How do YOU dose Cymbalta?

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Blitz2006

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So I know officially Cymbalta goes up to 120 mg/day, but I've been told that there is no clinical benefit/efficacy after crossing 60 mg. Is this true? I can't find paper that gives evidence for this.

Do you usually dose the 60 mg, 30 mg q12h or 60 mg q24h? I have a lot of patients that have neuropathic pain as well, and our hospital seems to like to jump straight to cymbalta....but pain docs usually also stop at 60 mg for neuropathy...

Do you think cymbalta is good, or better off using SSRI + gabapentin/lyrica for MDD + Neuropathic Pain?

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Here's a study showing optimal dosing at 60 (HAM D improvement @ 2 weeks with 60; delayed at higher doses but even then not different from 60): Dose-response relationship of duloxetine in placebo-controlled clinical trials in patients with major depressive disorder. - PubMed - NCBI

That said I guess the minimal antidepressant dosing is 40mg, but again most patients I have respond to 60 (or higher). I typical do 30mg (daily) x 3 days then increase to 60mg. I haven't had a reason to do BID dosing. I like to minimize meds, so I would pick cymbalta over a multi drug combo. In my experience patients like Cymbalta better than effexor (though I'm more apt to prescribe the latter because it's cheaper; however the quality of evidence for Effexor in treating neuropathic pain is poor).
 
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Interestingly enough, JAMA Psychiatry had a nice write up that included some commentary differentiating low dose Cymbalta (40-60mg) from high dose Cymbalta (80-120mg) for certain symptoms clusters and found some differences that I have appreciated clinically. I use higher doses when using Cymblata as the primary antidepressant, lower doses when using it in combination with another antidepressant.

JAMA Psychiatry. 2017 Apr 1;74(4):370-378. doi: 10.1001/jamapsychiatry.2017.0025.
Reevaluating the Efficacy and Predictability of Antidepressant Treatments: A Symptom Clustering Approach.
 
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Is Cymbalta better for this purpose?

Theoretically, since it has more norepi reuptake inhibition. You need to get effexor to 225/300 daily dose to get into the norepi range. Desvenlafaxine is the most noradrenergic but initial studies I saw showed it no better for treating pain, that may have changed though, I am certainly no pain specialist.
 
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I had a 52 year-old female patient who was admitted to the inpatient psychiatric unit due to depression and thoughts of suicide with a plan to cut her wrists because nothing was helping her overactive bladder. Patient had been tried on several medications, including Imipramine which made her condition worse. Her hourly trips to the bathroom were making it impossible for her to get a good night's sleep.

My first thought was "Depend Underwear," but a Google search for "depression overactive bladder treatment" led to information about Imipramine and Duloxetine (Cymbalta). A more specific search for "duloxetine overactive bladder" led to this:
http://www.renalandurologynews.com/news/duloxetine-may-relieve-oab-symptoms/article/24571/

Turns out Duloxetine (Cymbalta) is marketed for stress incontinence under the name Yentreve. Starting dose is 40mg twice a day.

After placing the patient on Cymbalta 40mg twice a day, she averaged 7 hours of sleep per night. Her depression and thoughts of suicide disappeared almost immediately.

Afterward, I felt like an expert in "Uropsychiatry" for the rest of the week.
 
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I had a 52 year-old female patient who was admitted to the inpatient psychiatric unit due to depression and thoughts of suicide with a plan to cut her wrists because nothing was helping her overactive bladder. Patient had been tried on several medications, including Imipramine which made her condition worse. Her hourly trips to the bathroom were making it impossible for her to get a good night's sleep.

My first thought was "Depend Underwear," but a Google search for "depression overactive bladder treatment" led to information about Imipramine and Duloxetine (Cymbalta). A more specific search for "duloxetine overactive bladder" led to this:
http://www.renalandurologynews.com/news/duloxetine-may-relieve-oab-symptoms/article/24571/

Turns out Duloxetine (Cymbalta) is marketed for stress incontinence under the name Yentreve. Starting dose is 40mg twice a day.

After placing the patient on Cymbalta 40mg twice a day, she averaged 7 hours of sleep per night. Her depression and thoughts of suicide disappeared almost immediately.

Afterward, I felt like an expert in "Uropsychiatry" for the rest of the week.

Very cool!

