidine, ciprofloxacin, paroxetine, fluoxetine, and quinidine (FDA, 2019).

Duloxetine may increase your risk of abnormal bleeding, like bruising, nose bleeds, and potentially life-threatening hemorrhages if taken with other medications that also affect bleeding, including aspirin, NSAIDs (nonsteroidal anti-inflammatory drugs) like ibuprofen or naproxen, and prescription blood thinners like warfarin (brand name Coumadin) (FDA, 2019):

Do not take duloxetine if you have had an allergic reaction to it in the past. 

Duloxetine should not be used by people with certain medical conditions like kidney disease or liver disease because of the increased risk of side effects (FDA, 2019).

People who drink heavily may experience severe liver injury if they take Cymbalta (FDA, 2019).

If you’re pregnant, plan to become pregnant, or breastfeeding, talk with your healthcare provider before taking duloxetine. Duloxetine is an FDA pregnancy Category C drug, which means that risks to the fetus can’t be ruled out (FDA, 2019). Your healthcare provider will work with you to determine if it’s safe to keep you on Cymbalta during pregnancy. 

1. Bains N, Abdijadid S. (2021). Major depressive disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK559078/

   Bhargava J, Hurley JA. (2020). Fibromyalgia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from  https://www.ncbi.nlm.nih.gov/books/NBK540974/

   Bodman MA, Varacallo M. (2021) Peripheral diabetic neuropathy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK442009/

   Dhaliwal JS, Spurling BC, Molla M. (2020). Duloxetine. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK549806/

   Food and Drug Administration (FDA). (2019). Cymbalta (duloxetine delayed-release capsules). Retrieved June 22, 2021 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/021427s052lbl.pdf

   Hirsch, M. & Birnbaum, R.J. (2020). Discontinuing antidepressant medications in adults. In UptoDate. Roy-Byrne, P.P. & Solomon, D. (Eds.). Retrieved from https://www.uptodate.com/contents/discontinuing-antidepressant-medications-in-adults

   Simon, L. V., & Keenaghan, M. (2021). Serotonin syndrome. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482377/

   UptoDate. (n.d.). Duloxetine: drug information. Retrieved on June 22, 2021 from https://www.uptodate.com/contents/duloxetine-drug-information

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Pharmacotherapy Update | Duloxetine (Cymbalta®)

Duloxetine (Cymbalta®)

Volume VII, Number 5 | September/October 2004

Ian Hollis, Pharm.D. Candidate

Return to Pharmacotherapy Update Index

Introduction

Duloxetine
(Cymbalta^®; Eli Lilly and Co.) is classified as a
selective serotonin and norepinephrine reuptake inhibitor (SSNRI).
It was approved by the Food and Drug Administration (FDA) in August
2004 for the treatment of major depressive disorder (MDD) and one
month later received an indication for the treatment of peripheral
neuropathic pain associated with diabetic neuropathy (DN).

Major Depressive Disorder (MDD)

MDD is characterized by a depressed
mood or loss of interest in activities for a minimum of 2 weeks.^1,2 At least four other symptoms must be experienced by the patient
and may include fatigue, change in sleep patterns or appetite, impaired
concentration, feelings of guilt, or periodic thoughts of death
or suicide.¹ MDD may manifest as unipolar depression,
referring only to the periodic occurrence of depressive symptoms,
or as bipolar depression, where depressive symptoms alternate with
manic episodes consisting of a combination of increased psychomotor
activity, decreased need for sleep, and delusional, grandiose, paranoid,
or psychotic behavior.^1,2

Approximately 15% of the general population will experience a major depressive
event at some point in their lives. A depressive event occurs more
often in women than in men.² A possible cause of depression
is a medical illness, either through psychological stress, the disease
itself, or the pharmacological treatment. Neuroendocrine hormonal
variations can also contribute to the etiology of MDD, especially
when combined with environmental stressors (e.g., death of a relative,
assault, or severe relationship issues).²

Pharmacotherapy for depression includes a variety of treatment options. The monoamine
oxidase inhibitors (MAOIs), such as phenelzine (Nardil™), increase
the concentration of serotonin (5-HT), norepinephrine (NE), and
dopamine (DA) within the neuronal synapse through inhibition of
the monoamine oxidase enzyme.^3,4 The potential for hypertensive
crisis, a severe and potentially life-threatening side effect, makes
the use of these agents undesirable. Tricyclic antidepressants (TCAs),
such as amitriptyline (Elavil^®) and imipramine (Tofranil^®),
block the reuptake of 5-HT and NE. This class of drugs has shown
good efficacy but has a burdensome adverse effect profile including
anticholinergic, neurologic, and cardiovascular adverse effects.⁴ The selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine
(Prozac^®), sertraline (Zoloft^®), paroxetine
(Paxil^®), fluvoxamine (Luvox^®), citalopram
(Celexa^®), and escitalopram (Lexapro^®),
were developed to achieve efficacy comparable to existing categories
of antidepressants while maintaining an improved safety profile.^4-6 This category of agents inhibits 5-HT reuptake and exhibits very
little of the unwanted results of the aforementioned agents that also block NE and/or DA.

Venlafaxine (Effexor^®) became the first agent in a category of
antidepressants known as the SSNRIs. It lacks the adverse effects
of TCAs while implementing the combined antagonism of 5-HT and NE.
This mechanism may lead to a more rapid onset of therapeutic effect.⁷ Unfortunately, venlafaxine has the potential to increase blood pressure
in a dose-dependent manner in approximately 3-13% of patients.⁸ Duloxetine is a new addition to the SSNRIs, and it appears to exhibit
a greater balance in the relative reuptake inhibition of 5-HT and NE.^7,9

Diabetic Neuropathy (DN)

DN is a set of clinical syndromes that affect distinct regions of
the nervous system and may be precipitated by various pathologic
mechanisms.¹⁰ It may involve somatic and/or autonomic
aspects of the peripheral nervous system. DN may present focally,
involving dysfunction of a single nerve or group of nerves, or diffusely,
involving a larger group or area of nerves.¹⁰ DN occurs
in approximately half of all patients with long-term diabetes mellitus
(DM), both type 1 and type 2.² The likelihood of its
presence, like most chronic complications of DM, is dependent on
the duration of time with DM and the degree of glycemic control.

One of the most common neuropathies related to DM is diffuse sensory
neuropathy, which is gradual in onset and first presents with pain
and loss of temperature and pressure sensation in the lower limbs.
The pain is burning and superficial and may be accompanied by poor
autonomic function such as sweating, dry skin, and decreased blood
flow.² Pain becomes constant for up to 10% of patients
with DN, and it may occur independently or in response to a stimulus
and may result in mood and sleep disorders.

Pharmacotherapy for DN-associated pain is determined by the type of fibers that
are involved (e.g., C-fiber and A-delta fiber).¹⁰ Pharmacotherapy
for C-fiber pain includes topical capsaicin or topical/oral clonidine
(Catapres^®). Pharmacotherapy for A-delta fiber pain
includes insulin, intravenous lidocaine, tramadol (Ultram^®),
dextromethorphan, and anticonvulsants such as carbamazepine (Tegretol^®),
phenytoin (Dilantin^®), gabapentin (Neurontin^®),
lamotrigine (Lamictal^®), and topiramate (Topamax^®).
Each of these agents has limitations, including method of administration and adverse effects.¹⁰

Pharmacology

Duloxetine has been shown to be a potent inhibitor of 5-HT and NE
reuptake and a weak inhibitor of DA reuptake.⁹ In an
in vitro study, duloxetine was shown to have a higher affinity for
5-HT transporters than NE transporters when compared with venlafaxine.⁷ Duloxetine has been shown to have little affinity for adrenergic,
cholinergic, histaminergic, dopaminergic, opioid, γ-amino
butyric acid (GABA), or glutamate receptors, nor does it inhibit
monoamine oxidase.⁹

Pharmacokinetics

The elimination half-life for duloxetine is approximately 12 hours,
with a range of 8-17 hours. Administration with food may delay the
maximum concentration (C_max) by approximately 4 hours
(from 6 to 10 hours), and it may also decrease the extent of absorption
(AUC) by 10%. Duloxetine is highly protein bound (>90%). It is
metabolized by hepatic oxidation through the cytochrome P450 (CYP)
2D6 and 1A2 isoenzymes. The majority (70%) of the metabolites are
eliminated in the urine and only 20% are excreted in feces. Unchanged
duloxetine represents only 1-3% of the total excreted products.^9,11