Here is a study and case report that shows this:

Duloxetine for the treatment of overactive bladder syndrome in multiple sclerosis: a pilot study. - PubMed - NCBI

Overactive Bladder Successfully Treated with Duloxetine in a Female Adolescent
 
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I had a 52 year-old female patient who was admitted to the inpatient psychiatric unit due to depression and thoughts of suicide with a plan to cut her wrists because nothing was helping her overactive bladder. Patient had been tried on several medications, including Imipramine which made her condition worse. Her hourly trips to the bathroom were making it impossible for her to get a good night's sleep.

My first thought was "Depend Underwear," but a Google search for "depression overactive bladder treatment" led to information about Imipramine and Duloxetine (Cymbalta). A more specific search for "duloxetine overactive bladder" led to this:
http://www.renalandurologynews.com/news/duloxetine-may-relieve-oab-symptoms/article/24571/

Turns out Duloxetine (Cymbalta) is marketed for stress incontinence under the name Yentreve. Starting dose is 40mg twice a day.

After placing the patient on Cymbalta 40mg twice a day, she averaged 7 hours of sleep per night. Her depression and thoughts of suicide disappeared almost immediately.

Afterward, I felt like an expert in "Uropsychiatry" for the rest of the week.

That's awesome (for you, and I guess the patient too)! I've never heard of Yentreve before. Thanks for this nugget.
 
Here's a study showing optimal dosing at 60 (HAM D improvement @ 2 weeks with 60; delayed at higher doses but even then not different from 60): Dose-response relationship of duloxetine in placebo-controlled clinical trials in patients with major depressive disorder. - PubMed - NCBI

That said I guess the minimal antidepressant dosing is 40mg, but again most patients I have respond to 60 (or higher). I typical do 30mg (daily) x 3 days then increase to 60mg. I haven't had a reason to do BID dosing. I like to minimize meds, so I would pick cymbalta over a multi drug combo. In my experience patients like Cymbalta better than effexor (though I'm more apt to prescribe the latter because it's cheaper; however the quality of evidence for Effexor in treating neuropathic pain is poor).

I pretty much do the same dosing schedule. One of my attendings in residency always pushed Cymbalta to 60 and fairly frequently to 90 and 120mg. I evaluate at 60, but if there's been partial, rather than full response, I'm not afraid to go to 90 or 120 since I'd rather have someone on 120mg of Cymbalta rather than 60mg of Cymbalta and 150mg of Wellbutrin XL, for example. The fewer meds, the better.
 
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I recommend taking it with a liberal helping of peanut butter.

(Or start everyone at 30mg for a week, increase to 60mg and see how we get on, increase again if it seems like a good idea.)
 
Here's a study showing optimal dosing at 60 (HAM D improvement @ 2 weeks with 60; delayed at higher doses but even then not different from 60): Dose-response relationship of duloxetine in placebo-controlled clinical trials in patients with major depressive disorder. - PubMed - NCBI

That said I guess the minimal antidepressant dosing is 40mg, but again most patients I have respond to 60 (or higher). I typical do 30mg (daily) x 3 days then increase to 60mg. I haven't had a reason to do BID dosing. I like to minimize meds, so I would pick cymbalta over a multi drug combo. In my experience patients like Cymbalta better than effexor (though I'm more apt to prescribe the latter because it's cheaper; however the quality of evidence for Effexor in treating neuropathic pain is poor).

This is also typically what I do. In the outpatient setting I'll sometimes stretch the "induction" at 30 mg daily to a week, but I otherwise don't increase the dose past 60 mg daily for treatment of mood symptoms. I will if someone has poorly-controlled neuropathic pain for which they've received some benefit from duloxetine but have persistent pain, but I'll just switch to another agent if there's an unsatisfactory response at 60 mg rather than continue to push the dose. The main exception to that is if they feel that they've had some improvement at the 60 mg dose - then I don't mind giving a higher dose a try before switching to a different agent.
 
Never. Why would I prescribe a drug that has even worse withdrawal than Effexor that has been shown to be less effective than any other newer antidepressant available in the US?

Worse than Effexor? Definitely not in my experience.

Less effective? Probably one of the most effective in my practice.
 
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Worse than Effexor? Definitely not in my experience.

Less effective? Probably one of the most effective in my practice.

I agree with this point. Since we cannot differentiate different neural chemical matricies into specific categories, need to look at regional differences in how medication works.
 
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