Select Clinical Studies

MDD

Goldstein and colleagues conducted an 8-week randomized,
double-blind, placebo-controlled trial evaluating duloxetine for
the treatment of MDD. Patients included in this study had a HAM-D-17
score of at least 15 and a CGI-S score >4. Patients (n=173)
were randomized to one of the following treatment groups: placebo,
duloxetine 40-60 mg twice daily, or fluoxetine 20 mg daily.⁵ Fluoxetine was present as a qualitative control arm for detection
of efficacy and was not compared to duloxetine. The primary efficacy
endpoint was the HAM-D-17 score. Secondary measures included the
CGI-S and PGI-I. A response rate was defined as a >50% reduction
in HAM-D-17 score from baseline, and a remission rate was defined
as a HAM-D-17 score <7. Safety measures were also assessed
and included discontinuation rates and blood pressure monitoring.
Duloxetine demonstrated a greater mean change in the HAM-D-17 score
from baseline to week 8 compared to placebo, -9.73 and -6.61, respectively
(p=0.009). Estimated probabilities of response for placebo, duloxetine,
and fluoxetine were 48%, 64%, and 52%, respectively and estimated
probabilities of remission were 32%, 56%, and 30%, respectively.
Select secondary measures can be located in Table 1. There were no statistically significant differences between
duloxetine and placebo in discontinuation rates (10% vs. 4.3%) and
adverse events except for asthenia (17.1% vs. 4.3%) and insomnia
(20% vs. 7.1%). Hypertension was reported in 4.3% and 5.7% of the
duloxetine-treated and placebo-treated patients, respectively. The
majority of the duloxetine patients (75%) were titrated to 120 mg/day.
The authors concluded that duloxetine is efficacious for the treatment
of MDD and is safe and well-tolerated.⁵

Detke and co-workers conducted a 9-week randomized, double-blind, placebo-controlled
trial evaluating duloxetine for the treatment of MDD in 245 patients.¹² Inclusion criteria (e.g., baseline disease severity) were similar
to the Goldstein study. Patients were randomized to duloxetine (60
mg once daily) or placebo. The primary efficacy measure was the
HAM-D-17 score. Secondary measures included the VAS and CGI-S, and
PGI-I scale as well as safety assessments.¹⁵ Response
and remission rate definitions were the same as in the Goldstein
trial. Duloxetine demonstrated a significantly greater mean change
in the HAM-D-17 score from baseline to week 9 compared to placebo,
-10.91 and -6.05, respectively (p<0.001). Select secondary measures
can be located in Table 1. Nausea, dry mouth and somnolence were the most common
adverse events in duloxetine-treated patients. Furthermore, no clinically
significant incidence of hypertension was noted. Adverse events
caused 17 duloxetine-treated patients and three placebo-treated
patients to discontinue therapy. The authors concluded that duloxetine
60 mg administered once daily was safe and effective for the treatment of MDD.¹²

In a second trial by Detke and colleagues, duloxetine demonstrated
a greater mean change in the HAM-D-17 score from baseline to week
9 compared to placebo, -10.46 and -8.29, respectively (p=0.024).⁶ Estimated probabilities of response and remission were 65% and 43%,
respectively for duloxetine compared with 42% and 28%, respectively
for placebo. Other secondary measures are detailed in Table 1. Discontinuation rates were more frequent in duloxetine-treated patients and the most frequent adverse events were nausea, dry mouth,
dizziness, and constipation. Additionally, there was not a significant
incidence of hypertension. The authors concluded that duloxetine
is safe and effective for the treatment of MDD when dosed at 60 mg daily.⁶

Table 1: Select Primary and Secondary Efficacy Measures for Duloxetine in the Treatment of MDD

P = Placebo

D = Duloxetine

Definition of scales^14-17

HAM-D-17 (Hamilton Rating Scale for Depression-17): Most widely used rating
scale for depression. Ratings to assess symptoms of depression done by clinician
through clinical interview on a 0 to 4 spectrum (0 = none, 4 = most severe).¹⁴

CGI-I, CGI-S (Clinical Global Impressions): Three-item scale which measures
overall illness factors. Severity of Illness (CGI-S) rated by clinician on a
1 to 7 scale (1 = normal, 7 = among the most severely ill patients). Global
Improvement (CGI-I) rated by clinician on a 1 to 7 scale (1 = very much improved,
7 = very much worse). Designed to be used to assess change over time.¹⁴

PGI (Patient Global Impressions
– Improvement): A scale used by the patient to rate their own improvement based
on a 0 to 7 scale (0 = not assessed, 7 = very much worse).

DN

The efficacy of duloxetine was studied in two randomized, double-blind,
placebo-controlled trials that were conducted in adult patients
(n=791) with DN.⁹ Both trials were 12 weeks in length
and included patients with a 6-month minimum history of DN. Both
trials compared duloxetine 60 mg administered once or twice daily
to placebo. In addition, one trial evaluated duloxetine 20 mg administered
daily compared to placebo. The primary efficacy measure was the
weekly mean of the 24-Hour Average Pain Severity score on an 11-point
Likert Scale (0=no pain, 10=worst pain; baseline pain score >4).
Treatment with duloxetine 60 mg once or twice daily improved the
mean pain scores from baseline in a statistically significant manner
compared to placebo and increased the proportion of patients with
at least a 50% reduction in pain score from baseline.⁹

Contraindications/Precautions

Duloxetine is contraindicated in patients with a known hypersensitivity
to any of the active or inactive ingredients. It is also contraindicated
for concomitant use with MAOIs and in patients with narrow-angle
glaucoma.⁹ Duloxetine should be avoided in patients with
known hepatic disease, and it may be necessary to reduce the dose
in patients with known hepatic insufficiency.⁹ Additionally,
due to the extent of renal clearance (70%) of both the parent drug
and its metabolites, duloxetine is also not recommended for use
in patients with end-stage renal disease (ESRD) requiring dialysis
(estimated creatinine clearance <10 mL/min) or in patients with
severe renal impairment (estimated creatinine clearance <30 mL/min).⁹ Finally, small increases (1-2 mm Hg) in blood pressure have been
noted and therefore baseline values and periodic monitoring of blood
pressure may be warranted in patients with pre-existing hypertension
or cardiac disease.⁹

Antidepressive agents that block 5-HT uptake can induce mania in a predisposed
subset of patients; therefore, duloxetine should be used with caution
in patients with a past medical history or family history of mania.⁹ All patients should be closely monitored during initiation of antidepressant
therapy, especially if there is a personal or family history of
suicidal ideation.^9,18

Adverse Reactions

The most common adverse events (incidence of 5% or
greater and at least twice the incidence compared to placebo patients)
for patients being treated with duloxetine for MDD include nausea,
dry mouth, constipation, decreased appetite, fatigue, somnolence,
and increased sweating.⁹

Table 2. Incidence of Adverse Events in Duloxetine-Treated MDD Patients

⁹

Duloxetine vs. Placebo

*Nausea was the only common adverse event that led to discontinuation and is
considered to be drug-related.

The most commonly observed adverse events (incidence of 5% or greater
and at least twice the incidence in placebo patients) in duloxetine-treated
DN patients were nausea, somnolence, dizziness, constipation, dry
mouth, hyperhidrosis, decreased appetite, and asthenia.⁹

Table 3. Incidence of Adverse Events in Duloxetine-Treated DN Patients

⁹

Duloxetine vs Placebo

*Nausea, somnolence, dizziness, and fatigue were the most common adverse events
that led to discontinuation and are considered to be drug-related.

Drug Interactions

Duloxetine is a substrate of CYP2D6.⁹ Duloxetine metabolism was decreased by coadministration with paroxetine,
a known CYP2D6 inhibitor.¹⁹ Duloxetine is also a substrate
of CYP1A2.⁸ Coadministration of duloxetine with fluvoxamine
a strong CYP1A2 inhibitor, increased the Cmax of duloxe-tine 2.5-fold
and the AUC 5-fold.⁹ Combination of duloxetine and any
strong CYP1A2 inhibitors (e.g., ketoconazole [Nizoral^®])
should be avoided.⁹

Data from clinical studies indicate that duloxetine is also an inhibitor
of CYP2D6.¹⁹ Duloxetine increased the Cmax and AUC of
desipramine (Norpramin^®), a drug almost exclusively
metabolized by CYP2D6, by 1.7- and 2.9-fold, respectively.¹⁹ Drugs that are principally metabolized by CYP2D6 and have
a narrow therapeutic index should be cautiously co-administered
with duloxetine.⁸ Plasma protein interactions are possible,
as duloxetine is highly protein bound and may cause dissociation
of other highly bound drugs from serum proteins.

Patients currently taking other medications with substantial serotonergic
activity should be monitored closely due to an increased risk of
serotonin syndrome. MAOIs should be discontinued 14 days before
initiation of duloxetine therapy to prevent this from occurring.
Additionally, a minimum of 5 days should separate the discontinuation
of duloxetine and the initiation of MAOIs.⁹

Pregnancy/Lactation

Duloxetine is categorized as a pregnancy-risk category C, meaning
reproductive studies conducted in animals have shown adverse effects
on the fetus and there are no controlled studies in women.^8,9 Neonates exposed to SSRIs and SSNRIs, late in the third trimester
have developed complications requiring prolonged hospitalization,
respiratory support, and tube feeding.⁹ These symptoms
(e.g., respiratory distress, seizures, hypoglycemia, tremor, and
temperature instability) can occur upon delivery and may be classified
as toxicity, discontinuation syndrome, or even serotonin syndrome.
Since there are no adequate and well-controlled studies in pregnant
women, duloxetine should be utilized only when the potential benefit
to the mother outweighs the potential risk to the fetus.

Duloxetine has been detected in the breast milk of lactating rats, but it is
currently unknown whether the parent drug or its metabolites enter
human breast milk. Therefore, duloxetine is not recommended for
use by breastfeeding mothers.⁹

Dosing
and Administration

The recommended oral dose for initiation
of therapy in MDD is 40 mg/day (administered as 20 mg twice daily)
to 60 mg/day (administered either as once daily or as 30 mg twice
daily). The recommended dose for diabetic peripheral neuropathic
pain is 60 mg daily. Although doses up to 120 mg/day have been utilized,
no clinical superiority has been demonstrated when compared to 60
mg/day and an increase of adverse events were noted at higher doses.⁹

Abrupt discontinuation of duloxetine should be avoided if possible. Withdrawal
symptoms such as headache, nausea, dizziness, abnormal dreams, sensory
disturbances, and agitation have been reported in patients stopping
therapy with this class of antidepressants.⁹

Investigational Uses

Arnold and colleagues conducted a randomized, double-blind,
placebo-controlled trial to evaluate the efficacy and safety of
duloxetine in subjects (n=207) with primary fibromyalgia with or
without MDD.²¹ Primary outcomes measures were the Fibromyalgia
Impact Questionnaire (FIQ) total score and FIQ pain score. Duloxetine-treated
patients, regardless of MDD history, showed improvement in fibromyalgia
symptoms and pain severity. The female cohort (89%) demonstrated
significantly greater improvement on most efficacy measures compared
to the male cohort. Patients were steadily titrated from 20 mg/day
to 120 mg/day of duloxetine by the second week of the therapy phase
(12 weeks). Insomnia, dry mouth, and constipation were significantly
greater in the duloxetine group compared to the placebo group. There
were no statistically significant differences in discontinuation
rates between the groups and most adverse events were of mild or
moderate severity. The authors concluded that duloxetine 60 mg twice
daily is safe and well-tolerated in fibromyalgia patients. Furthermore,
duloxetine demonstrated efficacy for the majority of outcome measures,
particularly in women and irrespective of MDD status.²¹

Studies have also been conducted to evaluate duloxetine’s efficacy in treating
stress urinary incontinence (SUI). One of these trials compared
duloxetine 20-, 40-, and 80-mg daily to placebo in women (n=553)
with >4 incontinence episodes per week.²² The
primary efficacy measurements were incontinence episode frequency
(IEF), incontinence quality of life (I-QOL), PGI-I, and mean time
between voids (MTBV). There was a statistically significant improvement
compared to placebo in all efficacy variables when using the 80
mg dose. The most common adverse events included nausea, fatigue,
headache, dizziness, dry mouth, insomnia, and constipation; however,
nausea was the most common adverse event leading to duloxetine discontinuation.
The authors concluded that duloxetine was safe and efficacious at a dose of 80 mg/day.

Additional trials have evaluated the efficacy and safety of duloxetine 80 mg/day
in female patients with SUI.²² Specifically, three of
these trials (n=1635) assessed the median percentage change in IEF
and the mean change in total I-QOL over 12 weeks. The median percentage
reduction in weekly IEF was 50-54% with duloxetine and 28-40% with
placebo (p significant). The mean improvement I-QOL score was 5.5-11.1
points with duloxetine and 4.1-6.8 points with placebo (p significant
for 2 out of 3 trials). The most common adverse events included
fatigue, insomnia, nausea, constipation, dizziness, headache, and
dry mouth. Fatigue and dizziness, however, were the most common
adverse events leading to duloxetine discontinuation. These data
suggest that duloxetine is safe and effective for women with SUI.²²

Duloxetine will most likely be marketed under a separate brand name, Yentreve,
by Eli Lilly and Co., for the treatment of SUI. The manufacturer
is projecting a first-half 2005 FDA-approval and market launch.
Currently, there is discussion at the FDA regarding the drug interaction
labeling for Yentreve. In SUI, patient medication profiles may include
long-term potent 2D6 and 1A2 inhibitors and may increase the risk
of duloxetine-related drug interactions.²³

Cost

Cymbalta^® is available as 20-, 30-, and 60-mg capsules.
At this time, there are no pharmacoeconomic studies evaluating duloxetine
therapy for MDD or DN.

Table
4. Cost Comparison

²⁴

F = FormularyAWP = Average Wholesale Price

Formulary Status

Cymbalta^® was added to The Cleveland
Clinic Foundation Formulary of Accepted Drugs in October 2004.

Conclusion

Duloxetine is a new member of the SSNRI class of antidepressants.
It is FDA-approved for the treatment of MDD and DN and is currently
being evaluated for women with SUI. Duloxetine has been shown to
be efficacious in the treatment of MDD and DN without clinically
significant blood pressure elevations. The most common adverse drug
events include nausea, constipation, and fatigue. The recommended
dose for MDD is 40-60 mg daily and for DN-associated pain is 60
mg/day. The cost of duloxetine is similar to venlafaxine. Duloxetine
is a novel therapeutic modality with a unique mechanism of action,
good efficacy and safety profile, and has the potential to be utilized
in a variety of pharmacological areas.

Return to Pharmacotherapy Update Index

References

1. Major Depressive Disorder. In: Diagnostic and Statistical Manual, 4th ed. First, MB, ed. Washington, D.C.:American Psychiatric Association;2000:349-61.
2. Reus VI. Mental Disorders. In: Harrison’s Principles of Internal Medicine, 16th ed. Kasper DL, Braunweld E, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. New York: McGraw-Hill; 2005:2552-6.
3. Delgado PL. Depression: the case for a monoamine deficiency. J Clin Psychiatry 2000;61 (Suppl 6):7-11.
4. Kando JC, Wells BG, Hayes PE. Depressive Disorders. In: Pharmacotherapy, A Pathophysiologic Approach, 5th ed. DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. New York: McGraw-Hill;2002:1244.
5. Goldstein DJ, Mallinckrodt C, Lu Y, Demitrack MA. Duloxetine in the treatment of major depressive disorder: a double-blind clinical trial. J Clin Psychiatry 2002;63(3):225-31.
6. Detke MJ, Lu Y, Goldstein DJ, McNamara RK, Demitrack MA. Duloxetine 60 mg once daily dosing versus placebo in the acute treatment of major depression. J Psychiatr Res 2002;36:383-90.
7. Bymaster FP, Dreshfield-Ahmad LJ, Threlkeld PG, Shaw JL, Thompson L, Nelson DL, et al. Comparative affinity of duloxetine and venlafaxine for serotonin and norepinephrine transporters in vitro and in vivo, human serotonin subtypes, and other neuronal receptors. Neuropsychopharmacology 2001;25(6):871-80.
8. Lacy CF, Armstrong LL, Goldman MP, Lance LL., eds. Drug Information Handbook, 12th ed. Hudson, OH; Lexi-Comp Inc;2004. ONLINE
9. Cymbalta® package insert. Indianapolis, IN: Eli Lilly Pharmaceuticals; 2004, September.
10. Vinik AI, Mehrabyan A. Diabetic Neuropathies. Med Clin North Am 2004;88:1-45.
11. Lantz RJ, Gillespie TA, Rash TJ, Kuo F, Skinner M, Kuan H-Y, et al. Metabolism, excretion, and pharmacokinetics of duloxetine in healthy human subjects. Drug Metab Dispos 2003;31:1142-50.
12. Detke MJ, Lu Y, Goldstein DJ, Hayes JR, Demitrack MA. Duloxetine, 60 mg once daily, for major depressive disorder: a randomized double-blind placebo-controlled trial. J Clin Psychiatry 2002;63(4):308-15.
13. Raskin J, Goldstein DJ, Mallinckrodt CH, Ferguson MB. Duloxetine in the long-term treatment of major depressive disorder. J Clin Psychiatry 2003;64(10):1237-44.
14. Sajatovic M, Ramirez, LF, eds. Depression rating scales. In: Rating Scales in Mental Health, 2nd ed. Hudson, OH. Lexi-Comp, Inc. 2003. pg 80-109.
15. DeLoach LJ, Higgins MS, Caplan AB, Stiff JL. The visual analog scale in the immediate postoperative period: intrasubject variability and correlation with a numeric scale. Anesth Analg 1998;86(1):102-6.
16. Sheehan DV, Harnett-Sheehan K, Raj BA. The measurement of disability. Int Clin Psychopharmacol 1996;Suppl 3:89-95.
17. Cervera-Enguix S, Ramirez N, Girala N, McKenna SP. The development and validation of a Spanish version of the quality of life in depression scale (QLDS). Eur Psychiatry 1999;14:392-8.
18. United States Food and Drug Administration Home Page [resource on World Wide Web]. URL: http://www.fda.gov/cder/drug/antidepressants. Available from Internet. Accessed 2004 Oct 27.
19. Skinner MH, Kuan HY, Pan A, Sathirakul K, Knadler MP, Gonzales CR, et al. Duloxetine is both an inhibitor an a substrate of cytochrome P4502D6 in healthy volunteers. Clin Pharmacol Ther 2003;73(3):170-7.
20. Lester BM, Cucca J, Andreozzi L, Flanagan P, Oh W. Possible association between fluoxetine hydrochloride and colic in an infant. J Am Acad Child Adolesc Psychiatry 1993;32(6):1253-5.
21. Arnold LM, Lu Y, Crofford LJ, Wohlreich M, Detke MJ, Iyengar S, et al. A double-blind, multicenter trial comparing duloxetine with placebo in the treatment of fibromyalgia patients with or without major depressive disorder. Arthritis Rheum 2004;50:2974-84.
22. Van Kerrebroeck PV. Duloxetine: an innovative approach for treating stress urinary incontinence. BJU Int 2004;94;Suppl 1:31-7.
23. FDC Reports Pharmaceutical Approvals Monthly 2004;9(11):33-4.
24. Cardinal Wholesaler, Inc. Accessed 10-29-04.

Duloxetine for depression, nerve pain, stress incontinence

What is Cymbalta?

Cymbalta capsules contain duloxetine which is a serotonin and noradrenaline reuptake inhibitor (SNRI) antidepressant.

Duloxetine is available as a generic medicine. It is only available on prescription in the UK.

There are two brands of duloxetine – Cymbalta (30mg, 60mg) and Yentreve (20mg,40mg). Yentreve is only licensed to treat stress urinary incontinence (SUI) in women.

What is duloxetine used for?

Duloxetine 30 mg capsules and duloxetine 60 mg capsules are used to treat the following conditions in adults:

• Depression.
• Generalised anxiety disorder (GAD).
• Nerve pain in the feet, legs or hands caused by nerve damage in adults with diabetes (diabetic peripheral neuropathic pain).

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How does duloxetine work?

Duloxetine hydrochloride works by enhancing the activity of the neurotransmitters serotonin and noradrenaline in the brain.

Neurotransmitters are natural body chemicals that act as chemical messengers between the nerve cells. Serotonin and noradrenaline are neurotransmitters known to be involved in regulating emotions, mood and behaviour, among other things. In depression and anxiety disorders less serotonin and noradrenaline than normal is released from nerve cells in the brain.

Duloxetine works by stopping the serotonin and noradrenaline that has been released from being reabsorbed back into the nerve cells in the brain. This helps to prolong their effects and over time this helps to lighten mood and relieve depression. Antidepressants like duloxetine have also been found to be effective in relieving symptoms of anxiety, such as panic and fear.

Duloxetine is thought relieve nerve pain by enhancing the nerve signals within the central nervous system that naturally inhibit pain.

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Key info to know about taking duloxetine

▪️ Duloxetine can make some people feel uncomfortably restless and unable to sit or stand still. This is most likely to occur within the first few weeks of treatment. Speak to your doctor If you experience this.

▪️ Duloxetine might make you feel dizzy, particularly when getting up from sitting or lying down.

▪️ Duloxetine may make you feel sleepy or dizzy and so could reduce your ability to drive or operate machinery safely. Do not drive or operate machinery until you know how this medicine affects you and you are sure it won’t affect your performance.

▪️ If you find duloxetine makes you feel tired or dizzy, then drinking alcohol could make this worse. Drinking alcohol could also increase the risk of duloxetine affecting your liver. It’s usually recommended that you avoid drinking alcohol while taking antidepressants because alcohol can make depression worse. If you want to drink alcohol while you’re taking duloxetine you should get advice from your doctor about whether this is a good idea for you.

▪️ Duloxetine is not suitable for people with severe liver or kidney problems.

▪️ Duloxetine should not be taken by anybody who have taken a monoamine oxidase inhibitor antidepressant (MAOI) in the last 14 days.

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How long does duloxetine take to work?

▪️ In depression and anxiety it may take between two to four weeks before duloxetine starts to work and you begin to feel better, so it is very important that you keep taking it, even if it doesn’t seem to make much difference at first. You’ll usually need to keep taking duloxetine every day for several months, and for at least six months after you feel better. You should keep taking it for as long as your doctor asks you to.

▪️ If you feel your depression or anxiety has got worse, or if you have any distressing thoughts, or feelings about suicide or harming yourself in these first few weeks, or indeed at any point during treatment or after stopping treatment, then it is very important to talk to your doctor.

▪️ With nerve pain duloxetine may start to help in a few days for some people, while others don’t see much difference for several weeks. It’s important to persevere with taking it, but if your pain hasn’t improved after two months you should see your doctor.

Dosage instructions for duloxetine

▪️ Duloxetine is usually taken once a day, either with or without food. The capsules should be swallowed whole with a drink of water.

▪️Try taking duloxetine at the same time each day, this will also help you remember to take it.

▪️ The usual recommended dose for depression is 60mg daily, for generalised anxiety disorders the starting dose is usually 30mg once a day, this may be increased to 60mg daily if needed.

▪️ The usual recommended dose for diabetic peripheral neuropathic pain is 60mg once a day. Your doctor will review this after two months to see if has helped.

▪️ Always follow the instructions given by your doctor regarding the dose you should take. Remember that it takes a while for duloxetine to start working, so keep taking it as prescribed even if it doesn’t seem to make much difference at first. Do not take more than the dose prescribed by your doctor.

▪️ Missed dose: If you forget to take a dose of duloxetine at your usual time, take it as soon as you remember that day. If you don’t remember until the following day, just leave out the missed dose and take your next dose as usual. Do not take a double dose to make up for a missed dose.

▪️ You should keep taking duloxetine every day for as long as your doctor asks you to. It’s normal for your doctor to ask you to keep taking it for several months after you feel better (at least six months for depression and at least a year for generalised anxiety disorder), as this has been shown to reduce the risk of your depression or anxiety coming back.

▪️ Do not suddenly stop taking duloxetine unless your doctor tells you to, as this can cause withdrawal symptoms such as sleep disturbances (including intense dreams), headaches, feeling sick, dizzy or weak, sweating, shaking, diarrhoea, pins and needles, burning or electric shock sensations and feeling anxious, agitated or irritable. Withdrawal symptoms are temporary and are not due to addiction or dependence on the medicine. They can usually be avoided by stopping the medicine gradually, over at least two weeks or longer, depending on your individual situation. Follow the instructions given by your doctor when it’s time to stop treatment. On very rare occasions some people have experienced withdrawal symptoms after accidentally missing a dose of duloxetine.

Duloxetine should be used with caution by

• Elderly people.
• People with bipolar affective disorder (manic depression) or a history of mania.
• People with a history of seizures, eg epilepsy.
• People with raised pressure in the eyeball or glaucoma.
• People with heart disease or high blood pressure (hypertension). Duloxetine can cause some people’s blood pressure to increase. It’s recommended that that your blood pressure is monitored while you are taking this medicine if you suffer from heart disease or high blood pressure, especially during the first month of treatment.
• People who are dehydrated or taking diuretic medicines.
• People with bleeding tendencies or who are taking medicine to prevent blood clotting for example anticoagulants such as warfarin.
• People taking medicines that can have side effects on the liver.

Is it safe to take duloxetine if pregnant?

Duloxetine should be avoided during pregnancy. However, it may be necessary for some women to take duloxetine during their pregnancy in order for them to remain well during the pregnancy and be able to care for their baby. It is important to talk to your doctor about the risks and benefits of taking duloxetine during the pregnancy compared with stopping treatment or using other treatments.

It is important to get medical advice from your doctor if you think you could be pregnant or want to plan a pregnancy while taking duloxetine.

If you decide to stop taking duloxetine you doctor will advise you how to do this. Remember that you should not stop taking duloxetine suddenly, as this can cause withdrawal symptoms such as dizziness, sleep disturbances (including intense dreams), headache, feeling sick or weak, pins and needles and anxiety. Your doctor will give you instructions on how to stop treatment gradually to avoid these effects.

Read more about using duloxetine during pregnancy here

Is it safe to take duloxetine if breastfeeding?

Duloxetine passes into breast milk in small amounts. The effect of this on a nursing infant hasn’t been fully established, so duloxetine is not usually recommended for women who are breastfeeding. However, if you were taking duloxetine during your pregnancy and are stabilised on this medicine, it may be possible for you to breastfeed your baby while staying on the treatment, providing the benefits outweigh any risks. It’s important to get medical advice from your doctor.

Possible side effects of duloxetine

Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects known to be associated with duloxetine. Just because a side effect is stated here doesn’t mean that all people taking duloxetine or Cymbalta capsules will experience that or any side effect.

Very common (affect more than 1 in 10 people)

• Sleepiness.
• Feeling dizzy.
• Headache.
• Feeling sick.
• Dry mouth.

Common (affect between 1 in 10 and 1 in 100 people)

• Decreased appetite and weight loss.
• Feeling anxious or agitated.
• Palpitations.
• Difficulty sleeping (insomnia).
• Abnormal dreams.
• Yawning.
• Blurred vision.
• Feeling shaky.
• Pins and needles sensations.
• Disturbances of the gut, such as abdominal pain, diarrhoea, constipation, indigestion, vomiting, wind.
• Sensation of ringing or other noise in the ears (tinnitus).
• Rash.
• Hot flushes.
• Increased sweating.
• Muscle spasm, pain or tightness.
• Sexual problems, such as reduced sex drive or problems with getting an erection or orgasm.

Uncommon (affect between 1 in 100 and 1 in 1000 people)

• Weight gain.
• Increased blood pressure or heart rate.
• Increase in blood sugar (hyperglycaemia), particularly in people with diabetes.
• Visual disturbances, dilated pupils.
• Difficulty passing urine.
• Cold hands or feet.
• Feeling hot or cold.
• Feeling thirsty.
• Taste disturbances.
• Teeth grinding.
• Problems concentrating.
• Feeling disorientated.
• Poor sleep quality.
• Muscle twitching, restless legs syndrome.
• Throat tightness.
• Increased tendency to bruise or bleed, eg nosebleeds, heavy periods, bleeding in the gut.
• Increased sensitivity of the skin to sunlight (photosensitivity).
• Liver problems such as inflammation of the liver (hepatitis).

Rare (affect between 1 in 1000 and 1 in 10,000 people)

• High blood cholesterol level.
• Convulsions.
• Mania, hallucinations, anger or aggression.
• Raised pressure in the eyeball (closed angle glaucoma). See a doctor straight away if you get symptoms of this, which include a painful red eye, blurred vision, sudden severe headache and seeing haloes around lights.
• Underactive thyroid gland.
• Low level of sodium in the blood. This can cause symptoms such as drowsiness, confusion, muscle twitching or convulsions. Elderly people may be particularly susceptible to this effect. Consult your doctor if you develop any of these symptoms while taking duloxetine, so that your blood sodium level can be checked if necessary.
• Serotonin syndrome (symptoms may include agitation, confusion, sweating, hallucinations, twitching, shivering, fast heartbeat and tremor). See a doctor straight away if you get these symptoms.

You should read the patient information leaflet that is supplied with your medication for more information about side effects associated with duloxetine. You can find a copy of this here

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If you think you have experienced side effects from this medicine you can report them using the yellow card scheme.

Can I take other medicines with duloxetine?

You should check with your pharmacist before taking any new medicines while you’re taking duloxetine, to make sure that the combination is safe.

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Painkillers with duloxetine

It is fine to take painkillers such as paracetamol, co-codamol with duloxetine. anti-inflammatory painkillers (NSAIDs) such as diclofenac, ibuprofen, diclofenac and naproxen should be used with caution if you are taking duloxetine, as there is an increased risk of bleeding the gut if taken together. Taking ibuprofen or aspirin for a few days is ok. See you doctor if you need to use NSAIDs for longer periods.

MAOIs and duloxetine

Duloxetine must not be taken at the same time as monoamine oxidase inhibitor antidepressants (MAOIs) such as phenelzine, isocarboxazid or tranylcypromine, or with selegiline, rasagiline or safinamide, which are MAOIs used to treat Parkinson’s disease. If you have been taking one of these MAOIs you should not start treatment with fluoxetine until at least 14 days after stopping the MAOI. Treatment with these MAOIs, or with the related antidepressant moclobemide, should not be started until at least five weeks after fluoxetine has been stopped.

Other medicine interactions with duloxetine

While you are taking duloxetine, don’t take any of the following medicines without checking with your doctor or pharmacist first, because there may be an increased risk of bleeding with the combination:

• anticoagulant medicines such as warfarin or dabigatran
• antiplatelet ‘blood thinning’ medicines such as low dose aspirin, clopidogrel or dipyridamole.
• cangrelor
• dapoxetine
• mefenamic acid
• meloxicam
• omega-3-acid ethyl esters.
• SSRI antidepressants such as fluoxetine.

You have a greater risk of getting side effects such as the serotonin syndrome if you take other medicines or drugs that enhance the activity of serotonin in the brain with duloxetine, this includes the following medicines:

• buspirone
• dapoxetine
• fentanyl
• illegal drugs such as cocaine, amphetamine and ecstasy (MDMA)
• linezolid
• lithium
• metoclopramide
• sibutramine
• the herbal remedy St John’s wort (Hypericum perforatum) – do not take this in combination with duloxetine
• tramadol
• triptans for migraine, such as sumatriptan
• tryptophan
• venlafaxine.

Read more detailed information about medicines that may interact with duloxetine here

Last updated 18.11.2019

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Cymbalta: Antidepressant Medication Overview

What is Cymbalta?

Cymbalta (Generic Name: duloxetine HCL) is a once-daily serotonin and norepinephrine reuptake inhibitor (SNRI) medication primarily used to treat depression and anxiety disorders in adolescents and adults. Its safety has not been established for children.

It may help to relieve common symptoms of depression including disinterest in typical activities, impaired concentration, change in weight or appetite, and insomnia.

Cymbalta is also used to treat nerve pain from diabetes, fibromyalgia, and chronic musculoskeletal pain.

How to Use Cymbalta

Before starting or refilling a Cymbalta prescription, read the medication guide included with your pills, as it may be updated with new information.

This guide should not replace a conversation with your doctor, who has a holistic view of your medical history, other diagnoses, and other prescriptions. If you have questions, ask your doctor or pharmacist before you begin taking the medication.

Dosage for Cymbalta

As with all medications, follow your Cymbalta prescription instructions exactly. Cymbalta is taken orally, with or without food, once daily, in the morning or evening. Capsules should be swallowed whole with water or other liquids. Capsules should never be opened, crushed, or chewed. If you are unable to swallow the capsule, discuss a different medication with your doctor.

Capsules are available in 20mg, 30mg, and 60mg dosages.

The optimal dosage varies based on the condition treated, but should not exceed 120mg per day. If you are over 60 years of age, or have certain health conditions, your doctor may recommend a lower dosage.

Your doctor may incrementally adjust your daily dosage until you experience the best response — that is, until you find the lowest dosage at which you experience the greatest improvement in symptoms without side effects.

During treatment, your doctor should evaluate an adolescent’s height and weight because Cymbalta can cause changes in appetite. If any problems are found, your doctor may recommend discontinuing treatment.

When discontinuing treatment, or decreasing dosage, patients should work with a doctor to gradually taper the level of medication. Stopping Cymbalta suddenly can create withdrawal symptoms including dizziness, nausea, headache, anxiety, fatigue, sleep disturbance, and prickling sensations in hands or feet.

Side Effects Associated with Cymbalta

The most common side effects of Cymbalta are similar to those associated with other SNRIs, like Effexor, and are as follows: nausea, dry mouth, sleepiness, fatigue, loss of appetite, increased sweating, and dizziness.

Other serious side effects include increased risk of suicidality or manic episode, vision problems, seizures, changes in blood pressure, low salt levels in the blood, trouble with urination, and changes in appetite or weight. Patients should be monitored and observed closely for worsening depression, changes in behavior, or suicidality, especially when starting treatment or changing dosage.

Taking Cymbalta may impair your or your teenager’s ability to drive, operate machinery, or perform other potentially dangerous tasks. This side effect usually wears off with time. If side effects are bothersome, or do not go away, talk to your doctor.

Most people taking this medication do not experience any of these side effects.

Disclose to your physician all mental health issues including any family history of suicide, bipolar disorder, mania, or depression. The FDA recommends evaluating patients for bipolar disorder prior to the administration of Cymbalta to avoid inducing a manic episode. Cymbalta may create new or exacerbate existing behavior problems, bipolar disorder, or suicidal ideation, especially in the first few months of treatment or after a dosage change. Call your doctor immediately if you or your child experiences new or worsening mental health symptoms including reckless behavior, hallucinations, or sudden excessive happiness or irritability.

Heavy alcohol use while taking Cymbalta increases your risk of acute liver damage. Some patients have experienced liver failure while taking Cymbalta. Contact your doctor immediately if you experience itching, right upper abdominal pain, dark urine, yellow skin or eyes, or increased liver enzymes.

Cymbalta increases serotonin levels in the brain, and can rarely lead to life-threatening serotonin syndrome, or toxicity. If you or your child experiences changes in mental status, coordination problems, muscle twitching, racing heartbeat, high or low blood pressure, sweating, vomiting or diarrhea, seek medical help immediately.

Discuss any bleeding disorders or irregular sodium levels with your doctor. Cymbalta can cause abnormal bleeding for some patients, and low salt concentration in the blood. The elderly may be at greater risk for these problems.

The above is not a complete list of potential side effects. If you notice any health changes not listed above, discuss them with your doctor or pharmacist.

Precautions Associated with Cymbalta

Store Cymbalta in a secure place out of the reach of children, and at room temperature. Do not share your Cymbalta prescription with anyone, even another person with depression. Sharing prescription medication is illegal, and can cause harm.

You should not take Cymbalta if you have taken a monoamine oxidase inhibitor (MAOI) within 14 days, or have narrow-angle glaucoma.

You should use caution when taking any SNRIs, including Cymbalta, and speak with your doctor if you have liver or kidney problems, diabetes, seizures, bipolar disorder, low blood sodium levels, a history of stroke or high blood pressure, or a history of bleeding problems.

If you’re thinking of becoming pregnant, discuss the use of Cymbalta with your doctor. It is not known if Cymbalta can cause fetal harm during pregnancy. It is recommended that mothers do not nurse while taking Cymbalta, as its safety for infants is unknown.

Interactions Associated with Cymbalta

Before taking Cymbalta, discuss all other active prescription medications with your doctor. Cymbalta can have a dangerous, possibly fatal, interaction with antidepressants including MAOIs. Taking Cymbalta while taking blood thinners like Coumadin, ibuprofen, or aspirin can increase the risk of abnormal bleeding. Using Cymbalta concurrently with medication that increases serotonin — like St. John’s wort, SSRIs, tryptophan, or street drugs like MDMA — can increase the risk of serotonin syndrome.

Share a list of all vitamin or herbal supplements, and prescription and non-prescription medications, you take with the pharmacist when you fill your prescription, and let all doctors and physicians know you are taking Cymbalta before having any surgery or laboratory tests.

Some medications and supplements that can interact with Cymbalta include: cimetidine; triptans for migraines; medicines used to treat mood, anxiety, and thought disorders; and tramadol.

The above is not a complete list of all possible drug interactions.

Sources:

http://www.fda.gov/downloads/drugs/drugsafety/ucm088579.pdf
http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022516lbl.pdf

90,000 11 reviews, instructions for use

Use during pregnancy and lactation

clinical experience with duloxetine during pregnancy is insufficient.

If it is necessary to use the drug during lactation, the question of stopping breastfeeding should be resolved (due to lack of experience in use).

Patients should be warned that in the event of a pregnancy or planning a pregnancy while using duloxetine, they should inform their doctor about it.

Application for violations of liver function

Use with caution in violation of liver function. In patients with impaired liver function, the initial dose of the drug should be reduced or the frequency of administration should be reduced.

Application for impaired renal function

Use with caution in impaired renal function.In patients with severe impaired renal function (CC

Special instructions

Use with caution in exacerbation of manic / hypomanic state, epileptic seizures, mydriasis, impaired liver or kidney function, in patients with a tendency to suicidal attempts.

When prescribing reuptake inhibitors Serotonin in combination with MAO inhibitors, there have been cases of serious reactions, sometimes fatal (hyperthermia, rigidity, myoclonus, various disorders with possible sharp fluctuations in vital signs and changes in mental status, including pronounced excitement with the transition to delirium and coma).Such reactions are also possible in cases when a serotonin reuptake inhibitor was canceled shortly before the appointment of MAO inhibitors (symptoms may develop, including those characteristic of neuroleptic malignant syndrome).

The effects of the combined use of duloxetine and MAO inhibitors have not been evaluated in either humans or animals. The use of duloxetine concurrently with MAO inhibitors or within 14 days after their withdrawal is not recommended, because duloxetine is a serotonin and norepinephrine (norepinephrine) reuptake inhibitor.MAO inhibitors should not be prescribed for at least 5 days after discontinuation of duloxetine.

Use with caution in patients with a history of manic episodes, as well as a history of epileptic seizures.

Depressive states are accompanied by a high risk of developing suicidal behavior. As a consequence, patients diagnosed with depression taking duloxetine should inform the physician of any disturbing thoughts and feelings.

During the use of the drug, the development of mydriasis is possible, caution should be exercised when prescribing duloxetine to patients with increased intraocular pressure or in persons at risk of developing acute angle-closure glaucoma.

In patients with arterial hypertension and / or other diseases of the cardiovascular system, it is recommended to control blood pressure.

Influence on the ability to drive vehicles and use mechanisms

Patients taking duloxetine should be careful when engaging in potentially hazardous activities (due to the possible occurrence of drowsiness).

Simbalta pregnancy and breastfeeding – Medum.ru

Please note: the use of any medicines, including the drug Simbalta, when
planning and during periods of pregnancy, lactation (breastfeeding) it is imperative
agree with the attending physician.Women with reproductive potential are advised to undergo
pregnancy testing.

Due to insufficient experience with duloxetine during pregnancy, the drug should be prescribed during pregnancy only if the potential benefit to the patient significantly outweighs the potential risk to the fetus. Patients should be warned that in the event of a pregnancy or planning a pregnancy during treatment with duloxetine, they should inform their doctor about it.

Epidemiological evidence suggests that the use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy, especially in late pregnancy, may increase the risk of persistent pulmonary hypertension in newborns. Despite the lack of studies examining the relationship between persistent pulmonary hypertension of newborns and the use of SSRIs, the potential risk cannot be excluded, given the mechanism of action of duloxetine (inhibition of serotonin reuptake).

As with other serotonergic drugs, withdrawal syndrome can occur in newborns when mother uses duloxetine late in pregnancy.

Withdrawal syndrome includes the following symptoms: low blood pressure, tremor, increased neuro-reflex excitability syndrome, feeding difficulties, respiratory distress syndrome, convulsions. Most of the symptoms were observed during labor or in the first few days after birth.

Due to the fact that duloxetine passes into breast milk (the concentration in the fetus is approximately 0.14% of the concentration in the mother, based on mg / kg of body weight), breastfeeding is not recommended during duloxetine therapy.

It is recommended that you familiarize yourself with the description of the active ingredient of Simbalta – Duloxetine.

Pay attention to the description of the use of the drug Simbalta during pregnancy and
lactation may differ depending on the manufacturer and the form of release used.In the reference
Medum provides the following information on the release forms of the drug Simbalta:

If you need to know more about the drug Simbalta – ask your question. Professionals or users
Medum will answer it shortly.

Interaction between Bisoprolol and Simbalta with simultaneous use

Interacts with

• norepinephrine, Antidepressant, antidepressants, Other antidepressants

Sympathomimetics that activate α- and β-adrenergic receptors (for example, adrenaline, norepinephrine): a vasoconstrictor effect mediated through α-adrenergic receptors is possible, which leads to an increase in blood pressure and increased intermittent claudication.Such an interaction is likely with the use of non-selective ß-blockers.

When combined with antihypertensive agents and agents, they exhibit hypotensive effects (for example, tricyclic antidepressants, barbiturates, phenothiazine), possibly increasing the risk of arterial hypotension.

Tricyclic and tetracyclic antidepressants, antipsychotics (neuroleptics), ethanol, sedatives and hypnotics increase the depression of the central nervous system.

Sympathomimetics acting on both beta and alpha adrenergic receptors (eg norepinephrine, adrenaline). The combination with bisoprolol can increase the alpha-adrenergic receptor-mediated vasoconstrictor effect of these drugs, which leads to an increase in blood pressure and exacerbation of intermittent claudication. Such an interaction is more likely with the use of non-selective beta-blockers.

The simultaneous use of antihypertensive drugs or other drugs that lower blood pressure (for example, tricyclic antidepressants, barbiturates, phenothiazines) may increase the risk of arterial hypotension.

Antihypertensive drugs, as well as other drugs with a possible antihypertensive effect (for example, tricyclic antidepressants, barbiturates, phenothiazines) can enhance the hypotensive effect of bisoprolol.

Tri- and tetracyclic antidepressants, antipsychotic drugs (antipsychotics), ethanol, sedatives and hypnotics increase central nervous system depression.

Tri- and tetracyclic antidepressants, antipsychotics (neuroleptics), ethanol, sedatives and hypnotics increase the depression of the central nervous system.The simultaneous use of Bisoprolol with MAO inhibitors (except MAO-B) is not recommended due to a significant increase in the hypotensive effect. The break in treatment between taking MAO inhibitors and Bisoprolol should be at least 14 days.

Tri- and tetracyclic antidepressants, antipsychotic drugs (neuroleptics), ethanol, sedative and hypnotic drugs increase CNS depression.

Simbalta tablets instructions for use – analogues – reviews – side effects

Simbalta is a drug from the group of antidepressants, which is used to treat severe emotional-volitional disorders.It is widely used in the American drug market, but in domestic practice it is used only in exceptional cases.

Release form

Simbalta is produced by the manufacturer in the form of capsules for oral administration. The dosage of the active substance in each capsule is 30 or 60 mg. The blister contains 7 to 14 capsules. One package can contain from two to four blisters. The international legal name of the drug is Duloxetine . Simbalta is the trade name for a product manufactured by Lilly.

Composition

The main active ingredient of simbalta is duloxetine. It determines the effect of the agent on the body. The dosage indicated on the package corresponds to the concentration of duloxetine.

Excipients include those that create the contents of the capsule and those that make up its wall. The contents include sugar and sucrose, hypromellose and its compounds, as well as talc, white dye and triethyl citrate. The capsule wall is formed by such substances as: gelatin, compounds of titanium, iron, sodium, as well as indigo carmine and several dyes.Excipients have no effect on the body.

Pharmacological group

Simbalta belongs to the group of antidepressants. Subgroup of the drug – selective serotonin and norepinephrine reuptake inhibitors. Like most drugs in this group, Simbalta has a weakly expressed ability to inhibit and reuptake of dopamine, which causes a large number of side effects of the drug.

Pharmacological properties

Simbalta belongs to the group of selective serotonin and norepinephrine reuptake inhibitors.This means that the drug selectively blocks the entry of only two substances from the extracellular space of the nervous system into neurons: norepinephrine and serotonin. However, like most members of this group, Simbalta does not significantly affect dopamine metabolism.

These three mediators: serotonin, norepinephrine and dopamine – are responsible for the emotional-volitional sphere of the psyche. With a decrease in their concentration, depression, anxiety, sleep disturbances and various emotional and behavioral disorders develop.In this case, it is important to reduce the concentration not inside the cells, but in the spaces between them.

Simbalta increases the content of mediators between cells, which leads to a gradual increase in their synthesis by cells and release into the intercellular space. This mechanism causes an increase in mood with the systematic administration of the drug and a decrease in anxiety.

Indications

Simbalta has a very limited list of indications for use. Prescription of the drug is justified in the following cases:

• Treatment of recurrent depressive disorder, current episode of severe depression;
• Single episode of severe depression;
• Severe neuropathic pain syndrome;
• Neuropathies in patients with diabetes mellitus;
• Anxiety disorder.

Simbalta is not used in the treatment of mild to moderate depression, it is not used for the prevention of depression and the treatment of insomnia. Patients with phobias are also advised to take lighter medications. In general, Simbalta is used in cases where treatment with other means may not be sufficient.

Contraindications

Simbalta is contraindicated in the following cases:

• Hypersensitivity to the components of the drug;
• Decompensated stage of renal failure;
• Decompensated stage of liver failure;
• Uncontrolled arterial hypertension;
• Hypertensive disease of the third stage;
• Increased intraocular pressure;
• History of epilepsy or convulsions of other genesis;
• Bipolar disorder;
• Taking antibiotics from the fluoroquinolone group;
• Children under 18 years of age.

It is forbidden to use Simbalta together with monoamine oxidase inhibitors. At least two weeks should elapse between the reception of the latter and the appointment of Simbalta. The reverse sequence of the appointment is possible a week after the complete cancellation of Simbalta.

Prescribing to pregnant women is allowed only if the benefit to the mother justifies the risk to the fetus.

Side effects

Simbalta can cause a large number of side reactions. All of them are divided into two groups: arising during the administration of the drug and appearing after the termination of treatment.The latter are part of the so-called “withdrawal syndrome”. You should learn more about it.

The first group of reactions is currently well studied by the pharmaceutical company. The groups of side effects that occur very often, often, infrequently and rarely are highlighted. Every tenth patient has reactions from the autonomic nervous system: headache, dizziness, dry mouth, periodic nausea. drowsiness. When you continue to take the drug, these symptoms disappear spontaneously.

More than one patient out of 100 has the following adverse reactions: insomnia, decreased libido, agitation, impaired appetite, weight loss, trembling limbs, feeling of numbness or “creeping creeps” in the limbs, flatulence, stool and urination disorders, myalgia, hyperhidrosis. The listed symptoms may disappear on their own or require additional treatment.

More than one patient per 1000 taking the drug has such symptoms as: apathy, thoughts of suicide, increased blood sugar, impaired attention, irritability, perverted taste, visual impairment, dilated pupils, increased heart rate, cardiac arrhythmias, increase or decrease in blood pressure, orthostatic collapse, nose and gastrointestinal bleeding, hematoma formation on the body, increased sensitivity to sunlight, weight gain.

One patient per 10,000 taking the drug may develop the following symptoms: increased intraocular pressure, hypertensive crisis, inversion of affect, suicidal attempts, delusional hallucinatory syndrome, Quincke’s edema, anaphylactic shock, toxic hepatitis, convulsions.

If symptoms from the last two groups occur, taking Simbalta should be discontinued and the patient should be treated for complications.

Overdose

In clinical studies, no lethal outcome was observed with an overdose of simbalta.Exceeding the recommended dose can lead to the development of serotonin syndrome, accompanied by a delirious state, delirium and hallucinations. In addition, impairment of consciousness up to coma is possible. Often, with a small overdose, drowsiness, vomiting and an increase in heart rate occur. In rare cases, convulsive syndrome.

There is no specific treatment for an overdose of Simbalta. Detoxification therapy is in progress.

Instructions for use

For depressive disorders and chronic pain, the average therapeutic dose is 60 mg.The drug should be drunk once a day, either in the morning or in the evening. In the event that this treatment turned out to be ineffective, the dosage is increased to the maximum possible – 120 mg. In this case, the daily dose is divided into two – in the morning and in the evening, one capsule each. The effectiveness of the treatment can be assessed after 8 weeks.

For anxiety disorder, the starting dosage is lower. In this case, Simbalta is prescribed 30 mg once a day. In case of ineffectiveness of treatment, you can double the dose, also dividing it into two doses.Gradually, you can increase the dosage by another 30 mg, and then by another 30 mg, reaching a maximum dose of 120 mg. Exceeding this value is not recommended due to the risk of side effects. The expected effect will appear after 4 weeks of administration.

Capsules are taken with plenty of water, food intake does not affect the absorption of the medication.

Analogues

There are only a few analogs that have the same active ingredient as simbalta, these include:

• Duloxetine Canon;
• Predant;
• Duloxenta.

In addition, there are drugs that belong to the same pharmacological group and have a similar mechanism of action. These include:

• Velaxin;
• Velafax;
• Venlafaxine;
• Milnacipran;
• Ixel.

All listed drugs are not interchangeable.

Reviews

Regina P .: “I took Simbalta for about six months due to severe depression. The drug helped me, but not right away.For about the first month I was dizzy and had a headache, but I did not notice the effect of the drug. After about a month, all the side effects were gone, and my mood began to improve a little. I took Simbalta for 4 months until I completely got rid of depression. ”

Denis M. : “I started taking Simbalta because of constant anxiety. I have been suffering from generalized anxiety disorder since childhood and I am periodically treated in the hospital. I took 30 mg, but there was no effect.When the dosage was increased, my anxiety began to decrease, but tremors in my arms and legs appeared, and blood pressure began to rise. I had to stop drinking Simbalta and switch to another drug. ”

Review of a psychiatrist : “Simbalta is not the most demanded drug on the domestic market of antidepressants. It fights very effectively even with advanced cases of depression, but there are several pitfalls. First of all, the large number of side effects severely limits the purpose of the drug.The patient must undergo a thorough examination before receiving the drug. In addition, Simbalta should only be taken in a hospital under supervision. This is associated with an increased risk of suicidal attempts in susceptible patients with severe depression. As a rule, doctors prefer safer drugs, using Symbalt as a reserve tool. Western colleagues prescribe Simbalta more often. ”

LIST OF HUMAN PREPARATIONS HAZARDOUS TO ANIMALS! ////////////////////////////// Every pet owner must Know that, despite the fact that our pets are often treated with human medicines, this does not mean that absolutely all medicines are safe for humans, and are also harmless for pets.It doesn’t matter if you yourself gave the drug to the animal for medicinal purposes or the animal accidentally, through an oversight, swallowed it, the consequences can be very serious. Here you will find a list of the human medications that pets are most likely to suffer from. 💊Nonsteroidal anti-inflammatory drugs (NSAIDs) First on our list are fairly common drugs that are in almost every home, related to non-steroidal anti-inflammatory drugs. The most famous of them are: Ibuprofen
Nurofen
Mig 400
Advil
Although these medications are safe for humans, even one tablet can cause serious harm to your pet.💊Analgesic (Paracetamol) Paracetamol and drugs based on it are quite popular as a pain reliever. Even though paracetamol is completely safe, including for children, it is dangerous for pets, especially cats. One paracetamol tablet can damage a cat’s red blood cells, limiting their ability to carry oxygen. In dogs, taking paracetamol leads to liver failure, and in large quantities to damage to red blood cells. 💊Antidepressants (Prozac, Simbalta, etc.)Some antidepressants are sometimes used to treat pets. However, in no case should you give your animal an antidepressant without the appointment of a veterinarian. Overdose can lead to serious neurological problems, dangerous heart rate, changes in blood pressure and body temperature. Some antidepressants can cause serious poisoning. 💊Preparations for the treatment of attention deficit disorder with manifestations of hyperreactivity. These drugs contain powerful stimulants.The ingestion of even a small amount of such drugs into the animal’s body can threaten the life of the animal. 💊Sleeping and sedative. These drugs help people reduce anxiety and sleep. However, in pets, they can have the exact opposite effect. In addition, these drugs can cause impaired coordination of movement and slowing of breathing in an animal. 💊 Contraceptive drugs. Fortunately, small doses of these drugs are generally not harmful to the animal’s health.However, large amounts can cause estrogen poisoning and other serious health problems. 💊 ACE inhibitors. These drugs are commonly used to treat hypertension in humans, sometimes in pets. Although overdoses can cause low blood pressure, dizziness and weakness, this category of drugs is fairly safe for animals. 💊Beta 1 – adrenergic blockers (Tenormin, Egilok s). Beta 1
Information from the site petsik.ru … – German Shepherds of Russia – International

LIST OF HUMAN PREPARATIONS HAZARDOUS TO ANIMALS! //////////////////// ////////////

Every pet owner should know that, despite the fact that our pets are often treated with human medications, this does not mean that absolutely all medications are safe for humans, are also harmless for pets.

It does not matter whether you yourself gave the drug to the animal for medicinal purposes or the animal accidentally, through an oversight, swallowed it, the consequences can be very serious.

Here you will find a list of the human medicines most commonly affected by pets.

💊Nonsteroidal anti-inflammatory drugs (NSAIDs)

The first on our list are fairly common drugs that are in almost every home, related to non-steroidal anti-inflammatory drugs.

The most famous of them are:

Ibuprofen
Nurofen
Mig 400
Advil
Although these medicines are safe for humans, even one tablet can cause serious harm to a pet.

💊Analgesic (Paracetamol)

Paracetamol and drugs based on it are quite popular as an anesthetic. Even though paracetamol is completely safe, including for children, it is dangerous for pets, especially cats.One paracetamol tablet can damage a cat’s red blood cells, limiting their ability to carry oxygen. In dogs, taking paracetamol leads to liver failure, and in large quantities to damage to red blood cells.

💊Antidepressants (Prozac, Simbalta, etc.)

Some antidepressants are sometimes used to treat pets. However, in no case should you give your animal an antidepressant without the appointment of a veterinarian. Overdose can lead to serious neurological problems, dangerous heart rate, changes in blood pressure and body temperature.Some antidepressants can cause serious poisoning.

💊Preparations for the treatment of attention deficit disorder with manifestations of hyperreactivity.

These preparations contain powerful stimulants. The ingestion of even a small amount of such drugs into the animal’s body can threaten the life of the animal.

💊Sleeping and sedative.

These drugs help people reduce anxiety and normalize sleep. However, in pets, they can have the exact opposite effect.In addition, these drugs can cause impaired coordination of movement and slowing of breathing in an animal.

💊 Contraceptive drugs.

Fortunately, small doses of these drugs usually do not harm the animal’s health. However, large amounts can cause estrogen poisoning and other serious health problems.

💊 ACE inhibitors.

These drugs are commonly used to treat hypertension in humans, sometimes in pets.Although overdoses can cause low blood pressure, dizziness and weakness, this category of drugs is fairly safe for animals.

💊Beta 1 – adrenergic blockers (Tenormin, Egilok s).

Beta 1 – blockers are used to lower blood pressure, but unlike ACE inhibitors, even a small amount of such drugs in the animal’s body can cause serious poisoning in pets. And in large quantities, it threatens the life of the animal.

💊Tyroid hormone preparations.

Pets, especially dogs, are sometimes prescribed thyroid hormones. It is noteworthy that the dose of thyroid hormone is higher than for humans. Therefore, if a dog accidentally eats a small amount of a thyroid hormone preparation, it is unlikely to affect its health. However, overdose in large amounts in cats and dogs can cause muscle tremors, nervousness, shortness of breath, fast heart rate, and aggression.

Always keep medications out of the reach of your pet. Never give human medications to animals without consulting a veterinarian, especially if you are not sure about their safety for the pet
Information from petsik.ru

# Veterinary_questions

Simbalta 30 mg, Cymbalta 30 mg, 98 pcs adults for treatment:

depressive diseases

generalized anxiety disorder (prolonged feeling of anxiety or nervousness)

Pain due to diabetic neuropathy (often called burning, tingling, tearing, shooting, or electric shock, which may cause loss of sensation in the affected area or contact, heat, cold, or pressure may cause pain)

For most patients with depressive illness or generalized anxiety disorder, the drug will take effect two weeks after starting treatment.However, it can take two to four weeks to get better. Talk to your doctor if you don’t feel better after this period. Your doctor may prescribe medication for you, even if you are feeling better, to prevent a relapse of your depressive illness or generalized anxiety disorder.

In patients with painful diabetic neuropathy, it may take several weeks for you to feel better. Talk to your doctor if you don’t feel better after two months.

contraindication

The medicine should not be taken if you are

are allergic to duloxetine or any other ingredient in this medication.

has liver disease.

have severe kidney disease.

Take another medicine called a monoamine oxidase inhibitor (MAOI), or have taken within the past 14 days.

Fluvoxamine, which is commonly used to treat depression, or ciporfloxacin or enoxacin, which is used to treat various infections.

Take other medicines containing the active ingredient dulexin.

Talk to your doctor if you have high blood pressure or heart disease. Your doctor will tell you if you can take the medicine.

buy Cymbalta

Buy in Moscow Cymbalta

Buy in St. Petersburg Cymbalta

Sertraline (Zoloft, Asentra, Stimuloton) – CyberPedia

Sertraline is effective in the treatment of major depression, panic disorder, OCD, social phobia, dysthymia and atypical depressive disorders. Its efficacy and side effects are similar to other SSRIs. The half-life of sertraline is shorter than that of fluoxetine and is approximately 25 hours; as a result of its metabolism, a less active metabolite is formed, the half-life of which is 60-70 hours. Sertraline intake is started with a dose of 25-50 mg per day in somatically healthy patients and is increased after 1-2 weeks to 100 mg per day. Doses can vary from 50 mg to 200 mg per day, but in many cases only 50 mg is enough.You can take sertraline at the same time, and if the dose is 100 mg or more, then twice a day. Compared to fluoxetine, sertraline is more likely to cause nausea, diarrhea and other gastrointestinal symptoms. Side symptoms in the form of activation are less pronounced. When taking sertraline, there are no anticholinergic and cardiovascular side effects characteristic of cyclic antidepressants . It is significantly less dangerous in case of overdose compared to cyclic antidepressants and MAOIs. Sertraline does not cause weight gain. However, it often causes sexual dysfunction (delayed ejaculation in men and anorgasmia in men and women). Sertraline can provoke mania in bipolar disorder.

Paroxetine (Paxil)

Another widely used drug from the SSRI class and its profile of action is similar to that of other drugs in this group. But compared with other SSRIs , when taking Paroxetine, the sedative effect is somewhat more pronounced.

Side effects are similar to those of other SSRIs and include insomnia or drowsiness, nausea, asthenia, tremors, and delayed ejaculation or anorgasmia. Paxil sometimes causes weight gain. Anxiety and sleep disturbances are rare. Paroxetine is more likely to cause constipation than other SSRIs, presumably due to its secondary anticholinergic effect. The drug has no active metabolites, so the risk of side effects in drug interactions is low.Treatment with paroxetine begins with 20 mg , the dose is taken in one dose in the morning; in elderly patients, as well as in persons with severely impaired liver and kidney function, the initial dose should be 10 mg per day. In patients without a therapeutic effect within 4 weeks, the dose can be increased to to 50 mg per day or to 40 mg at days in the elderly. For panic disorder, doses up to 60 mg per day are effective.

Citalopram and escitalopram

The most selective of all SSRIs, i.e.because they do not have other significant pharmacodynamic effects, except for the inhibition of the serotonin transporter. Therefore, they have the most favorable spectrum of side effects of all SSRIs. Unlike the racemate (mixture of isomers) of citalopram, escitalopram is represented only by the S-isomer (the R-isomer has no therapeutic effect), which is reflected in the name of this drug. At the same time, escitalopram surpasses its predecessor in terms of effectiveness and tolerability of . Side effects are rare.This is m. anxiety and insomnia; the most common side effect is nausea. Often they pass spontaneously. Prescribing indications are the same as for other SSRIs, including panic disorder and OCD. The risk of drug interactions when taking drugs is the lowest among all SSRIs, due to their minimal effect on the cytochrome P 450 system. short half-life.

The doses of citalopram used range from 20 to 60 mg, with the highest doses being used in the treatment of OCD. Usually start with a single dose of 20 mg, but in case of nausea, the dose can be reduced to 10 mg, in some patients and 5 mg. An effective dose is 20 to 40 mg and is highly individualized.

Escitalopram has lower doses – the initial dose is 5-10 mg / day, the maximum dose is 20 mg / day. For patients over 65 years old – the initial dose is 5 mg, the maximum dose is 10 mg / day.

Fluvoxamine (fevarin): In terms of the spectrum of effectiveness, it is similar to other SSRIs. Treatment usually starts with a single dose of 50 mg, then escalates to the usual therapeutic dosage of 150-250 mg / day. The half-life is 15 hours. Side effects are similar to other SSRIs, but nausea and even vomiting are more common than other SSRIs, and sexual dysfunction, on the contrary, is less common.

At insufficient effectiveness of SSRIs, TCAs can be added, which sometimes leads to a pronounced effect. TCAs are added starting at low doses (10 mg) and rarely up to 75 mg.

Group IOZSN

Venlafaxine. A modern effective drug. Venlafaxine at lower doses (<150 mg) acts as an SSRI for Serotonin. A with an increase in the dosage of , the noradrenergic mechanism increases, because in high doses inhibits the reuptake of both norepinephrine and serotonin.Therefore, it can be used as an SSRI, meaning the ability to change the mechanism of action when the dose is increased, if initially, at low doses, the course of treatment was ineffective. Venlafaxine lacks anticholinergic, antihistaminergic effects, and the ability to block α1-adrenergic receptors. Venlafaxine is metabolized by cytochrome P450, and drugs that inhibit the activity of this enzyme can increase the plasma concentration of venlafaxine.

The usual dosage ranges from 75 to 225 mg, with the daily dose being divided into two doses, i.e.because venlafaxine has a short half-life. In stationary conditions with severe depression, it is permissible to use doses up to 450 mg / day. The safety and side effects of venlafaxine are similar to those of SSRIs. The initiation of treatment may be accompanied by the onset or increase in anxiety or nervousness. Unlike SSRIs, venlafaxine, like TCAs, may cause increased sweating.

Important: at higher doses (over 150 mg), 5-7% of patients may develop a moderate but persistent increase in blood pressure. Therefore, in high doses, it is not recommended for use in persons with hypertension. In general, when treating venlafaxine, baseline blood pressure should be monitored and retested after dose escalation.

Ixel (milnacipran)

Does not have a sedative effect, but physiologically improves nighttime sleep and does not negatively affect cognitive functions. Ixel does not affect the cardiac conduction system and blood pressure, therefore it can be prescribed to elderly patients who are constantly taking cardiotropic drugs.

The half-life of the drug is 8 hours, therefore it is used twice a day.